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  • Pitching a Baseball Is Not Good for the Arm

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      Health Talk: Pitching and Other Sports Injuries

    Abigail Trafford
    Host: Abigail Trafford
    Hosted by The Post's Health Editor
    Tuesday, April 6, 1999

    Dr. Benjamin Shaffer, director of sports medicine at Georgetown University Medical Center and team doctor for the Georgetown Hoyas sports teams, talked about pitching injuries for "Health Talk," a weekly discussion with Abigail Trafford, The Post's Health editor.

    Read the transcript below.

    Abigail Trafford: Hello and welcome to Health Talk. Our subject is sports--sports medicine and sports injuries. The baseball season has started. Do you know what a pitch does to your arm? Our guest today is a sports medicine expert, Benjamin Shaffer of Georgetown University Medical Center and team doctor for the Hoyas. Send us your questions.


    Abigail Trafford: Our cover story today looks at the throw in baseball. Just why is the pitch such an extraordinary feat? And potentially hazardous to the arm?

    Dr. Benjamin Shaffer: The pitch is an extraordinary feat because it requires enormous recruitment of forces to hurl an object at over 100 miles an hour. Although humans have been built in a way to allow for throwing objects at such high rates, and in that respect, is an expected part of our armamentarium, to be able to do so reliably, accurately and repetitively is an abnormal and unusual activity. Due to the high stresses involved in throwing, wear, break down and stress related injuries to the shoulder girdle and arm are inevitable, even in highly-conditioned and trained athletes.


    Fairfax, Virginia: What, in laymen terms, is Tommy John surgery? What sort of arm injury is that and are what are the chances for a pitcher to bounce back from it?

    Dr. Benjamin Shaffer: The Tommy John procedure was devised by Frank Jobe, an orthopedic surgeon in Los Angeles, and first performed on this athlete as a salvage effort to return him to play. At the time, there were no alternative surgical procedures to allow return of a throwing athlete (ie pitcher) to activity once they had developed insufficiency of the medial collateral ligament of the elbow. So the answer to your question is the Medial Collateral Ligament is the structure which is over the medial (inside near the funny bone) aspect of the elbow. IT is usually injured from an acute forceful throw such as in javelin throwing or with repetitive throwing such as in baseball. Expect for these sports, it is a rare injury. Treatment usually requires surgery.


    Arlington, VA: How much knee pain is too much pain? Often when I use the cross trainer, stair master or run I experience some discomfort in my left knee. Not enough to keep me from working out, but is this a warning sign of troubles to come? I currently lift weights to keep the muscles around my knee stable, is there anything else I can do?

    Abigail Trafford: Ben, Everybody who exercises asks this question. You're supposed to work through the pain, no pain, no gain, but you're not supposed to work out in pain. What's the answer?

    Dr. Benjamin Shaffer: HOw much pain is too much pain is a good question, and to some degree is variable, depending upon your pain threshhold, goals, etc. But in general, mild discomfort that is tolerabe during the activity, and that generally subsides within a few hours of the exercise is probably ok. When pain is persistent, ie does not go away within a few hours but instead takes days, or when the pain is accompanied by other symptoms such as "locking up" (where the knee actually gets stuck), or with visible swelling, may suggest a more significant problem. IF symptoms are mild but continue to interfere with your activity, then evaluation at some point may be reasonable, just for your peace of mind.


    ALexandria, VA: I'm 29 y.o female and am concerned about my knees. When I squat or walk down stairs I have slight pain, but the real problem is the noise - sounds like someone's crinkling a bag of chips in both knees. My knees crack and pop very audibly. They're also sore after I sit for a long time.

    I jog and play recreational soccer several times a week with slight pain, although I sometimes wear a patellar stabilizer because it seems to help the pain. Am I going to have big problems with my knees as I age? Is there anything I can do to head this off at the pass?

    Thanks.

    Abigail Trafford: We hear that knees are a real weakness in women. Why is this? What advice can you give.

