The whys - and why nots - of ACL reconstruction

Interesting and important piece last week on the New York Times "Phys Ed" blog on ACL injuries and whether the most aggressive treatment (surgery) is always best. Research just published in the New England Journal of Medicine raises real doubts. Patients who had ACL reconstruction- an expensive and relatively complicated operation - were followed in a study by researchers from the University of Sweden along with a second group that opted to forgo surgery and be treated with physical therapy only.

Surprising outcome. The Times reports, that “more than half the A.C.L. reconstructions” currently being conducted on injured knees “could be avoided without adversely affecting outcomes.”

The article continues, "Part of the reason for A.C.L. surgery’s popularity is that by most measures, it works. In the current study, most of the group members who had reconstructive surgery reported that their injured knees felt healthy after two years and that they had returned to activity — not, in most cases, at the same level as before their injuries, but they were active. Significantly, their knees also were notably more “stable” than the joints that hadn’t been surgically fixed. Stability is, in theory, desirable. A stable knee rarely gives way.

The article, though, goes on to explain that sports docs and researchers are split on the importance of a 'stable" knee. There seems to be agreement that it's very important for athletes in pivot, cut, change direction sports like basketball and lacrosse. In straight-ahead activities like running and biking, it appears to be less important. (There's even disagreement about that, though.)

I say the decision to have surgery on a damaged ACL is more complicated. A few years ago, I wrote an article about a spike in Tommy John surgeries being performed on high school pitchers. I interviewed James Andrews and Lewis Yocum, two prominent sports orthopedists, about the increase in the number of such patients showing up in their operating rooms. Yocum expressed his concern that sometimes he was operating on kids with limited futures in baseball. Maybe a year or two more of high school ball and that was it.

"Just because we have a hammer doesn't mean everything is a nail. Obviously, the surgery isn't designed for everybody," Yocum said.

The parallel carries only so far. And every kid deserves the best knee that modern medicine can provide. But everything isn't a nail.

Hat tip to my pal Ed Wiest.

"We see kids hurt before they become athletes"

Suddenly - and encouragingly - overuse sports injuries are getting a lot of attention this month in some prominent publications.

James Andrews gets much of the credit. Two articles this week focus on the surgeon's new initiative Stop Sports Injuries. Andrews sees a startling number of kids with overuse injuries in his clinic in Birmingham. This year, as president of the American Orthopaedic Society for Sports Medicine, he nudged the surgeons' organization into backing STOP.

The STOP program launched in April - with Andrews doing a round of interviews and the unveiling of an impressive Web site. More stuff is coming, including - if Andrews can find the millions in funding that he seeks - a National Youth Sports Day when sports docs would fan out to youth leagues around the country preaching about the dangers of starting too soon and doing too much.

Already, Andrews has lined up an A-list of STOP spokespeople, friends and ex-patients, including Charles Barkley, Jack Nicklaus, Terry Bradshaw, Bo Jackson, and John Smoltz, among them.

The Boston Globe ran this article Thursday.

I wrote a piece for Sports Illustrated in the current issue (June 7). In it, Andrews says: "I don't think epidemic is too strong a word. We're seeing kids hurt before they even have a chance to become athletes."

Education is a helpful thing, no doubt. What Andrews is doing - and what he has talked his star patients into assisting with - is fabulous. The key will be to persuade those of us with big ambitions for our kids that we're not helping them reach their potential as athletes. If anything, the opposite is true. Tough being a hot-shot travel team player with a cast on your leg or arm in a sling

What all youth baseball coaches should know

Today's assignment. Read this.

It's the American Sports Medicine Institute's new "position statement" on youth baseball pitchers and injury prevention.

In July, ASMI's top researcher, Glenn Fleisig, shared findings from a study of youth pitchers for an article I wrote for the New York Times.

The study looked at 29 youth pitchers from ages 9 to 14. All were given instructions to throw their curves — fastballs and changeups, too — as if they were in a real game. The results were surprising, even to the researchers. Curves were less stressful than fastballs and nothing linked curves to elbow injuries. The real culprit for these injuries - along with inadequate conditioning and pitching mechanics, according to ASMI - seemed to be overuse, kids throwing too many pitches and playing baseball too many months of the year.

Fleisig got clobbered for the study's observations about curveballs. One ESPN talking head, after a discourse on how he blew up his elbow throwing curves in high school, called Fleisig a "quack." Other reaction was nearly as over-the-top.

These revised guidelines, which Dr. Fleisig tells me were prompted by the "buzz" over the Times story, do not retreat from Fleisig's earlier comment about curves. "Throwing curveballs has been suggested as a risk factor, but the existing research does not support this," the report states.

