Why Are All the Pitchers Getting Hurt?

Anyone following Major League Baseball this season has noticed a rash of high-end pitchers injuring their elbow early this season. 

To me, even more importantly, we are seeing more and more high school players get hurt. We are in week 3 of the high school baseball season. This week alone we have had 10 pitchers reach out or come in because of arm pain.

At the professional level, some of the highest paid players in the game, the world's most talented arms, have been shut down with injuries. The injuries haven’t discriminated: young pitchers and more seasoned veterans, starters and relievers. No arm has been safe.

People have been describing it as a “pandemic” in the media. While that is certainly an over exaggeration, we have seen a significant rise in arm injuries over the past years. Since 2016, the rate of Tommy John surgery in MLB pitchers has risen by 29%. Even more concerning, the rate of re-injury, or needing a second tommy john injury is rising. Just this year, Spencer Strider and Shohei Ohtani, two of the best pitchers in the world, have undergone their second Tommy John surgery.

So what is going on?

Truthfully, I don’t have an answer. And while many “experts” are yelling across the internet on how to fix elbow injuries, the MLB and the MLB Players’ union are each blaming each other for the rise of injuries. And no one has the answers right now.

Clayton Kershaw may have said it best in another recent interview with The Athletic, “If someone says, ‘I have it figured out,’ I wouldn’t listen to them. I’m very wary of people that think they have it all figured out when all of this is still happening. If you had it figured out, you would’ve told somebody and made a billion dollars. You know what I mean? Nobody knows.”

Despite all the advancements in our understanding of pitching, training, biomechanics, etc. we are currently moving in the wrong direction. Pitchers are getting injured more frequently, not less.

Injuries are multifactorial and there are many potential things contributing to the pain and injuries. Rather than playing the blame game at the professional game, people need to work together to learn more about what is going on and how we can help players stay on the field and compete.

We owe it to the next generation of baseball to work together at every level of the game to better understand what is going on and how to help players improve their performance and remain healthy for the long run.

Possible Causes

Here is a quick run down of some of the things that have been suggested publicly and some of the things we have noticed with players in our office who are dealing with arm injuries.

Rule Changes

Starting last year, professional baseball has made rule changes that added a pitch clock and reduced mound visits to help games speed up. This has been great for baseball TV viewership and fan experience.

However, some pitchers feel that the pitch clock is increasing arm fatigue and therefore increasing injury risk.

The MLB has continually cited a study from Johns Hopkins that indicates the pitch clock has had no effect on arm injuries.

As if one rule change wasn’t enough, two years ago the league cracked down on pitchers' use of sticky substances that helped them grip the ball and increase their spin rate. This was supposed to help increase offense and make baseball more exciting. Pitchers argued this affected their command and increased the demand on their arm to grip the baseball.  

The argument is more stress on the forearm muscle leads to greater fatigue, and potentially increased rates of injuries.

So who is right? Are the rule changes making arm injuries more common?

Honestly, we don’t know right now, but rather than play the blame game, the sport needs to continue studying the effects of the rule changes.

Increased Demand on Pitcher Performance

Last week, Spencer Strider, star pitcher for the Atlanta Braves and one of the players who just tore his UCL and will undergo Tommy John Surgery said, “Baseball pays for strikeouts.”

Baseball as an industry has moved toward valuing velocity, spin rate, and strikeouts more than the ability to last 9 innings for a starting pitcher.

At every level, from youth to professional, there is an emphasis on throwing hard. When I ask a player how their outing went, they always answer with where their velocity was for the game. If you want to make varsity, play in college or get drafted, you need to throw hard.

The average fastball velocity in the MLB was 90.5mph in 2008, and in 2023 it was over 94mph.

This velocity increase is correlated with an increased elbow stress. It is also correlated with improved performance, more strikeouts and more successful careers.

Does throwing hard mean you are destined to get injured? No! 