    Dr. Benjamin Shaffer: Your question is a good one and one of the most frequently asked. The noise that the knee can make can be disquieting and unsettling. But fortunately, most of the time, it has no significance and does not herald the inevitable decline of knee function or onset of arthritis. Most of the time, discomfort in the front of the knee, somewhat generalized, often in both knees, and related to prolonged sitting, standing or stair-climbing, worsened with squatting, suggests mild irritation of the patellofemoral joint, the articulation between the patella (kneecap) and femur (thigh bone). Grating sensation usually reflects small bands of soft tissue (known as "plica") which are located within the knee in everyone to variable degrees, and which when the knee cap passes over, "snap" or "pop". When this happens several times in sequence it can feel like grating or clicking. Unless associated with significant pain or inabiltiy to participate in activity, this symptoms is usually ignored. Rarely do the cartilage surfaces actually become rough and may cause the grating. This condition is known as "chondromalacia" or softening or irregularity of the cartilage.

    With respect to women, this may be somewhat more common in women, and has to do with the alignment of the legs due to a slightly broaded pelvis and a different angle of patellar tracking. But women and men have the same response to treatment, which usuallyl involves specific strengthening exercises to optimize function of the quads (especially the medial or innner aspect known as the VMO) and sometimes to use devices (tape, patellar sleeve) to decrease the excursion of the patella. Modifying activity by decreasing jumping, running and hilly terrain is also helpful.


    McLean, VA: I am a 25 year old female. Last summer I trained for my first Marathon, and after a few months and many training runs, I developed a problem with fluid buildup behind both of my knees- I saw a sports massage therapist twice a week who worked the fluid out, and instructed me on how to adjust my stride to keep it from happening. As this spring approaches and marathon training will resume, do you have any tips for preventing that type of knee pain as I progress in my training? I will be without the services of the massage therapist this year. Many Thanks-
    JH

    Dr. Benjamin Shaffer: Congratulations on getting back up on that horse! That's a fun marathon and may be particularly good for you if you have any patellofemoral problems (sounds like you might if you have discomfort in the front of the knees) because it is relatively flat. My suggestion would be to progress gradually in your training, consider the use of an anti-inflammatory such as Motrin or Alleve (if you have no history of GI upset, ulcer, pregnancy, other reaction or problem with other medication) for short periods. Probably modifying your activity when and if they become symptomatic would be reaonsable and you still have plenty of time to get a good base. Bottom line, if symptoms develop, you may want to consider seeing someone to determine the cause of the "fluid" build-up. But if massage treatment was effective, my guess is that you may do ok. GOod luck!


    springfield va: is it true that dairy products help with sore muscles?

    Abigail Trafford: I hope this is true, but. . . Ben, what about this?

    Dr. Benjamin Shaffer: I must express my ignorance on this theory. I am not aware of scientific evidence of studies that have demonstrated a particular benefit other than having a normal calcium level, which of course dairy products do have.


    Washington, DC: Recently, I played a game of pretty intense flag football, and the next day, I was so sore I could hardly walk. My body was not used to using those muscles. It has taken more than 3 days for me to feel better. My question is, what is the best thing to do for soreness? Hot baths? Advil? Rest?

    Abigail Trafford: We are always told not to play sports vigorously if we're not in shape. But who can resist being a weekend warrior? I love to play sports on the weekend. Then I'm sore. It's not fair. What's your advice, Ben.

    Dr. Benjamin Shaffer: I'd tell you all the tricks for avoiding being a weekend warrior but that would put me out of business. In all seriousness, the things you suggested, rest, anti-inflammtory and use of a jacuzzi or moist heat seem to be the most effective strategies for the kind of delayed onset muscle soreness you developed.
    Avoiding this problem altogether would be nice, but unfortunately, our work, responsibilities and weather changes invite this problem every year. The best way to avoid being the weekend warrior is to space it out over the week, not just the weekend. Abusive activity all crammed into one day is an invitation not just for soreness but for potential injury. Attention to warming up (bike, walk), stretching and then gradual introduction to actitity, and not over-doing it, seems to be the best advice I can give you.


    Washington, DC: I have a friend who's had a shoulder problem for a long time. He has a hard time lifting his arm above a 90 degree angle, because he has so much pain and weakness in his upper arm and shoulder. He continues to lift weights and even does the shoulder press machine--gritting his teeth all the while. I've told him that pain is bad and he should work on his range of motion instead of trying to push his shoulder beyond its capacity. Any suggestions for exercises?

