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More young pitchers face big league arm trouble

By Christopher Smith
csmith@eagletribune.com

Former Salem High pitcher Connor Nolan has a scar that crosses his elbow as a souvenir of the Tommy John surgery he needed in 2008. MARY SCHWALM/Staff photo

Connor Nolan pitched almost year round as a teen.

“I threw high school, Legion, fall ball,” Nolan said. “You just want to get noticed. It’s hard, especially coming from the northeast.”

Nolan, a graduate of Salem, N.H., High and a 2007 Eagle-Tribune All-Star, was determined to win a college baseball scholarship.

He finally achieved his dream, winning a baseball scholarship to Florida State.

But in the process, he ruined his pitching arm and his hopes of making the big leagues.

The beginning of the end came in 2008 when he tore his ulnar collateral ligament — the ligament that connects the upper arm bone to the inside bone of the forearm. A four-inch scar that crosses his elbow is a souvenir of the Tommy John surgery he needed to repair the damage.

Nolan is just one example of a trend affecting young pitchers, one that should trouble their parents and coaches.

Tommy John surgery is named for a former Dodgers and Yankees pitcher, and it is usually associated with professional players. Red Sox pitchers Daisuke Matsuzaka, John Lackey and Rich Hill have all undergone the surgery since June.

But increasingly, Tommy John surgery is being performed on amateur pitchers in college, high school and even youth leagues.

Andrews Sports Medicine & Orthopaedic Center in Birmingham, Ala., is one of the nation’s leading centers for the procedure.

Of the 1,607 surgeries performed at Andrews from 1994 through 2010, 374 — 23 percent — were performed on youth and high school athletes. And the percentage has been on the rise. In 2010, 31 percent of Tommy John surgeries at Andrews were on youth and high school pitchers. Ten years earlier, the figure was 18 percent.

“The most rapidly growing demographic of Tommy John surgery is actually in youth baseball,” said Dr. Thomas Gill, chief of Massachusetts General Hospital sports medicine service and former Boston Red Sox medical director.

Many factors contribute to the rise.

Salem's Connor Nolan earned a baseball scholarship to Florida State. (Courtesy photo)

Young pitchers are throwing year-round, even in snowbelt states, thanks to indoor practice facilities. Under pressure to impress coaches and scouts, pitchers are throwing with elbow pain as early as Little League and throwing too many pitches during games. Some coaches are also using young pitchers to play other positions, like catcher and shortstop. They’re throwing hard and often on what are supposed to be their days of rest.

“Probably the most common cause is overuse in our young population,” said Dr. Luke Oh, a sports medicine orthopedic surgeon at Massachusetts General Hospital and a Boston Red Sox team physician.

Shoulder woes

Connor Nolan pitched almost year round in high school. (Courtesy photo)

Now 23, Connor Nolan was pitching freshman ball for St. Johns River Community College in Palatka, Fla., and beginning to attract notice from pro scouts when he tore his ulnar collateral ligament and underwent Tommy John surgery in 2008.

Nolan said he had been pitching without a stop for two years straight. “I was throwing in the winter,” he said.

Before the tear, he had some elbow pain but wanted to impress his coach and the scouts.

“I was throwing really well in the fall. My velocity was there. My breaking ball was good. I just pushed it too much.”

After the surgery, Nolan returned to the mound in the fall of 2009.

But his arm angle had changed from over the top to three-quarters style. “When I switched my arm angle, something didn’t feel right in my shoulder, but I was throwing good,” he said. “I was throwing low-to-mid 90s.”

His fastball reached 94 mph at a showcase where Florida State discovered him.

Nolan enrolled at Florida State in 2010. But playing ball that fall, he tore his labrum — the cartilage that, among other things, helps hold the shoulder joint together.

He underwent shoulder surgery.

Gill, the sports medicine expert, said it’s not unusual for young players who have undergone Tommy John surgery to develop shoulder problems.

“They’re getting labral injuries or rotator cuff injuries simply because they didn’t keep their shoulder (conditioning) program going and their shoulder strength up. They were doing all the rehab for the elbow.”

Nolan said doctors told him it would take eight to 10 months to recover from shoulder surgery. Instead, he was rushed back after six months to pitch out of the bullpen last spring. He blames himself as well as Florida State.

