Reprinted from Until It Hurts: America's Obsession with Youth Sports and How It Harms Our Kids, by Mark Hyman. Copyright © 2009 by Mark Hyman. By permission of Beacon Press, www.beacon.org.
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Even 27 years after playing his last Little League game, Patrick Grady still can't forgive coaches and league officials for what they took from him.
At the time, Grady was 12 years old and playing Little League baseball in Westchester County, New York. By his account he was one of the league's star pitchers, striking out most of the batters he faced and winning almost all the games he pitched. His coaches were impressed. They pitched him constantly. During his two Little League seasons Grady estimates that he was his team's pitcher in two-thirds of its games. There are Little League rules to prevent such abuse. But as Grady recalls, his coaches disregarded them, and league officials didn't object.
Even when Grady's arm began to show alarming signs of overuse, grownups failed to step in. First his elbow ached. Then he began to lose feeling in his pinkie and ring fingers. Through it all he kept pitching. During an all-star game featuring the most talented players from the local league, Grady was the pitcher and alerted his coach to a terrible pain. When rain delayed the game for a while, the coach led Grady off the diamond to the snack bar. There, Grady insists, the coach stuck his star pitcher's arm in the freezer next to the ice pops, so that with his arm at 30-degree temperature, "I'd be numb enough to pitch the last four innings."
Grady's coaches presumably got what they wanted from their Little League experiences. With the aid of their top-notch pitcher, they had the thrill of seeing their teams win championships. They lived out their dreams and showed off their coaching prowess for approving parents and other spectators. The cost to Patrick Grady was high. His dream of playing for a college or even a high school baseball team never materialized. At 15, he had surgery to transpose a nerve in his elbow and never pitched again. "My potential career in baseball vaporized," he says.
Make no mistake: Injuries are inherent to youth sports, as inevitable as car pools and grass stains. In 2003 more than 3.5 million children under age 15 suffered a sports injury that required medical treatment -- about one attended injury for every 10 players. Many were the result of garden-variety mishaps: a base runner turning an ankle at second base or a field hockey goalie nicked by a point-blank shot.
Yet within the statistics is a hidden stat not as easily shrugged off. Each year as many as half of all youth sports injuries are the result of overuse -- a regimen of sports play and training so intense that a child's body rebels. In some high-volume clinics the picture is still worse. Lyle Micheli, the youth sports medicine pioneer, estimates that of the 70 young patients who file into his clinic each Thursday at Children's Hospital Boston, 75 percent are victims of overuse injuries -- soccer players with tender knees, swimmers whose shoulders hang like limp spaghetti and the never-ending line of baseball pitchers accompanied by their aching elbows. Back in the early 1990s the figure was at about 20 percent. That tells Micheli that in his decades-long battle against overuse injuries, the frayed muscle fibers and inflamed tendons are winning. "As a medical society, we've been pretty ineffective dealing with this," he says. "Nothing seems to be working."
What makes overuse injuries so infuriating to the Michelis of the world are two simple truths. First, unlike acute traumatic injuries -- dislocations, hyperextensions, and other mishaps -- injuries caused by overuse are easily prevented. By introducing variety, moderation and rest into an everyday sports routine, a child's risk can be cut to nearly zero. Second, adults are the great enablers of overuse injuries. Where we go, ruptured ligaments and chronic tendonitis inevitably follow. Before the adult-dominated era of youth sports, "We didn't talk about these kinds of injuries, at least in the [medical] literature," notes Dr. John DiFiori, chief of sports medicine at UCLA's Comprehensive Sports Medicine Center and physician for UCLA's intercollegiate sports teams. And for good reason. Until parents showed up there wasn't much to discuss. Children entertaining themselves at their own pace, in their own way, simply did not play sports until it hurt. "Little League shoulder, tennis elbow, you don't see it unless kids are in an organized sport," notes DiFiori.