    Abigail Trafford: Ben, I once had a frozen shoulder and it was the most awful pain. Finally--with some physical therapy--it went away. How much of a problem is the frozen shoulder? And then what about this viewer's friend. What is his problem?

    Dr. Benjamin Shaffer: I would agree with you that your friend might be better served with working on his range of motion rather than strength. There are a number of potential reasons that he may have restriction in his overhead motion, including actual restriction due to stiffness or frozen shoulder, or limitation due to pain. Stiffness is uncommon in younger individuals, and most commonly reflects arthritis. Frozen shoulder is a specfici entity in which the shoulder becomes progressively stiff and restricted, and most commonly occurs in women in their forties and fifties and is painful. Other problems that can prevent overhead motion due to pain include rotator cuff tendonitis, tendon injuries, AC arthritis (the joint between the collar bone and shoulder blade), and injuries to the structures inside the shoulder.
    He may need to consider evaluation if his pain is so severe as to prevent his overhead movement.


    Fairfax Station, Va: What weight lifting do you recommend for little leaguer pitchers, ages 11 and 12, to help build arm strength and to increase the speed of their pitches.

    Abigail Trafford: Do kids of this age face special risks? Their bones aren't fully grown. Does the pitch put a lot of strain on a growing arm? What's good advice for parents who want their children to play ball--and play to win--and not get injuries?

    Dr. Benjamin Shaffer: I appreciate the question about kids, particularly little league athletes.
    First remember that kids are not little adults, and they in particular have growth plates that place them at risk of injury from repetitive activities. Pay attention to their symptoms of pain or weakness or inaccuracy and give them a rest. Specific guidelines have been developed to decrease the incidence of little league injuries, with demonstrable results. The number of pitches little leaguers can throw is specified clearly according to guidelines enumerated by the Little Leauge Organization. They may well have specific recommendations about weights, but I am sorry that I am unable to quote them for you now. If you want to contact me separately I'll be happy to help you follow this up.


    Arlington, Virginia: About a month ago, I tore my quad muscle and partially dislocated my knee cap in my left leg. I was given anti-inflamatory pills to reduce the swelling and put in a knee imobalizer. After about a week and a half, the swelling subsided but not entirely. Thus, I am to undergo an MRI exam. Given the fact that swelling is still persistent, I get sharp pains from time to time inside and around the knee, and my leg feels a little unsteady to walk on, what would be your prognosis? Did I do more damage besides tearing the quad and dislocating the knee cap? Will surgery be required? What kind of rehab will I need and for how long? Will I be able to play sports like soccer and basketball -not on a professional basis- again? Will I even recover fully or will my performance not be the same in terms of athletics? What are the long term effects of such an injury in my old age? Thank you very much for all of your time and best wishes.

    Abigail Trafford: Oh, those knees!

    Dr. Benjamin Shaffer: SOrry to hear about your knee
    Disloction of a knee cap is a painful and as you know debilitating event. It is not unusual to continue to have some symptoms. The usual treatment (assuming this in fact IS your diagnosis) is immobilization for three weeks, followed by a rehabilitation program. The fact that you have swelling still is expected and does not necessarily reflect anything more worrisome. You need to get into a good rehab program after the immobilizer. The biggest problem with this condition is the risk that it will happen again, which is best avoided through a specific exercise program. Your doctor can help you arrange to be seen and cared for by a good therapist. The prognosis is otherwise good.


    Ridgefield, CT: I have a question about a common injury which occurs in baseball players as well as in many other sports. I suffered a herniated disc -L5-S1-as a rower for Georgetown in 1990. I was fine until last year when a rigorous yoga class sparked symptoms such as back pain as well as sciatica, numbness, and weakness in my left leg. Today, the pain is gone, but after much physical therapy, my left leg still feels "different". What type of rehab do you recommend to allow me back into sports with minimal relapses.