But, there is a trend for increasing velocity and increasing injuries. It is a commonly repeated phrase that every professional pitcher we’ve worked with has said, “everyone throws hardest right before they blow out.”

As a baseball industry, players, coaches, teams, organizations, strength coaches, pitching coaches, athletic trainers, physical therapists, biomechanists, and so on, we need to be looking at how pitchers recover, train, throw, and rehab to support the increasing demands on their arm.

Simply saying, “don’t throw as hard” is not the answer. Pitchers need to perform to continue to play, and as long as performance is based on velocity, strikeouts and spin rates, we need to do better to help protect their arm.

Pitch Design and Shaping

With the improvement and introduction of new technology, like Trackman and Rapsodo into baseball, it has opened up new opportunities for players to get feedback on their pitches.  Players and coaches are able to get feedback on what the ball is doing all the way from their hand to home plate. 

Players can specifically “shape” or “design” pitches to be harder to hit by maximizing movement through spin rate, release point, etc.

This has led to a creation of new pitches, such as the sweeper or power change up.  

While these pitches are “nasty” and great strikeout pitches, some people feel they may be leading to more stress on the arm and an increase in injuries.

Dr. Keith Meister, team physician for the Texas Rangers recently was interviewed for an article in The Athletic. He feels he has seen an increase in arm injuries in pitchers that pursue high spin pitches that require the player to squeeze the baseball very hard. 

These pitches are new and there has been no biomechanical research to this point to look at the effect of grip strength on the baseball or higher spin pitches with different grips being a cause for increased arm strength. But this is an area that should be studied. 

There is one thing about pitch design work that I don’t see discussed a lot. Going through an extensive pitch design process and learning new pitches over the off-season can lead to a lot more time on the mound. This inadvertently can result in pitchers throwing more “innings” in a calendar year then they are used to.

This might be something to consider when looking at your throwing calendar and determining how many innings you throw this year. 

How Much You Throw and When

Every year, the most injuries in professional baseball happen early in the season. In Wisconsin, we see a similar trend in high school players getting hurt at the beginning of the season. 

What leads to this? Honestly, more questions than answers. 

• What did the player do in the off-season?
• What type of throwing program did they follow?
• Did they take a period to completely rest their arm, or did they throw year round?
• Were they working on new pitches or gaining velocity?
• Did they throw baseballs and play catch or throw plyoballs and do drill work?
• How quickly did they ramp up in the season?
• Did they stick to their weekly routine when the season started?

While the simple answer is to pick one thing and blame it on that, the real answer is likely more nuanced and complicated. Let me give you a few examples that we’ve seen in our clinic to illustrate this point.

Player A took 8 weeks off at the end of baseball season. He followed a long toss based throwing program and then took 6 weeks to build up his bullpen progressions before the start of the baseball season. He then threw several sets of live at bats, working up to 50 total pitches. As the season started, his throwing routine changed and he stopped his gym based workouts. His first outing, he threw 70 competitive pitches and then his elbow and forearm were hurting the next day.  

Depending on your personal bias. You could pick any number of things to blame for his arm pain:

• He took to much time off from throwing
• He played long toss rather than working on his mechanics
• He threw to many pitches in his first game
• He didn’t maintain his gym routine as the season started

I wish it was that simple and we could just pick one.

As a second example, Player B decided to take no time off after summer baseball because he wanted to follow a velocity program to try to improve his performance before the next season. 

He worked with a new pitching coach and spent much of his training time throwing plyoballs, working on his mechanics and playing less catch. He performed “run and guns” to work on his velocity. Once he got on the mound, he started working on pitch design and incorporated a new breaking ball that spun more than any of his previous pitches. At the end of the off-season, he’d gained 4-5mph of velocity. 

He became his team's number 1 pitching option and set a new PR for velocity in a game. After his third start, his elbow starts hurting. 

Again, based on your bias you could pick several things from this story to blame. 