“It was sort of my fault and their fault,” Nolan said. “I wanted to get out there and throw.”

Nolan said he would throw a few innings, then be unable to throw for a week and a half.

“I was in so much pain, I just couldn’t do it anymore,” Nolan said. “My arm has sort of reached that point where you want to play but you can’t.”

Nolan is still at Florida State, studying sociology and criminology, but does not expect to pitch competitively again.

‘Kids overworked’

Connor Nolan during his younger years. (Courtesy photo)

Gill said youth pitchers in his hometown outside Boston play baseball year-round and pitch in as many as three different leagues simultaneously.

Each league might limit the number of pitches that can be thrown in a week, Gill said, but doesn’t keep track of the number thrown in other leagues.

“Plus let’s say a pitcher is then a catcher or a shortstop or a third baseman when he is not pitching. … Kids today are just getting completely overworked and are throwing way, way too much.”

Gill said major leaguers typically don’t throw from the end of the season until Jan. 1.

“Whereas kids now, they’re throwing year-round,” Gill said. “They simply have to have a season down.”

But Nolan said there is pressure to keep pitching, even with elbow pain, both to help your team and get ahead in the game.

“I think everybody who is a pitcher pitches with pain,” Nolan said. “You just work through it.”

Seven of 18 local varsity coaches surveyed by The Eagle-Tribune said they believe at least half of today’s high school pitchers would pitch with arm pain without saying anything.

Longtime Pinkerton Academy baseball coach Ron Manseau said playing in pain is part of the culture of high school athletes. “They’ve been brought up through the ranks (and told), ‘Toughen up, be a man about things, handle it, don’t complain,’” Manseau said.

But Dr. Oh, the sports orthopedic surgeon, said that must change.

“They should not be pitching with elbow pain really at any level but particularly as a young person.”

Gill said young pitchers risk damage even though they are throwing at slower speeds than professionals because their elbow musculature is not as well formed.

“So they have much less protection of the ligament and the stresses that the ligament sees,” Gill said.

Nolan wishes he had known as much in high school as he does now about the risks he faced by pitching so much.

“I didn’t really understand arm injuries,” Nolan said. “I just threw. I was a skinny, scrawny, tall kid who just threw hard.”

Four pitchers who played through pain

By Christopher Smith
csmith@eagletribune.com

Frank Riley: Ironman once pitched 18-inning game

Frank Riley is a former Methuen High School pitching legend. (File photo)

Frank Riley, one of the Merrimack Valley’s greatest high school pitchers ever and a 1978 Methuen High graduate, once pitched all 18 innings of an extra-inning game.

“I pitched many games where I went 10 innings or more,” Riley said. “Basically, the problem was, too, that I was one of the better hitters on the team so I would play in the outfield after I pitched.

“So if I ever had to cut one loose from the outfield, like a day or two after I pitched, my arm would be hanging down on the ground for the next couple of days.”

Riley went on to pitch for the University of New Haven and the University of Lowell. His elbow was always sore, but he never saw a doctor about it and never had Tommy John surgery.

He blew out his shoulder while pitching for an amateur summer league team when he was about 24, ending any hopes of turning pro. He kept pitching for a few years but quit when the pain became too great and “I couldn’t cut it loose” as a pitcher anymore.

“There’s no question that you have a lot of regrets when you just throw too many innings and too often,” said Riley, 51, now living in Wilmington and working as a project manager for Data Electronic Devices.

Rich Robinson: Overworked in Little League

Rich Robinson was overworked from Little League until the pros. (Courtesy photo)

Rich Robinson, the Andover freshman baseball coach and a 1965 North Andover High graduate, played parts of five seasons in the Boston Red Sox minor league system. He experienced elbow and shoulder injuries during his career, although he never had Tommy John surgery.

“Two things usually cause it: mechanics and overuse,” said Robinson, 64, of North Andover, a retired Lawrence phys ed teacher. “Now, with kids who are running into arm problems — it’s (usually) overuse.”

Robinson said he was overused from Little League on.

At North Andover High, he’d pitch a game one day then be called on to pitch an inning or two a couple days later and again two days after that. “You were almost a regular.”

Robinson said some high school programs still use pitchers that much.

“I’m not a big advocate,” he said. “I think you need to rest in between. You can still throw in between. But you need to rest.”