    Dr. Benjamin Shaffer: Lumbar problems are indeed a common athlteic problem, and particularly in rowers. Given that your symptoms have subsided what I recommend is a good program to help strengthen the muscles that contribute to your normal posture and activities. Most people who develop symptoms have problems with their trunk musculature, the abdominal obliques and paravertebral muscles of the lumbar spine. Definitive treatment invovles strengthening these muscles in what is called a "Lumbar Stabilization" program. THere are a number of good books out there describing exercises for the back, but if you have already had a documented disc, with numbness and weakness, I would suggest you contact your primary care physiciain or orthopaedist and see if they cannot hook you up with a good physical therapist who can oversee this program for you.
    Good luck and GO HOYAS!


    Washington, D.C.: What are your thoughts on chiropractic medicine? I visited one for an extended period about 10 years ago and he did a world of good for my lower back and for my neck, which seemed to be causing migraine headaches. I now am having some cramping and muscle pain in my lower back again, and am thinking of going back. Given that back problems are so difficult to cure, what is my best option? Is physical therapy a better answer?

    Abigail Trafford: Several years agao, a federal panel endorsed chiropractic medicine for the treatment of lower back pain. How can people decide when--or whether to consult a chiropractor?

    Dr. Benjamin Shaffer: THis is a very good question and I suspect that the answer is most likely determined by whom you ask. Certainly there are some excellent chiropracters who provide defitinitive "hands on" care. Conversely, if you have symptoms, like the most recent writer, that include possible numbness or weakness, or certainly if you have any problem with bowel or bladder symptoms, then you are probably best advised to see a physician (medial doctor). Physical therapists are also extremely helpful in providing definitive treatment of lumbar spine as well as other disorders, and do so with local "modalities" (Heat, electrical stim, ultrasound, massage), and motion and strength exercises. Conversely, chiropractic medicine often involves more manipulation for treatment. They each have their advantages, but otehr then these superficial remarks, I'm not able to better sort out what you should specifically do.


    Fairfax, VA: Several months ago, I accidently snagged my pinky toe on a chair and figured the broken toe would heal by itself. However, I continue to have pain along the outer ridge of my foot, where the pinky toe meets the foot. This is especially painful when I pronate while running. Any thoughts for getting this problem completely healed?

    Abigail Trafford: Long ago I broke my big toe--playing soccor in a field. I kicked a buried tree stump along with the ball. The pain was horrible. But I learned that toes are very difficult. What advice do you have for this viewer?

    Dr. Benjamin Shaffer: These can be nagging and aggravating injuries. Perhaps you did not break the toe, but rather tore some of the soft tissues around it (which may take longer to heal). On the other hand, if you did break it (known as a fracture), perhaps it has not healed and may require treatment.
    It's quite possible that even after examining you and taking X-ray, you may need nothing more than a simple device (orthotic or tape) to insert into your shoe to make you more comfortable. I would recommend you see someone you trust to evaluate your foot. THis can be either a podiatrist that you have familiarity with, or an orthopaedist who has expereicne with foot and ankle problems.


    Okinawa, Japan: What causes occasional pain in the knee while running? Sharp pains in the joints, one knee only, feels like bone on bone. No previous injuries to the knee. The knee is stiff and sore a few days after the run. Pain only occurs if I run over 3 miles. Age 38.

    Abigail Trafford: The knee again!

    Dr. Benjamin Shaffer: Thank you for your question.
    I am at a bit of a loss to tell you definitively what the diagnosis without the benefit of examininng your knee. Telemedicine isn't compleltely here yet, but some general comments I hope will help you.
    Soreness and stiffness after activity is common and may not be due to any serious malady at all. But if it continues and you want to maintain activity, and particularly if you feel "bone on Bone" contact, you may want to consider having your knee evaluated to ensure there is nothing structurally wrong. Having said that, most problems like this turn out to be nothing identifiable.


    Fairfax, VA: I've just started running-jogging -about a year go- and I've been trying to figure out why I get cramps -usually on one side of my stomach, alternating- sometimes. When I get them, I have to stop b-c it hurts so much -annoying!-

    I've figured out that it happens more when I'm doing walking-jogging intervals than when I just warm up and run. But a lot of times it happens when I've been jogging for 30-35 minutes and then I take a walk break. When I start jogging again in 5 minutes, CRAMPS!

