The one thing that almost everyone will agree on when discussing America’s pastime is that it’s a really difficult game to play well, especially at the professional level. A major league baseball player who hits the ball one out of every three to four chances at the plate is considered to be an all-star; hit the ball out of the ball park on a regular basis and the player becomes a local hero. A pitcher who wins more than half of his 30 to 34 starts in a season can expect to earn a contract in excess of $10 million dollars per year. Needless to say, the pressure to perform on the individual player is enormous. Millions of dollars hang in the balance on a daily basis and when things don’t go well, a player faces the ire of the fans and, potentially worse, a trip down to the minor leagues to “work things out.” It is therefore no wonder that professional baseball players push their bodies to the limit on a daily basis. It is also no wonder that, as team physicians, the most common injuries that we see among professional players are overuse injuries. We therefore have to play a dual role: 1) protect the player from overuse injuries and 2) diagnose and manage overuse injuries when they occur.
Role of Team Physician
The primary job of the team physician, and of the entire medical staff, is injury prevention. Professional baseball players are surrounded by coaches, trainers, doctors, physical therapists, massage therapists, strength coaches, chiropractors and nutritionists, all there to design a program of rest and recovery, to monitor each player’s health and to intercede at the first signs of trouble. Trouble always visits. Trouble usually presents initially in the form of fatigue. When a pitcher becomes fatigued, he is unable to keep his arm in the same position during the pitching motion for the entire game. This is usually first recognized by either the pitcher himself or, more often, by the pitching coach watching from the dugout. When a position player becomes fatigued his productivity usually goes down, either at the plate or in the field or both. After the game, we examine the player, discuss the findings with the player and the training staff and make a decision about the best course of treatment. Treatment may involve testing or a consultation with another member of the medical team. Treatment almost certainly includes a period of rest followed by a rehabilitation program. Early intervention can help to prevent injury, but unfortunately does not eliminate it altogether.
Common Injuries – Shoulder and Elbow
The most common injuries that we see among professional baseball players are injuries of the shoulder and elbow. The throwing motion and more specifically the pitching motion are not good for the body. The pitching motion uses the lower body and the trunk to generate enormous forces around the shoulder and elbow which then propels the ball 90 feet at speeds of up to 100 mph. For a starting pitcher, this motion is repeated 100 times each game, every 5th day, 32 times during a season for a total of roughly 3,200 pitches. This does not include warm up pitches before the game (60), pitches thrown between innings (50) and pitches thrown two days after every start (40). Add in 750 pitches thrown during spring training and it brings the total number of pitches thrown for a starting major league pitcher at over 8,200 each season. For position players (non-pitchers), the season can be even tougher physically. Position players participate in 162 games from April 1st to October 1st and then in additional playoff games up to Halloween for those teams playing in the World Series. Throw in 20 Spring Training games and it adds up to significant wear and tear on a player’s body.
Common Overuse Injury of the Rotator Cuff in Pitchers
The most common overuse injury that we see in pitchers is inflammation of the rotator cuff, the muscles in the shoulder that keep the arm in the correct position during the throwing motion. This is often a result of fatigue to either the lower body or to the shoulder itself. Pitchers are careful to maintain good strength of the legs, trunk and shoulder muscles during the season, but injuries can occur despite conscientious maintenance. Repetitive loads to the elbow can fatigue the muscles that support the elbow joint and overload the medial collateral ligament, resulting in failure of this ligament. The first thing that a pitcher experiences with either of these injuries is a loss of velocity and/or control of his pitches. Again, either the player or the pitching coach will recognize a change in the quality of the pitches and will immediately consult the medical staff. We examine the patient and will in most cases perform an X-ray and usually an MRI. These injuries are usually season ending injuries and in some cases, especially injuries involving the rotator cuff, can be career ending. We can reconstruct the medial collateral ligament in the elbow using a donor tendon with reliable results for return to play at a competitive level. The success rate for return to play for a pitcher following a repair of the rotator cuff is much less predictable and is historically low.
Injuries in Position Players
Position players injure their shoulder or elbow, but can also injure any muscle or joint in the body from either overuse or from trauma during play. When position players become fatigued they are more susceptible to injury. A fatigued, dehydrated player who has played 15 games in a row and has been travelling for 10 of those games is more likely to pull a hamstring sprinting from home plate to first base. That same player is more likely to strain a muscle around his rib cage trying to hit a 95 mph fast ball and swinging out of his shoes. These injuries are potentially preventable as long as the medical staff have given the players the appropriate rest and recovery and nutrition. But just as with pitchers, an injury prevention program is not perfect. Position players can also tear rotator cuff muscles and elbow ligaments. The good news for position players is that when these injuries occur, and even when they require surgery, the climb back to play is somewhat easier than it is for pitchers.
As team physicians, the season is a constant monitoring program. The key to a successful (low injury rate) season is to work closely with the entire staff to observe the players and intervene early and often. It doesn’t always work out as planned, but when it does work, and a healthy team is firing on all cylinders, it is a beautiful sight to see.
Dr. Struan Coleman is an orthopedic surgeon and specializes in sports medicine at Hospital for Special Surgery. He is currently the head team physician for the New York Mets.