David Blank: Honest answers needed by coach

Andover High School graduate David Blank led the Warriors to their first ever state baseball championship in 1991. While in college he underwent Tommy John surgery ending any hopes of a professional baseball career. (Tim Jean, Eagle-Tribune)

David Blank, who pitched Andover High to its first state title in 1991, had Tommy John surgery in 1994 during his junior year at South Florida.

Blank, 39, of Andover, now owns DB’s Baseball & Softball Instructional Academy in North Andover.

Blank, who said he pitched with elbow pain beginning in Little League, blames overuse in college for the ligament tear that led to Tommy John surgery.

“I was pitching a lot out of the bullpen,” Blank said. “It really got to a point in college where I had a ton of appearances in just one year.”

After the surgery, his fastball lost almost 10 mph and he decided against trying to turn pro, despite being offered a free agent contract.

Now as a coach, he monitors pitch counts and routinely asks his pitchers how they are feeling.

“I just need a honest answer,” he said.

Jay Yennaco: ‘Throwing is an unnatural motion’

Jay Yennaco pitching for Pinkerton Academy on May 3, 1995. (File photo)

Jay Yennaco, 36, of Windham was a star pitcher at Pinkerton Academy in Derry, before being selected by the Boston Red Sox in the third round of the June 1995 amateur draft. He said he was never overused but did pitch with pain.

“There was not a tremendous amount of times that I pitched that I felt perfect. I’ll leave it at that,” said Yennaco, who now owns Delahunty Nurseries & Florist in Windham.

Yennaco had Tommy John surgery in 2001.

The doctors “felt as though in my case it was simply just a lot of use,” Yennaco said. “Throwing is a pretty unnatural motion for your body. You create a tremendous amount of torque and stress and use from what is an unnatural motion. So I just think that eventually in some people that just catches up to them over a certain period of time.”

________________________________

WHAT IS TOMMY JOHN SURGERY?

Tommy John surgery is named for the major league pitcher who in 1974 became the first person to undergo what was then a radical procedure. The surgery was developed and first performed by Dr. Frank Jobe.

Former Andover High pitcher David Blank shows his scar from Tommy John surgery. (Tim Jean, Eagle-Tribune

The surgery is done to replace the ulnar collateral ligament, which ligament connects bones in the upper and lower arm and helps stabilize the elbow joint and allow the arm to flex.

To replace the torn ligament, a tendon graft is taken from another part of the body, typically the forearm and wrist area.

Dr. Luke Oh, a sports medicine orthopedic surgeon at Massachusetts General Hospital, said the palmaris longus tendon is commonly used. “It is one of the wrist flexors but it appears to have the least contribution to wrist flexion so there are many major leaguers who have had the surgery using that graft and it has not affected their pitching or wrist motion,” Oh said.

Holes are drilled into the humerus (the bone in the upper arm that extends from the shoulder to elbow) and the ulna (the longer bone of the two forearm bones). The tendon is then wrapped with the torn ligament and woven through the holes in the two bones.

The surgery has a 90 to 95 percent success rate.

When he had the surgery in 1974, Tommy John was pitching for the Los Angeles Dodgers. He took the 1975 season off but in 1976 returned to pitch for another 18 seasons with the Dodgers New York Yankees and other teams. Now 68, John posted a lifetime 288-231 record and a 3.34 ERA. The left-hander made four All-Star teams, three of them after the surgery, and finished second for the 1979 American League Cy Young.

RISE AMONG YOUTHS

TOMMY JOHN SURGERIES at Andrews Sports Medicine and Orthopaedic Center in Alabama. Notice the increase of Tommy John surgeries among youths and high schoolers in recent years:

Year

Youth and High School

TOTAL

% Youth & High School

1994

0

6

0%

1995

2

21

10%

1996

1

31

3%

1997

1

23

4%

1998

5

43

12%

1999

12

65

18%

2000

17

93

18%

2001

17

93

18%

2002

19

110

17%

2003

45

172

26%

2004

35

174

20%

2005

42

153

27%

2006

36

140

26%

2007

38

125

30%

2008

33

103

32%

2009 34 121 28%
2010 41 131 31%

TOTAL

374

1607

23%


Source: ASMI.org

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Recovering pitcher’s advice: If you feel pain, get it checked

By Christopher Smith
csmith@eagletribune.com

Methuen's Chris Carmain, a junior at Northeastern, rehabs at Mass General Hospital in Boston following his Tommy John surgery in August. MARY SCHWALM/Staff photo

Chris Carmain’s fastball reached 94 mph despite sometimes searing pain in his elbow.

