Sunday, May 23, 2004
Q&A: Dr. Timothy Kremchek
Dr. Timothy Kremchek, Reds team medical director, sat for a Q&A with Enquirer reporter John Erardi.
Q. You evaluated twice the youth arm injuries (80) in 2002 than you did in 2001 (40). Why you think this is?
A. Because I think the word's gotten out among the coaches and parents that we are not about keeping the kids from playing. The parents now know, 'If you're hurt, let's go see the doc. He'll put you on some exercises, you'll miss a week or two and come back and feel better.' They're less intimidated about thinking that their season is over. Most of the time, we can nip it in the bud and they can go play. Knowing that, the kids, the parents and the coaches hide the injuries less. They're much more open to treatment so they can continue to play.
Q. But a pitcher can't still pitch, if his arm is hurt. What do you let them do?
A. Often, these pitchers at a young age are some of the better athletes. I find a way for them to be able to hit, DH, play first base and maybe even right field, depending on their age and how much action they're going to get out there. I think it's extremely important to keep them with the team, continue those bonds and not drift off.
Q. What kinds of things do you hear from youth baseball coaches?
A. I get more phone calls than you can imagine. They want to know if the injury was their fault. They don't want to hurt kids. Most of them are fathers and friends and relatives and going out there and spending the time coaching. I educate them, but I never put them on the hook unless it's grossly obvious. We need them out there, continuing to do their thing.
Q. Physiologically, what is it about boys and their elbows? Why all these elbow injuries?
A. One of the reasons we don't let young pitchers throw 'stuff' - curveball, sliders, forkballs - is because of the tremendous stress it places on the elbow. You're snapping off those pitches, and placing a lot of torque and stress on the elbow. The elbow has sixth growth centers. The biggest growth center, where the biggest stress is, is ... the inside (i.e. the body side) of the elbow, where all the muscles which originate from that go into the hand. When you flick the ball, it's all coming from the muscles that originate there.
Q. And in the young person, the arm isn't fully developed yet, so ...
A. That's right. When you're young and you're going through those growth spurts, the growth plate becomes more vulnerable. It is a weak link. The ligament is actually much more stronger than the growth plate. The ligament will pull right off it. In a fully developed arm, the bone is stronger than the ligament and the ligament is what gives.
Q. So, you're actually dealing with quite a few broken growth plates in these youngsters, then?
A. Yes, it's called an 'avulsion.' The muscles pull so strong, they pull the growth-plate bone right off the elbow.
Q. How much does that hurt?
A. That hurts a lot. These kids hear a pop and have pain and can't move their elbow. Sometimes, they get numbness and tingling into their fingers. They know something's wrong. They can't even attempt to throw the ball again.
Q. Does it require surgery to fix it?
A. If it (the growth plate) is pulled off and displaced enough, you have to put a screw in it.
Q. What about the shoulder? It's not as susceptible to injuries of that nature?
A. Well, you can break the growth plate in the shoulder, too. Kids have a growth plate up there in the humerus, and if that takes the stress, that can break also. That's what happened to Philip Santoro, who you're writing about. His was caught early. I've seen kids that have actually broken the growth plate all the way off and we have to put a pin in it.
Q. So, in general, the shoulder is more resilient?
A. Yes, the rotator cuff in a youngster is more resilient (than in an adult). You can aggravate it, but you can (heal) it with the proper rest and exercise programs ... For every 20 elbows that I see involving a growth plate situation, I see one shoulder.
Q. Why is that?
A. Young kids have tremendous motion in their shoulders. So the stress isn't on the shoulder bone, as much as it is on the elbow. These kids are loosey-goosey. Their rotator cuff is more resilient, the capsule and ligament of the shoulder are more resilient. They can have tendonitis and muscle imbalance and they are much easier to deal with, just with exercise and rehab. You do much less shoulder surgery on a youngster who throws than you do on his elbow. The loose shoulders don't get the fractures, the tighter shoulders do.
Q. Do you advocate a throwing program (i.e. between starts) for young pitchers?
A. Yes. Go back to the old days. You've heard guys who grew up (in the 1930s, all the way through the 1970s) talk about it: they were on 'throwing programs' and didn't even know it. We played in the backyard every day and we would play with these hardcoated rubber balls and pitching and hitting and playing baseball. We didn't have any arm problems! Now the problem is that the kids have formal practice and games and that's it. If they go rainout, rainout, rainout, they aren't throwing; they jump out of the car at a full sprint for the next game, and they've done no throwing in-between, and they say they're ready.
Q. So, you advocate 'long toss' - throwing long distance, but without appreciable arc on the ball - as a good way to develop arm strength between starts?
A. Yes. It puts a minimal amount of stress on the shoulder and elbow, and allows you to keep the same 'kinematics' - the same mo-tions - and they build arm strength, endurance and protect you against injury.
Q. What about the use of rubber tubing as a way to strengthen and protect the throwing arm? I've heard a lot about that. Can you get young kids to do that?