    Why do cramps happen? What are the likely causes? What can I do?

    Abigail Trafford: I was told as a child that I would get cramps if I ran around after eating. Is there any truth to that? And what about the viewer's problem? What can people do about cramps if they get them while they're running or playing in a game?

    Dr. Benjamin Shaffer: I am answering you more out of sympathy and recognition of the frustration as a fellow runner rather than an educated individual about cramps. There are indeed many theories about cramps, including not doing activity after eating. It sounds as though you have wisely identified the pattern that is associated with cramping, and though it sounds dumb I would recommend that you take that into consideration and run accordingly to avoid situtations that provoke cramps in you. I'm not sure who I could recommend you see about this as it is not within the purvue of any one particular specialist. Perhaps some athletic trainers for track teams are aware. Avoid dehyrdation in warm weather and consider salt intake (tablets) when it is particularly hot and you are losing lots of electrolytes.
    Finally, avoiding runner after eating is probably a good idea, but it is variable. I knon some people who are able to eat and then exercise without problem and others who get cramps every time. KNow you own body is probably the best advice.


    Tysons Corner, VA: In early January I fractured the inner bone in left my wrist. Although the injury has healed, I still have lingering tightness and limited movement in my wrist, particularly on the outside of the wrist -opposite where the fracture occured- Perhaps a touch of tendonitis? My Orthopedic Dr. did not give me very many pointers on what exercises will strengthen it and restore full movement to the wrist- can you give me some tips? Many thanks...

    Dr. Benjamin Shaffer: The specific exercises depend on the nature of the injury. In general, stretching (using your opposite "good" hand) in different planes, followed by use of elastic tubing or weights for strengthening would the treatment rendered by a therapist. If you continue to be symptomatic, perhaps you should contact your md and advise him/her that you would like to either be re-evaluated for the prospect of visiting a therapist or being referred directly. Good for you that you want to make a complete recovery!


    Silver Spring, MD: In February I strained my periformis on the left side which made walking difficult and painful. Running impossible. As the pain in the glutes diminish, I developed bad sciatica and pain in my groin muscles. Why the groin and sciatic pain?

    Dr. Benjamin Shaffer: I'm not sure what the diagnosis is. HOw did you do it? Was it an acute "pull". MOst of the time, theses problems occur as a consequence of strain the hamstrings, which attach in the ischial area (near where your buttocks meets your thigh), where the sciatic nerve and piriformis are located. This usually requires a period of rest, anti-inflammatory, gentle stretching, strengthening and gradul return to activity. You may want to consider seeing a physician for definitive diagnosis and/or PT referral if your symptoms persist.


    Rockville, MD: Here we go with the knees again :- I have been diagnosed with Patello-femoral syndrome. My case is interesting in that my knee is almost on the inside of my leg! I have been doing the exercises recommended by my doctor and have started a daily walk of about 1.5 to 2 miles -it takes about 30 to 40 mins-. I still get pain in my knee, but find that Advil or Ibuprofen helps. Am I putting myself at higher risk for surgery by walking? I would really like to start running again. Any good recommendations on knee support?? Thanks :-

    Dr. Benjamin Shaffer: I'm not sure what you mean by your knee being "on the inside of my leg". In general, walking is not a problem and does not put you at risk of significant problems. I like the neoprene sleeve with a cut out for the patella as a standard type brace if you're looking for a little support and have some patellar problems.


    Washington, DC: I am 31 and female, in the
    process of gearing up for my
    first marathon. Ever since a 3-day episode of inflammation
    in my left Achilles tendon, I have had intermittent pain
    if I put too much stress on the tendon. Running more is starting to exacerbate it again. Do you have any suggestions how to manage this -other than rest, ice, stretching- while still continuing to train? My overriding objective is to be able to run increasing amounts of miles without rupturing the tendon and-or having constant pain. Any ideas?

    Dr. Benjamin Shaffer: YOu may have significant inflammation in your tendon or tendon sheath and they key is to stop running and get evaluated to see if tehre is anything else that can be done. The only thing that may help that is easy that you've not mentioned would be the use of a small heel lift, perhaps 1/4 inch in each shoe to decrease the strain in the tendon, but that may not be enough. You may want to have the tendon evaluated rather than ongoing frustration.