Then last summer, he felt a pop in his arm after throwing a pitch.

“I threw another pitch and it felt like someone had shot me in the elbow,” he said. “Just excru

Methuen's Chris Carmain, a junior at Northeastern, takes a break from rehab to show his Tommy John scar. MARY SCHWALM/Staff photo.

ciating pain.”

His hand felt hot, then tingly. Then it began to feel cold and he couldn’t feel it anymore.

Carmain, 20, of Methuen, a Northeastern University pitcher, said he had felt pain in his elbow as early as Little League but never told anyone.

“You don’t want to come off the field, ever,” Carmain said. “There’s definitely an aspect of pressure that you don’t want to let the team down.”

The pop he felt last summer was his ulnar collateral ligament tearing. The ligament connects two bones — the humerus in the upper arm and the ulna in the forearm — stabilizing the elbow joint.

MRI scans showed the ligament had begun to tear in high school, when Carmain was pitching for St. John’s Prep in Danvers.

Carmain underwent ulnar collateral ligament reconstruction, better known as Tommy John surgery, on Aug. 18.

He’ll miss the 2012 baseball season but has learned an important lesson.

“Definitely, if you’re experiencing pain, get it checked out,” Carmain said. “Don’t wait.”

Carmain also learned that he spent his high school years doing the wrong shoulder-strengthening exercises and, as a result, he had an especially weak shoulder.

He got the word when he visited Dr. Luke Oh after his tear. Oh is an orthopedic surgeon who performs about 40 Tommy John surgeries a year at Massachusetts General Hospital.

Chris Carmain pitching for St. John's Prep in 2009. (File photo)

As the number of Tommy John surgeries grows among adults and teens, shoulder strength is becoming a major issue for young pitchers. The right kind of shoulder strengthening exercises can help avoid Tommy John surgery, or recover from it.

“I have yet to see a young athlete that needs a Tommy John surgery that came in with a very sturdy and strong shoulder and rotator cuff,” Oh said.  “If the shoulder is not optimized … then the elbow sees more load and it’s at increased risk of injury.”

Carmain’s weak shoulder contributed to the development of partial tears in his ulnar collateral ligament during high school.

He now advises other young pitchers to “get on a shoulder rehab program … Rehab even if you’re not hurt.”

The torque and force of throwing a pitch off a mound can overwhelm the ulnar collateral ligament, Oh said.

“The ligament cannot withstand the force of a single pitch,” Oh added.

But the rotator cuff and shoulder internal rotators, plus the flexor pronator group of tendons in the elbow, can help protect the ligament and prevent it from tearing.

“That’s why it’s critical to strengthen and optimize all of those muscle groups in addition to paying attention to things like pitching mechanics,” Oh said.

Pitchers in their late teens might be the same height as a major league pitcher, but their muscle groups still need time to develop.

“Their rotator cuff muscles and other elbow stabilizers like the muscle group in the flexor pronator mass have not been developed optimally to throw a ball 80 or 90 mph,” Oh said.

Carmain never learned the proper shoulder exercises until his sophomore year at Northeastern.

Methuen's Chris Carmain, a junior at Northeastern, rehabs at Mass General. MARY SCHWALM/Staff photo.

He did overhead presses and shrugs in high school. “Both lead to tightness and overexposed my shoulder,” he said.

“You need to (exercise) the small muscle groups with bands and light weights to keep the shoulder stable,” he said.

Carmain now undergoes physical therapy three days each week, two hours each day. The other four days each week he exercises on his own for an hour, working on his rotator cuff and his “lats,” the major muscles in the back.

“High school coaches should have an idea of how to strengthen a shoulder and should have some kind of regimen for pitchers and position players to follow,” Carmain said. “But if you really want to get the strength necessary, then you need to go to a private coach or at least a physical therapist.”

Experts separate Tommy John surgery fact and fiction

By Christopher Smith
csmith@eagletribune.com

Can a pitcher tear his ulnar collateral ligament on one pitch? Is it true that Tommy John surgery to replace the ligament can make you a better pitcher?