The ASMI statement does flesh out important dos and don'ts for keeping kid pitchers safe. Note that USA Baseball's recommended pitch limits are more restrictive than Little League Baseball's. That's a subject for another day.

Another viewpoint on kids and curveballs

Found this at Checkswing.net, which is hosting a lively forum on kids, curves and the Times article. This post was written by a gentleman named Tom LaPrade:

"It amazes me that so many youth coaches who I've shared this article with refuse to acknowledge the validity of the studies. It's as though the notion that a curveball is more dangerous than a fastball is a religious crede of some sort, Not one of the youth coaches I've talked to is a scientist of the biomechanics of throwing, so what other reason could they have for their resistance to these studies than the fact that, for them, the "danger" of throwing a curveball is merely continued worship at the altar of baseball myth?

"But one thing that is obvious is that the act of throwing in any fashion is violent on the arm. Thus it is a legitimate question to ask which methods of throwing are MORE violent. There are probably a handful of experts without an agenda who are qualified to answer this question. And Nissen and Fleiseg are those people.

"So I accept this study as a scientific breakthrough. It’s the role of science to challenge received wisdom and preconceived pieties. I have no personal reason to doubt the study. I never felt any different as a kid throwing one kind of pitch over another, and as a coach I've never heard a kid complain about throwing curveballs v. fastballs. If a valid, peer-reviewed, blinded, controlled study by leaders in the field of biomechanics of throwing conclude that a curve is no less safe than a fastball, wouldn't it be awfully presumptuous of us to dispute it just because most people I know think curveballs arent as safe as fastballs? Who's to say the act of throwing the changeup with the unnatural grip and awkward pronation of the wrist (does anyone throw anything with that motion except a baseball pitcher tossing a changeup?) is not the most dangerous of pitches?

"People used to say the world was flat because that's what the smart people used to say, it looked flat, and everybody repeated the "fact" that the world was flat. Thankfully there were people who had the temerity to challenge these convictions that were based more on certitude than certainty. Think about it, if in fact these studies are correct, then we may be hurting kids by telling them to throw fastballs. Shouldnt the truth be more important than our cherished shibboleths?"

"Now you tell us that curves don't destroy arms?"

Reaction to Sunday's curveball article in the Times.

Rob Neyer, ESPN.com

"Wait a minute ... Now you're telling us that curveballs don't destroy the tender arms of adolescent pitchers? I can't say I'm all that surprised."


St. Louis Post Dispatch

"The larger issue in childhood arm injuries may be overuse: Too many pitches thrown in too many games too close together. The study suggested that young pitchers be allowed to throw no more than 80 pitches in a game, and that seasons should be limited."


ESPN Sports Nation TV
"Would you teach your kid to throw a curve? New research contradicts the conventional wisdom that throwing curves destroys young arms. Dr. James Andrews strongly disagrees with the findings."

Also:

Tim Keown, ESPN Radio Extra Point

Then, a worthwhile discussion of the article and the issue at BaseballFever.com.

And also chatter about kids and curves yesterday on Pardon the Interruption (with Mike Wilbon reflecting on his childhood bender) and the Dan Patrick Show.

Finally, I found this recent article on Dr. Andrews, Glenn Fleisig and their research at ESPN the Mag. Hat tip to Chris Sprow.

More on youth league pitchers and curveballs

In yesterday's New York Times, I wrote about kids and curveballs. Physicians and coaches have been warning about the dangers to young arms from curveballs for decades. Are they too cautious?

Maybe, according to two recent studies that found no connection between curves and elbow injuries in kids.

The article includes reaction from orthopedic surgeons who don't see the research as the last word.

Here's an interview that didn't make the article. I spoke with Joseph Chandler, Director of Medical Services Emeritus for the Atlanta Braves and an expert on kids and baseball injuries. He's not convinced that curves are harmless.


Question- Your reaction to the curveball research? (performed at the American Sports Medicine Institute)

Answer- This is a study that needed to be done. The problem is how it is interpreted, how the results are used. People need to remember it is a laboratory study done under laboratory conditions using a small number of pitchers, a small number of pitches.


Q-Are the results a setback for surgeons hoping to discourage curves for kids?
A-I think a lot of people wish the study had shown the curveball is a terrible pitch. It didn't really show that. So perhaps the curveball is not the devil. But there are certainly troubling things associated with kids throwing lots of curveballs.

Q-For instance.
A-Overuse. Kids throwing too many pitches. Kids pitching year round.

Q-How should parents and coaches interpret the curveball research?
A-One of the interesting things in the study is this: People see what they want to see. They focus on what they want the study to show. Some will take from this: Oh, you see the curveball is not a bad pitch. When they could be saying: what a great pitch the changeup is. (The study showed changeups generating less force on young elbows than fastballs or curves) So maybe the curveball is not the devil. But when you start throwing it so young, it makes it harder for a kid to truly learn how to pitch and build arm strength.