    Washington, DC : I'm 44 -male- and until almost 4 years ago I ran 3-7 miles every other day -or more often-. In the 1995 G'town 10K I developed tendonitis in my right foot, and since then running has been too painful to do. Frankly just walking aggravates the problem. I've seen doctors -- taken anti-inflammatories and even flexeril -- all to no avail. I want to run again. What do you suggest?

    Dr. Benjamin Shaffer: I'd suggest getting a diagnosis!
    Despite seeing "doctors" it doesn't sound as though you've been left with any specific diagnosis, which of course would permit determination of what if anything you ought to do about it. It is not "normal" to have to give you running at your young age, unless there is some particular reason!


    Fairfax Station, VA: How is it that someone like Cal Ripken can avoid serious injury for an entire career and others seem chronically plagued by what seem like bizarre injuries? It can't be all attributed to luck, can it?

    Abigail Trafford: What about luck?

    Dr. Benjamin Shaffer: As we say in medicine, "Better be lucky than good". It does seem true that in some cases, if it weren't for bad luck, they'd have no luck at all. And to some degree that is obviously life. But there is some control over luck, which has also been defined as when effort meets opportunity. As in the case of the "weekend warrior" being smart, returning only after warming up, stretching out, gradually engaging in activity, maintaining a good level of overall fitness and conditioning and avoiding "overdoing" it are all caveats that great athletes like Cal have in common.


    St. George, Utah: I have three children that play sports. We have had several injuries-surgeries and would like to prevent future ones. I have several questions for you. My 14 year old son plays Little League baseball. They do not have the protective face gear on their batting helmets. How do you feel about that? Do you see many face injuries at that level of play? My son also plays a lot of golf. What can we do to prevent back injuries that are so common with that sport?

    My last question is about my 17 year old daughter. She had ACL surgery last year from a basketball injury. Do you feel that girls are more prone to ACL problems? Do you think that the female athlete should train and prepare any differently to prevent such injuries? Thanks!

    Dr. Benjamin Shaffer: Since I don't take care of little leaguers at the moment I must say I'm not aware of how big a problem it is to not have face protection, but other than the catcher, I'm not sure how necessary it is.
    With respect to the back, maintaining good abdominal tone is the key to back longevity. Abds strength is the key
    Finally with respect to your daughter, ACL injuries in the young high school and college athelte have been shown in a number of studies to be more common in women than men, and most likely this reflects smaller ligaments, although many other theories abound.


    Rockville, MD: Me with the kneecap on the inside of the leg! What I mean is that when I stand with my foot pointing straight out like it is supposed to, my right kneecap is pointing to my left leg instead of straight out like it is supposed to!

    Dr. Benjamin Shaffer: Thanks for the additional information. It doesn't sound like anything that puts you at risk of worsening. I would wear a patellar sleeve if that helps you and walk galore, unless it causes significant symptoms.


    FAIRFAX, VA: HAVING PLAYED BASKETBALL FOR WHAT HAS SEEMINGLY BEEN ALL OF MY LIFE, I HAVE TENDONITOUS IN BOTH OF MY KNEES. CURRENTLY, I AM LOOKING FOR EXCERCISES THAT WILL STRENGTHEN MY KNEES WITHOUT DAMAGING THEM ANY FURTHER. WHAT DO YOU SUGGEST?

    Dr. Benjamin Shaffer: Strengthening the quads is best done in the terminal thirty degrees, which permits strengthening without overloading the joint. These are called "short arc quads" exercises and are the best exercise to strenghten the muscles without aggravating the joint.


    Washington, D.C.: I started running about a year ago and I haven't had any problems until recently. I now have shin splints. I bought new running shoes but that hasn't helped. What can I do to get rid of shin splints? I don't want to have to take a long break from running. Thanks.

    Dr. Benjamin Shaffer: YOu may have to take a break from running.
    Get your alignment looked at to see if you are a "pronator" which may contribute to your shin splints. If you are, orthotics may help.


    Abigail Trafford: Thank you Ben very much. And thank you all for sending us your questions. Play well--play safely.


       
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