It's not just pitcher's elbow. And it's not just adolescent boys. The rainbow of overuse injuries is strikingly diverse. In an average year, pediatric sports medicine specialist Eric Small treats children who've overdone it in baseball, basketball, track, figuring skating, volleyball and football. "I see one or two fencers a year," he says, and their issues are no joke -- wrist and elbow tendonitis and sometimes a condition known as thoracic outlet syndrome, a pinched nerve in the shoulder blade that leaves its victims with numbness in their fingers and hands. Two-thirds of Small's patients are girls, many suffering the King Kong of girls sports injuries -- ACL tears. The age of overuse patients also is cause for alarm -- it's falling fast. Pediatrician Rebecca Demorest, who practices at New York City's Hospital for Special Surgery, sees youth baseball pitchers ushered into her waiting room at age eight.
The American Academy of Pediatrics is worried enough to have issued two policy statements on overuse injuries in three years, the latest in 2007. Says pediatrician Joel Brenner, its principal author, "We always hear about the obesity epidemic. Yet, on the other end of the spectrum, there's definitely a group of kids who are too active."
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For every overuse injury, there's a story of a risk recognized too late or an adult's burning ambition left unchecked. Orthopedic surgeon Scott Maughon recalls an anxious mother who came to his Atlanta office with her 10-year-old daughter, a tennis player with an aching shoulder. The mother explained to Maughon that her daughter was rapidly climbing the Georgia state junior tennis rankings. To meet the family's goals for her, the girl had two weeks to reach number 5. Maughon tells me that, during an exam, he diagnosed a stress fracture, a potentially serious injury that could interfere with the normal growth of the girl's shoulder. He explained to the mother that her daughter should take an extended break from tennis of up to six months. It wasn't the answer the mother had come for. As Maughon recalls, she flew into a "yelling, screaming, stomping" rage, assailing the doctor for being overly cautious and insisting that her daughter didn't need any time off -- she could be treated just as well with physical therapy. "It was one of those cases where a parent absolutely, totally refuses to deal with reality," says Maughon. "Do parents think I get a thrill out of shutting a kid down? That I'm telling them their child needs rest when their child doesn't need rest? You can go to a chiropractor. Wish on a star. Try a magnet. Wear garlic. The fact of the matter is your child needs rest."
DiFiori recalls a mother bringing her 10-year-old son to his office with complaints of a pain in his knee. The boy was a gifted soccer player, and his father was his coach. DiFiori diagnosed the boy with a growth-plate injury, similar to ones suffered by gymnasts and marathon runners. Growth plates are areas of growing tissue at the ends of bones in children. They're among the weakest structures in the human skeleton -- weaker than ligaments and tendons, which join bones to one another. Growth-plate injuries among youth athletes are common -- and often serious. A damaged growth plate may interfere with the normal growth of a child's bone.
The injury clearly was the result of overuse. From the mother, DiFiori learned that the boy had been playing soccer nearly nonstop, multiple games and practices each week, for two years. The previous year, he had just two weeks off. DiFiori prescribed a lengthy break. The mother approved and, within a year, the boy had recovered. In the life of a sports medicine physician, the case was uneventful stuff. DiFiori recalls it vividly only because of the reaction of the boy's father to the diagnosis -- angry and defiant. "He kept asking, 'How could he have this injury? Why does he have to stop playing?' Later, I got an e-mail from the mother thanking me and apologizing for [her husband's] behavior."
The father's reluctance to accept his son's diagnosis troubled DiFiori. "You have a kid who is not capable intellectually of understanding the situation and a parent who is insisting on behavior resulting in an injury," DiFiori says. "Some people would have viewed it as child abuse."