Q-In light of the new research, have your thoughts changed about when kids can safely begin throwing curves?
A-My philosophy has always been and to this day is not before fourteen-and-a-half. Why do I come up with that? It's an age where general body maturation is to a point that it can withstand more stress on the arm. Waiting until 14 protects the arm and gives a kid a chance to learn how to pitch.

Q- Little League Baseball has no rules regarding curves. The kids are 11, 12 and 13. Should there be a policy?
A-I think there should be a statement or policy discouraging breaking balls. I think it would be very difficult to prohibit curves. Who is going to monitor that? Who is going to decide what is a curveball?

Q-You polled 100 major- and minor-league pitchers in the Braves organization about when as youth players they began throwing curves. What did you learn?
A-For the most part, they didn’t throw them when they were 10-11-12 years old. The average age was 14. For major leaguers, it was 15. That's not firm scientific data (that kids who defer on throwing curves remain healthier and ultimately have more success). But it's pretty darn good.

Tommy John surgery comes to high school

For parents - and there will be plenty - spending July 4 weekend in
the bleachers at youth baseball tournaments, consider this.

The table below is a window into the operating room of James
Andrews, the prominent orthopedic surgeon and sports doc to many
pro athletes. Note the spike in kid athletes undergoing Tommy John surgery. Fifteen years ago, patients coming to Dr. Andrews for the ligament replacement operation were exclusively college and professional pitchers. Not a single high school pitcher. Certainly no patients younger than that.

Now, a different story. In 2008, kid players accounted for nearly one in three of Dr. Andrews' TJ patients. Frightening.

Click on the chart - much easier reading.

Mouthguards, helmets and Tommy John surgery

As followers of this blog know (due to my railing on the subject) all youth sports injuries are not created equally. There are two major types: acute injuries that are incidental to the sport being played, i.e., turning an ankle on second base or catching an elbow in the face during a fight for a rebound; and overuse injuries caused pretty much by one thing: playing sports so intensely that a kid's body breaks.

Some recent info on both types:

According to a new study, the number of acute baseball injuries is falling, at least those that are showing up in hospital emergency rooms. The annual number of those injuries fell 24.9 per cent from 1994 to 2006, according to the research, just published in Pediatrics.

From the report: "The most commonly injured body parts were the face (33.5%) and the upper extremity (32.4%). The most common injury diagnoses were soft tissue injury (34.3%) and fracture (18.4%). The most common mechanism of injury was being hit by the baseball (46.0%). Children in the 9- to 12-year age group had the highest injury rate (2.4 per 1000 population). When injury rates were calculated by using baseball-participation data (2003), children in the 12- to 17-year age group had a higher injury rate (19.8 per 1000 participants) than those in the 6- to 11-year age group (12.1 per 1000 participants)."

More from the study: "Youth baseball is a relatively safe sport for children. Although injury rates and the total number of injuries declined during the study period, our findings indicate that there are opportunities for making baseball an even safer sport for children. We recommend that all youth baseball players wear properly fitted mouth guards, that all leagues, schools, and parks install safety bases, that all batters use helmets with face shields, and that all players use safety baseballs."

Meanwhile, there's less (i.e., nothing) to indicate a dip in overuse injuries among youth baseball players. In fact, the anecdotal reports point to just the opposite. Here's the latest alarm bell, a good piece on youth pitchers undergoing Tommy John surgery in last week's Oregonian. If you question whether we're really putting kids at risk, consider this paragraph from the article:

"Dr. James Andrews of Birmingham, Ala., has become a household name in the baseball world. He has seen a steadily rising percentage of young pitchers coming in for his elbow ligament replacement surgery. More than one-quarter of his 853 patients in the past six years were at the high school level or younger. One was 7."

The legacy of Tommy John

Youth baseball injuries are a favorite (better said, frequent) topic in this space. I wanted to call attention to a new study that underscores the seriousness of the problem.

Tommy John surgery, invented in 1974 as a last resort for saving the career of the great major-leaguer, has become a common operation among amateur pitchers. And this population seemingly gets younger each year. Dr. James Andrews, the orthopedic surgeon to the stars, whose patients include pro athletes in virtually every sport, has witnessed a remarkable spike in the number of his high school patients.

Before 1997, 12 of Dr. Andrews's 97 Tommy John patients were 18 or younger - 12 per cent. In 2005, 62 of 188 were high school students - nearly a third.

The operation is highly successful. Most kids get back to pitching eventually. But before that day comes there are surgical risks, tens of thousands of dollars in medical expenses, casts, slings, physical therapy and the like. Where are we (parents and coaches) when these promising young arms are being worn out?