Biomechanical studies on baseball pitchers have for years warned about the dangers of baseball pitchers pitching back-to-back games and not properly resting their arm, and while pitching limits are not universal in all levels of baseball, some head way as been made, especially within Little League Baseball.
Unfortunately the same thing can’t be said for softball, where there has been little focus on overuse shoulder and arm injuries in pitchers. While Little League Softball has some pitching guidelines, at the high school and college levels, there are no pitching limits at all.
The rise in softball pitchers with overuse shoulder and arm injuries, however, is causing some orthopedic doctors to speak out about the need for pitch limits in softball, despite lack of support from coaches and players who say that there is less of a risk in softball because the throwing mechanism is different.
An article in the Denver Post, “Should pitching limits be implemented in high school softball? Divided stakeholders weigh in,” recently highlighted the divide between doctors and players and their coaches when it comes to pitching limits in softball. The crux of the issue is that coaches and players believe that proper technique and guidance reduces risk of injury—not pitch counts.
Underhanded Pitching vs. Overhand Pitching
A long held belief in the industry is that the underhanded pitch in softball doesn’t cause the same wear and tear on the rotator cuff that baseball players experience.
Orthopedic doctors say, however, that the windmill motion used in softball does place a lot of pressure on the back, neck, shoulder, forearm and wrist of their pitchers. And with the popularity of travel ball and elite summer teams the risk of overuse injury is increasing.
While very few biomechanical studies have focused on softball pitching injuries, a study led by Kristen L. Thomas, M.D., an orthopedic surgeon with Legacy Emanuel Medical Center in Portland, Oregon, does offer some important insights. Thomas, who was included in the Denver Post article, also shared her data with OTW.
62% of Softball Pitchers Report Shoulder Injury and Require Medical Intervention
In her study on NCCAA Division softball players which was presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting in San Francisco, California, Thomas and colleagues evaluated 50 pitchers from NCAA Division I, II and III, and were able to collect pitching logs from 6 of the 14 softball teams that participated in the study. They categorized the pitching injury as grade 1, which was an injury without time loss, grade 2 which was an injury with time lost and grade 3 which was a season-ending injury.
Before the start of the season Thomas used a goniometer to measure range of motion and a dynamometer to measure shoulder strength, and she also collected weekly injury surveys as well as pitch logs from coaches. According to the data, out of the 50 pitchers, 20 of them had grade 1 injuries, 6 had grade 2 injuries and no one had a grade 3 injury.
She told OTW, “During my research, I looked at 50 players on 14 different college softball teams. On average, the schools had three to four pitchers on their team but some played multiple positions. When talking with the players, most of them had shoulder pain or problems in the past and sought medical attention.”
According to the data collected, 31 pitchers (62%) reported a previous shoulder injury that required medical intervention. Sixteen percent were diagnosed with rotator cuff tendonitis or shoulder impingement, 10% had biceps tendonitis, 10% had a SLAP tear [SLAP stands for superior labral tear from anterior to posterior] and 3% pitcher had a partial thickness rotator cuff tear. Nineteen pitchers (61%) could not recall the specific shoulder diagnosis but stated that they had shoulder pain. Fifteen pitchers (48%) required formal physical therapy due to their shoulder injury, and seven pitchers (23%) took time away from softball due to their injury. However, most of them did it in the off season while they were home.
Only 9 of the 14 teams participating in the study recorded pitch logs for their pitchers. Seven of the 9 teams did not actually record pitch count. They kept score cards of the batters to know how to pitch to them in the future so Thomas used their score cards to count pitches. Of the nine teams, five coaches submitted pitch logs. The average pitch count for the season was 1,243 pitches (range 152–2,516). The average pitch count per game was 82.5 (25–129).
Pitch Counts
She added that these players “did not go through the team doctor and many did not even know who their team doctor was. They also did not complain about their pain to their coaches because they wanted to continue playing, and when I spoke with the coaches, most of them did not think that any of their players were hurt.”
She emphasized the need for pitch counts to be more thoroughly studied in softball in order to determine a safe range for players, saying, “Many softball teams carry a small number of players who pitch. The players pitch a majority, if not all, of the innings of a game and may pitch consecutive days. This is also in addition to pitching in practice.”
Other orthopedic doctors besides Thomas are also raising their voices in concern. Steve Jordan, M.D., an orthopedic surgeon for the Andrews Institute in Florida, told the Denver Post that he has seen about a threefold increase in softball pitching injuries at his practice over the past decade.
Stephen J. Nicholas, M.D., director of the Nicholas Institute of Sports Medicine and Athletic Trauma has also been voicing his concerns. He told the lohud.com [“As softball becomes a year-round sport, pitchers could be at risk to injury from overuse”] back in 2015 that chronic injuries are resulting from not giving the shoulders enough recovery time from the stresses of the pitching the game. He said that while poor technique is still the number one cause of pitching injuries in softball, overuse injuries are close behind it.
He said, because there is no pitch count in high school and college softball, these athletes are pitching doubleheaders and consecutive days. He points to specializing in year-round sports as the biggest contributor to the rise in softball injuries.
Conflicting Statistics
Despite data from studies like these, the jury is still out about whether too much pitching in softball is dangerous. This is because most statistics on softball pitching injuries don’t suggest a need for pitching guidelines or mandatory rest days.
Injury statistics from the National Federation of State High School Associations for example actually show a decrease in throwing-related injuries. Their data shows that while the overall injury rate for softball had increased from a rate of 1.1 for every 1,000 participants in 2005-06 to 1.34 in 2016-2017, throwing-related injuries had actually decreased. In 2005-2006, 17.2% of all reported injuries were to the shoulder or arm compared to 8.8% in 2016-2017. In addition, in 2005-2006, 10.4% of all reported injuries were to pitchers but that number decreased to 8% in 2016-2017.
Another factor, according to Nicholas, is that when baseball statistics are compared to softball statistics, the numbers can be a little misleading because there are overall more baseball players than softball players. When you look at the 5:1 ratio between baseball and softball injuries, he explained in the lohud.com article, you need to keep in mind that part of that difference is because there are more baseball players than softball players. He said that when you look at every 1,000 players for each sport, the injury rates are a lot more similar. And in fact in his own practice he has been seeing more women with ulnar collateral ligament injuries.
Need for More Research
With coaches and players pushing back against a need for stricter pitching guidelines in softball, protecting softball pitchers from overuse injury can be a real challenge for orthopedic physicians, but Thomas said that they still need to speak up.
She told OTW, “This is a difficult conversation to have because the culture of softball is rooted in the ‘fact’ that underhand pitching is not stressful to the shoulder and so the pitch count does not have to be limited like in baseball. However, like with concussions, we cannot leave players’ health up to players and coaches. They are not in a position to protect the players from injury.”
Thomas also called for more studies to be done. She said, “Biomechanical studies of the windmill pitch show that there are high forces and torques across the shoulder with peak compressive forces similar to those reported in professional baseball pitchers. This coupled with the fact that many pitchers are pitching most practices and most games adds an overuse component to the problems.
“Softball shoulder injury risk and prevention has received far less attention than baseball pitching in the orthopedic literature. There needs to be large studies that look at pitch count and injury just like little league baseball.”