Joseph Chandler has had similar issues with adults he had not even met yet. When he was the team doctor for the Atlanta Braves, the parents of youth pitchers in the area often would seek him out in times of great urgency. Unlike other patients who explained their problems when they came to the office, these moms and dads would call weeks before their appointments, Chandler remembers, with warnings like, " 'I can't really talk about this in front of my son. But you need to understand that he has big league potential; he's something special!' " Chandler says, "It floored me. What kind of pressure must 12-year-old kids be under from their parents?"
It's not all our fault. There is no shortage of cultural cues to disable a parent's normally good sense. The pressure to compete, to win, to stay even with the family next door recedes at times, but it is the rare family that banishes it altogether. Sports psychologist Richard Ginsburg likens it to a river's current that, once waded into, requires great effort to escape. "Once the flow grabs you and takes you, it's hard to step back," he says.
Then there is the coterie of adult accomplices who stand ready to help a child get to the next level -- professional coaches. In individual sports such as gymnastics, figure skating and tennis, they're ubiquitous. Every child needs one, and just about every child has one. Such coaches can spend several hours with a young athlete each day, honing skills and, in healthy relationships, building friendship and trust. But when the ambition of the child, the coach, or both, goes unchecked, things can go terribly wrong.
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Joe Chandler is a trim, mustachioed man with a piercing voice that squeaks higher when he laughs, which is often. A first meeting with him ends with Chandler shaking hands and opening his arms to give a visitor a bear hug. He spent the first half of his professional life in the operating room inserting screws and pins into broken bones. He ran a busy orthopedic practice in Atlanta and was team orthopedist for the Braves, caring for the million-dollar arms of star pitchers such as Tom Glavine and John Smoltz. Over the last half of his career he hopes to do as much for eight- and nine-year-old baseball pitchers.
Chandler's changed course was not entirely voluntary. In 1997, while performing surgery, he damaged his hand, an injury that eventually forced him out of the operating room. He continued seeing patients, however, including many with overuse baseball injuries. At that same time, overuse injuries were spiking among pitchers in the Braves minor league organization. Chandler wondered why. He knew the Braves weren't responsible -- he had the pitch logs proving that. But what was? Curious, he quizzed Braves players, trying to piece together their baseball lives as children. How old had they been when they became pitchers? When had they thrown their first curveball?
Then, Chandler embarked on another project. For years he'd watched the Little League World Series on TV, marveling at the poise and talent of the young pitchers. The laws of probability, if nothing else, dictated that some would become stars in professional baseball. Yet, as far as Chandler knew, none had. Somewhere between the little green diamonds in Williamsport and the 50,000-seat ballpark where Chandler worked in Atlanta, these young pitchers were vanishing. It didn't fit with Little League Baseball's record of keeping youth players safe, one that officials deservedly call attention to and take pride in. After all, it was Little League Baseball that introduced batting helmets with ear flaps in 1959. And Little League Baseball has stayed on message under Stephen Keener, the organization's president and CEO since 1994, banning on-deck circles (to protect waiting batters from being slammed by batted balls) and, beginning in 2008, mandating breakaway bases, to reduce injuries from tumbling awkwardly into the next base.
Those safety steps are progressive and, for the most part, uncontroversial. They keep players in the game -- end of story. Pitching rules are a far more complicated proposition because they balance interests at the heart of Little League Baseball. On the one hand, young pitching arms must not be overworked. On the other, every coach wants his ace on the mound for the big game.
For 50 years the only protection offered to youth pitchers was a rule limiting them to six innings in a week of games. The rule was easily enforced, but skirted the issue of greatest concern -- the number of pitches children toss during those innings. Chandler decided to count. He acquired videos of old Little League World Series, and with assistance from Braves minor league players, he noted each pitch. In 2006 Chandler and Nick Crocker, a former Braves minor-league player, repeated the exercise, this time screening all 32 World Series games and an eye-bugging 3,798 pitches.