• Pitch design work
• Following a velocity based program
• Throwing plyoballs rather than playing catch
• Not taking time off from throwing

Hopefully, these two case studies show how difficult off-season decision making is for baseball players. Currently, there is no “best” off-season program, but we recommend players individualize their program to their needs.

“Correct” Mechanics

Unfortunately, there is no one “right” way to throw a baseball. You don’t get more strikes called because you threw the ball with “perfect technique.”

The overall goal with mechanics is to develop a delivery that maximizes arm efficiency. Or put another way, the highest possible arm speed (performance) at the lowest possible cost (least valgus stress on the elbow). 

There are many different potential ways to accomplish this while throwing the baseball, and players should not be forced into one method of pitching. Players should be allowed to develop their own unique style that fits what their body is physically capable of. 

A player that has great hip mobility and thoracic spine extension might be able to use a different move down the mound than a player that is very tight and restricted in those areas. 

There are certain movements, positions or technical flaws that we see reduce arm efficiency. Meaning, it either limits performance (velocity) or increases stress on the arm.

Things like flying open, getting your arm up late, or drifting too far toward third base as you come down the mound can be robbing you of performance or increasing your risk of injury.  

We encourage all players to go through a 3D throwing analysis or 2D video analysis and work with a qualified pitching coach to help them maximize their mechanics to improve their arm efficiency and performance. 

Previous Injury is the Biggest Risk Factor for Future Injuries 

This might be the most concerning trend we are seeing in baseball and could be influencing current injury rates at the professional level. 

The number one risk of injury is a previous injury in the same area. 

Did you have little league elbow as an adolescent? You are at an increased risk of injury later in your career. 

Forearm muscle strain in high school? Increased risk of injuring your elbow in the future.

One Tommy John Surgery in college? Increased risk of a forearm muscle strain or a second Tommy John injury in the future.

Please note that increased risk is not a guarantee of a future injury, but the longer we can put off the first injury, the more we can protect the youngest players, the better. 

It is rare to meet a high school player that throws hard and is a D1 level recruit that hasn’t had a period of forced shutdown for injury at some point in their career. Whether it be for a UCL sprain, little league shoulder or little league elbow, injuries in youth players are very common. 

A recent study showed that approximately 25.6% of high school baseball players would injure their throwing arm over a 7 year period. The good news is that only about 5% of those injuries in high school required surgery. 

But what if you play beyond high school? Your risk of an arm injury that requires surgery goes up 4.3x.

By addressing and reducing injuries at the youth level, we may be able to have an effect at reducing injury risk at the college and ultimately professional level. 

What about arm care routines?

There is a robust market online now to sell “arm care” routines that will keep your arm healthy. 

Having a good exercise routine (especially one that is specific to you) is important and likely crucial to maintaining health. It is not enough. 

We see many players that utilize an arm care routine and think it will help “protect” them from throwing too many pitches, not taking enough rest or not having a good off-season or in-season throwing routine. 

Hopefully, if you’ve gotten this far, you will see that it is more complicated than any one thing.

So what can we do?

This was a long blog and it may leave you with more questions and answers.  But I wanted to end with a few big takeaways on what needs to be done to help address this issue:

• Hopefully, the MLB and the MLBPA can work together, rather than fight each other, to study and learn more about arm injuries, the effect of spin, velocity, arm care programs, etc. 
• Buying an online “arm care” routine will not be enough to protect your arm
• Youth baseball needs to focus more on maintaining arm health and less on performance and “winning” games
• You need to develop efficient mechanics
• But efficient mechanics alone will not protect you from improper workloads
• The off-season is key, you need to work with a skilled coach to help you plan your off-season for your specific needs and goals. 
• Baseball is prioritizing pitcher performance with velocity and strikeouts, we need to better understand the effect and alter how we do things to help keep pitchers on the mound
• Rule changes may have an effect on injury risk. Could we use them to reduce injury risk in the future?

If you're looking for a course on how you can improve your own odds of staying healthy this baseball season, take our mini-course and you'll learn strategies, exercises, and routines to help boost your arm health.