Two experts on Tommy John surgery — Dr. Luke Oh and Dr. Thomas Gill — talked about myths and realities of the procedure in separate interviews with The Eagle-Tribune.

Oh is a sports medicine orthopedic surgeon at Massachusetts General Hospital and a Boston Red Sox team physician. Gill is the chief of Massachusetts General Hospital’s sports medicine service, a former Red Sox medical director and a current medical director for the New England Patriots. Here are excerpts from the interviews.

Q: Can the ulnar collateral ligament tear on one pitch?

Dr. Luke Oh (courtesy photo)

Dr. Oh: Some pitchers may describe throwing a single pitch, they hear a pop and have pain in the medial aspect of the elbow and discover that they have torn the ligament. But these usually happen in people who have been throwing for a while. Their ligament has undergone some attenuation and stretching over their careers. And it very well may be that a single pitch can complete that tear or complete the injury to a full-sized tear.

Q: Is surgery needed for a partial tear?

Dr. Oh: Sometimes it’s possible to rehab through it and get back to pitching. But if it’s a really big partial tear, it really functionally behaves like a ligament that can’t sustain the torque of throwing. So those people may end up having surgery if they fail rehab.

Q: What is the normal recovery time from Tommy John surgery?

Dr. Oh: About 11 months to 16 months. The professional athletes at the minor league and major league levels take closer to the one-year mark. … But at the high school and college levels, they do take a little bit longer because these young athletes don’t have the same rotator cuff strength that major league ballplayers have.

Q: What is the success rate of Tommy John surgery?

Dr. Oh: At the professional level, it’s reported anywhere between 82 to 92 percent. At the high school level, it is probably closer to 73 to 75 percent success rate of returning back to the previous level of activity.

Q: What are the three most common causes of a tear of the ulnar collateral ligament?

Dr. Thomas Gill (courtesy photo)

Dr. Gill: Probably the single biggest factor is how hard you throw. If you look at a lot of the people around the league who are throwing consistently 97, 98, 99 (mph) or certainly those who break 100, they’re at an extremely high risk of tearing their ulnar collateral ligament over time. The second (factor) is the mechanics of your throw. For people who just throw a huge amount of breaking pitches, their elbow is going to be under higher stress on the inner side. And then lastly, it’s the cumulative effects of throwing.

Q: Is tearing the ulnar collateral ligament something that happens in any other sport besides baseball?

Dr. Gill: It’s extraordinarily rare to have to do a Tommy John surgery on someone who is not a thrower or a baseball player. Certainly if you throw a javelin in track and field, that’s probably another activity where you see it a lot.

Q: Can the surgery make you a better pitcher?

Dr. Gill: That is probably one of the single biggest misconceptions about the surgery. I’ve actually had parents come up and say that they would like their son to get Tommy John surgery because it would help his performance. And the kid’s totally healthy. That’s an incredible piece of misinformation. There’s no reason to think that anything we do as surgeons is ever going to be better than what we were created with. The single biggest factor to people coming back and performing better is that for a lot of athletes, one of the reasons they tore their ligament to start with may be that they never really had a structured workout program before. After a Tommy John, if you want to have any chance at all of making it back, then you have to have a very structured, very specific rehab program that incorporates strength conditioning, mechanics. So part of it is that they are in better overall condition than they were before. They had to work on their mechanics again so they’re actually paying attention to how they are throwing.

Q: How do you treat a high school or college pitcher with a partial tear?

Dr. Gill: We don’t jump to surgery. I’ll usually shut him down for three months from throwing and then rehab him after that. To be a professional pitcher, more often than not, it would be extremely difficult to continue to pitch with an ulnar collateral ligament injury. But there are players in Major League Baseball that have a partial tear and they’re still fine. And we’ve actually had a couple come through over the years that had a complete tear and are still pitching in the major leagues. And how they’re able to do that is anyone’s guess.

_____________________________________

Bad technique, overuse harm teenage arms

By Christopher Smith
csmith@eagletribune.com

Frank Carey here in 2000 winning his 500th career game as a manager. (File photo)

North Reading High baseball coach Frank Carey says coaches put too much emphasis on pitch count.

“I would rather see a kid throw 200 pitches the right way than 90 the wrong way,” Carey has said before and continues to believe.