The data was startling. Some Little Leaguers in Williamsport, Chandler and Crocker discovered, worked as hard as grown men pitching in big league ballparks. In the clinching game of the 2007 World Series, Red Sox starting (and winning) pitcher Jon Lester tossed 92 pitches -- one less pitch than those thrown on average by kids who tossed complete games in the 2006 Little League World Series (a complete game in Little League is six innings). One overworked lad threw a Nolan Ryan-esque 116 pitches.
Data on curveballs was just as surprising. Curveballs are hard-to-hit pitches designed to dart over and around the bats of opposing hitters. They're thrown differently than other pitches, often with a wrist snap and twist of the elbow that puts added stress on developing arms. Anyone who has watched a Little League World Series knows that curveballs are as much a part of the scene at Williamsport as cotton candy and souvenir programs. Chandler's research showed just how curve-happy the annual tournament had become. In the 2001 championship game, for instance, the surgeon's analysis showed pitchers for teams from Tokyo and Apopka, Fla., tossing curves an astonishing 64 percent of the time.
Chandler wasn't alone in trying to rouse Little League Baseball. James Andrews also was making a racket. Andrews is the James Brown of orthopedic surgery -- the hardest-working man in the operating room and a prolific researcher, too. With Glenn Fleisig, his colleague at the renowned American Sports Medicine Institute, the research arm of Andrews's surgical center in Birmingham, Ala., Andrews has devoted years to the study of overuse injuries, probing the risks to the human arm when it whips thousands of pitches over hundreds of games. Their studies are arcane to some, endlessly fascinating to others. (One finding: Pitchers who throw more than 80 pitches in a game have four times the risk of injury leading to surgery compared to pitchers who don't.) There's no doubt that they have painted a remarkable and alarming picture of how easy it is to destroy a young player's future.
Little League Baseball listens to Andrews and Fleisig -- to a point. In 2004, when the duo joined USA Baseball, a governing body for the sport, in offering safety recommendations for kid pitchers, the powers that be in Williamsport got the message. For the first time Keener and the Little League front office embraced mandatory pitch counts. But rather than accept limits proposed by Andrews and Fleisig -- 75 pitches per game and a maximum of 100 pitches in a week -- Little League arrived at its own watered-down standards: 85 pitches in a game and allowing 11-year-olds to throw those 85 pitches after three days of rest. That doesn't include warm-up pitches before the game and the 10 or so tosses from the mound between innings. The new rules place no restrictions on those.
The situation is more troubling during the Little League postseason -- the World Series and the qualifying tournaments leading up to that famous event. In those games young pitchers can go to the mound on two days' rest, creating the unhappy possibility of a child throwing an arm-numbing 255 pitches in a week. That has almost happened. In the 2007 tournament, according to the Sports Business Journal, pitchers from teams in Minnesota, Oregon and Texas all threw 230 to 240 pitches in one week. Kyle Cotcamp of Ohio tossed an incredible 267 in nine days. If the New York Yankees asked any of their grownup pitchers to do the same, they'd have a revolt on their hands.
Little League Baseball's decades-old tolerance of curveballs is just as puzzling. In August 2005 I wrote an article for TheNew York Times under the headline "Warnings for Children Are Clear, but Curveballs Are Rising, Not Sinking." The piece explained that curveballs had become an accepted part of Little League Baseball, a curiosity given that everyone from doctors to professional baseball players believed they should be outlawed for kid pitchers. Joe Chandler was quoted saying he believed strongly that children should not begin to throw curveballs until they were at least 14. Professional pitchers surveyed by Chandler were even more cautious, saying they wouldn't allow their sons to learn the pitch until they'd nearly turned 15. Even Little League's Keener came across as anticurve in the article, saying, "We are hearing from more and more medical professionals that the danger is there." Curves are getting closer scrutiny these days. In 2006 Little League Baseball joined a five-year study led by researchers at the University of North Carolina looking into the effects of the pitches on the arms of youngsters. By my count, that would make the results available after 2010, Little League Baseball's 72nd anniversary. The adults don't seem to be in a great hurry.