A. Yes, if you make it fun, and do it as a team. I'm a big believer in the tubing. The reason is because using the tubing, doing what are called the 'Jobe Exercises,' which give you consistent, resistant ... strengthening of the muscles, is the only exercise that works those muscles. I've had dads say to me, 'My son is lifting weights.' But most kids who are lifting weights do military press, bench press, arm curls, triceps and they aren't touching any of the muscles of the rotator cuff. And the biggest muscle in the rotator cuff is the decelerator - the muscle that allows your arm to actually rotate, turn out. It protects your shoulder. There isn't an exercise that works that, other than those bands ... With young kids, the 9- and 10-year-olds, you have to do it in a fun way. A lot of these kids on the select teams tie the (rubber) band to the fence and do their exercises before practice and do them as a team, and if you're a little kid, it's kind of fun, and the coaches watch for form. If you can do some, it's better than none, at that age. As they get older, all the kids should be doing it. We've got all of our high schools doing it, not only for the pitchers, but for the catchers, too.
Q. What kind of arm injuries do you see in young catchers compared to young pitchers?
A. The worst injuries I've seen - and Jim Andrews (famed orthopedic surgeon James Andrews of Birmingham, Ala., one of Kremchek's mentors) has talked about this - are catchers. When a pitcher throws a pitch, it's a very controlled situation. Almost every time a catcher throws - other than back to the pitcher - it's an immediate type of response: throwing to second, whipping it to first, third, whatever, different angles . (Arm) injuries in catchers are much more difficult to come back from. ... Catchers need to get warmed up properly - not just be thrown into a game. Proper warm-up is not making a couple of throws.
Q. What's your opinion of weight training at a young age?
A. I'm a believer in weight training, but the biggest problem I have with it in young kids is doing it incorrectly and doing it too much. The macho image of 'How much can I bench-press?' isn't good (for a baseball player). The young kid doesn't want to do repetition and build muscle; they want to see how much they can lift. But, under the right, controlled situation, weight training at a young age is very safe as long as the weights aren't too heavy and are done correctly.
Q. In the main newspaper story, we show your pitch-count limits for the pitchers of various ages. But what if a young pitcher has a particularly high pitch-count for one inning. Should the coach take that kid out of there before the kid has reached his allotted pitch count for the game? For example: Say you've got a pitch count of 70 on a good, strong, 10-year-old in the middle of the summer, and he throws 10 pitches in the first inning and 30 in the second, do you let him back out there for the third?
A. You've got to pay close attention to that high pitch-count inning. You don't want the kid out there struggling. One thing with young kids is they'll get frustrated and try to throw it harder. And a fatigue factor comes along with that, too. Also, they're afraid that their coach is going to take them out, that their parents are looking at them, that their teammates are looking at them, and they get embarrassed. I'd get that kid out of there. I'd try to be aware of whether he's changed his mechanics. If a kid is struggling, really laboring, get him out of there. What's the good of keeping somebody out who's getting his brains kicked in? I don't have a set number of pitches for that situation. Just be aware of what you're watching take place.
Q. Are boys' arms where girls' knees were a few years ago? For a while there, there was a rash of torn ACLs among girl soccer players. Trainers got the girls to concentrate on building up quads and hamstrings as a way to protect the knee. Are boys' arms in need of better conditioning of their shoulder and back muscles so as to prevent elbow injury?
A. Yes, and that's a good analogy ... What we're learning is that a strength program ... and a jumping and exercise program can decrease the aspect of having ACL tears, especially if you build up the hamstrings ... We're in the same way now with the throwers. They need an exercise program to strengthen the shoulder and have a throwing program in between (game) appearances.
Q. Do you evaluate many young female softball players?
A. All the time - more and more as the game's become more popular. We're talking about girls now playing fast-pitch softball in high school who didn't grow up throwing...Girls are playing well into college and their mid-20s. The personal instructors are working with young females on a regular basis now, where before we would see only a small number of females enjoying softball.
Q. I've heard stories that a lot of times that the dads of young pitchers who play for overzealous coaches will side with the coach when he is pushing a kids' pitch limit in the guise of toughening the kid up. What that coach is actually doing is trying to win a game. Keeping in mind that if a coach isn't going to protect a kid's arm, then the parents better do so, what is the mom's role? And do you see evidence of that in your work?
A. Yes. Sometimes the moms and dads are at odds with each other. Because dad wants to push it, and mom says no. Sometimes it's a separated or broken family, where Dad is pushing a kid to play, and Mom comes in mad as a hornet about what's going on. Boy, oh boy, that can become a nasty, nasty situation. I don't know who to talk to! I don't want to blame anybody, yet you know what's going on.
Q. What else sometimes comes into play?
A. I've really noticed over the last few years that the more these kids play and travel, that there's a social aspect of being with all the these other people. The better your kid is, the (higher your social place). It's almost like being the king lion. Saturday nights, people don't go out anymore, they go to the ballgame. I'm not very good with the psychiatry bit, but there's a lot of social interaction in these situations."
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