Carey let one of his pitchers, A.J. Richardson, pitch all 16 innings and throw 223 pitches in a 2-1 victory over Hamilton-Wenham in 2002.

But Carey, one of the winningest coaches in state history, said he has never had a pitcher miss a start with an arm problem or have arm problems later in his career due to a high pitch count in high school.

“You hear a story about a kid pitching a 12- or 14-inning game,” Carey said. “People today think that’s heresy. I don’t think there’s anything wrong with it.”

Many disagree. As an increasing number of Tommy John surgeries are performed on young pitchers, doctors say coaches must keep a pitch count for every game, week, season and year

The USA Baseball Medical & Safety Advisory Committee has issued pitch count guideline for pitchers ages 9 through 14. It recommends, for example, that 13- and 14-year-old pitchers not throw more than 75 pitches a game, 125 pitches a week, 1,000 pitches a season or 3,000 pitches a year.

But those guidelines are widely ignored, and arm problems are on the rise as the summer game becomes a year-round game and players play in multiple leagues, experts say.

“It’s almost like a youth epidemic now, where kids are throwing too much and playing on too many teams and they are playing year-round,” said Dr. Thomas Gill, chief of Massachusetts General Hospital sports medicine service and former medical director of the Boston Red Sox.

Carey’s philosophy

Frank Carey thinks other coaches put too much emphasis on pitch count. (File photo)

Carey actually thinks some young pitchers don’t throw enough.

“I go down to the Dominican (Republic), and I’ve been going there for 30 years vacationing and going to baseball fields seeing that culture, and those kids are throwing all the time,” Carey said.

“In fact, I have my grandson throwing now against the cement wall in the garage,” Carey added. “He’s 8 years old.”

Carey primarily has used a two-man rotation his entire coaching career. The North Reading Hornets typically play Tuesdays, Thursdays and Saturdays.

“Whoever I pitch on Tuesday is pitching on Saturday,” Carey said.

The secret, Carey says, is to train pitchers to pitch in a way that minimizes the stress on the elbow.

Carey has his pitchers throw striped baseballs during practice to help analyze the rotation and arm motion.

Carey does not let his pitchers throw sliders. He has them throw an overhand curve instead.

“When you throw a ‘slurve’ or a slider, now you’re putting pressure on the ulnar nerve,” he said. “It puts strain on that ulnar (collateral) ligament. … There are a lot of major leaguers who throw sliders. All of them have arm problems eventually.”

Another viewpoint

Methuen coach Dave Fabrizio, second from the right, when pitchers throw year-round, “the arm never gets a chance to recover.” (File photo)

Dr. Luke Oh, a sports medicine orthopedic surgeon at Massachusetts General Hospital and a Boston Red Sox team physician, said overuse is the most common cause of the ligament damage that leads to Tommy John surgery.

Of 18 local varsity baseball coaches surveyed by The Eagle-Tribune, 11 say they know of high school and American Legion coaches who use certain pitchers too often, putting them at risk of arm problems later.

In addition to limiting the number of pitches thrown in a game or season, the USA Baseball Medical & Safety Advisory Committee recommends that pitchers not play baseball more than nine months a year or engage in other sports that put stress on the elbow, like competitive swimming.

Methuen High baseball coach Dave Fabrizio said when pitchers throw year-round, “the arm never gets a chance to recover.”

“Within a season, throwing a lot is good for you,” he said. “It’s when they are throwing in December, throwing in January, these leagues that never end, that’s when the damage comes in.”

Gill said parents need to pay attention to make sure their kid isn’t being overused.

“It is completely important for parents to really be able to keep track of how much their son or daughter is throwing and to make sure that they’re controlling it and that the athlete is controlling what their workload is pitching,” Gill said.

HELPFUL LINKS TO ARM EXERCISES AND MORE:

Sports medicine doctors interviewed for this series said doing the correct arm conditioning exercises is essential to preventing arm injuries.

Arm strengthening exercises should be started as early as Little League. The first link is an injury prevention program of 10 exercises for Little Leaguers written by Red Sox head athletic trainer Mike Reinold.

Wrist and elbow strengthening and stretching exercises

Shoulder rotator cuff and scapular strengthening program

Strength training for the shoulder

Protecting young pitching arms

Guidelines from USA Baseball Medical & Safety Advisory Committee

Sports conditioning programs

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