How MLB Pitchers can Lower their Risk of Injury

Today is the Opening Day of the 2024 season of Major League Baseball (MLB) . When it comes to significant injuries on baseball teams, the pitching staff faces the greatest risk. Here are the 4 biggest reasons why season-ending injuries happen—and how they might be avoided in the first place.

Risk #1: Rushing return-to-play

Return-to-play can be delicate and rife with injury potential. For most pitchers, once they return to play, it takes a solid four to six weeks before they achieve the ability to perform at their best.?

In a regular season, there is a significant uptick of injuries in April. Although players are steadily improving in the pre-season, they often only unleash their full power when they play their first few regular season games, sometimes injuring themselves in the process.?

Some players who are concerned about an existing injury may work through it carefully in spring training. Once they face live batters in the regular season, their competitive spirit will drive them to pitch at their highest level.

What to do:

• Coaches and trainers need to work with pitchers to ease them into gameplay and prime shape. Ramping up takes time and trying to ramp too quickly can lead to injuries.
• During any pre-season training, teams would be wise to follow their previously successful schedule and routine for pitchers, which means that their progression to full performance will occur during the first month of the regular season.?
• Once seasonal play starts, the number of innings pitched may need to be limited based on a structured return to full effort.

Risk #2: Velocity

When it comes to pitcher injuries, velocity is the enemy. Increasing velocity of a throw is directly related to increased torque—or twisting—of the elbow, which is resisted primarily by the ulnar collateral ligament (UCL) on the inside of the elbow and the muscles of the forearm.?

Combining increased velocity with increased torque—and failing to buffer these appropriately with proper throwing mechanics and developed forearm muscles—can put so much force on the ligament that it tears, causing a season-ending injury. It makes sense that statistically fast-throwing pitchers (above an average of 93 mph) have the highest rate of injuries.?

Of course, from a game strategy point of view, fastballs can win games. But consistently throwing fast pitches can become a precursor to Tommy John surgery, a procedure to fix a UCL injury.

Unfortunately, this particular type of injury is increasingly common amongst teen pitchers who may have the strength to throw fast but have not yet mastered the technique to do so without putting too much pressure directly on their UCL. Or, if they’ve experienced success when they throw fast, they may try to do that in the beginning of a new season before their pitching mechanics are at their best—an almost certain prescription for injury.

What to do:

• Young pitchers should work on the ability to throw at least three different types of pitches so they can avoid the overload of throwing fastballs for the vast majority of their pitches. These can include a curveball, change-up, fastball and, if they're capable, a slider. Furthermore, not every fastball should be thrown at maximum effort.

Risk #3: Pitch counts

Overuse and fatigue lead to poor mechanics, which then places more pressure on the elbow and shoulder. That said, there has been increasing interest in the possibility that reducing pitch counts, which may allow only 3 to 4 innings of pitching per game, may reduce the risk of injury among starting pitchers.?

Statistically, injuries are sustained most commonly by starters, and after the first 30 pitches—especially if they are not mixing their off-speed pitches with maximum effort throws. There is very little room for error when pitching fastballs, so when fatigue sets in, the risk of injury rises significantly.

Interestingly, this study my colleagues and I worked on showed that as pitchers age, they throw more pitches per game, per season, and per year. They are also more likely than younger pitchers to violate pitch count recommendations. Older pitchers, however, tend to pitch with improved mechanics and velocity.

What to do:

• Coaches and trainers should be alert to signs of fatigue or mechanical issues at all times so that a player can be pulled pre-injury even when the player thinks they are doing well.?
• Pay special attention to younger MLB pitchers (those 20-25 years old) who may not be as sophisticated with their offseason training. Younger players need guidance to pace themselves and take adequate rest time.

Risk #4: Pitching a complete game (often)

Studies have shown that increased pitching workload—such as pitching a complete game—is a risk factor for injury. In MLB, pitching a complete game is becoming less common due to the average number of pitches needed to throw a complete game against increasingly talented hitters and the growing awareness about overuse injuries in baseball pitchers.

A 2018 study I was involved in found that 74% of pitchers who threw a complete game during the study period spent time on the annual injured list (IL), while only 20% of those who did not throw a complete game spent time on the IL. Meanwhile, pitchers who threw a complete game were significantly more likely than controls to spend subsequent seasons on the IL. The greatest risk was being a high-volume pitcher who throws a significant number of innings per season.

What to do:

• Limit starting pitchers to 30 pitches per game.?
• If starting pitcher is limited to 30 pitchers per game, rest pitchers for three days (rather than five to seven days).
• If starting pitcher is limited to 30 pitchers per game, allow pitchers to pitch every third or fourth game.?
• Stack your starters, scheduling two per game before the middle relievers and closing pitcher.

How to change baseball

After considering the main risks that contribute to pitcher injuries, it begs the question: Should pitching rules be changed to preserve our pitchers??

For a game as traditional and historical as baseball, change can be met with great resistance. But in 2020, MLB wisely increased the number of pitchers allowed per team to a maximum of 14. Perhaps in the future, the MLB will make further changes to ensure the long-term health of its pitchers. Ultimately, pitchers would play fewer innings, more often.?

In the meantime, the pitching risks can be managed by easing back into play, respecting the need for excellent biomechanics when throwing fastballs, reducing pitch counts, and minimizing overuse by avoiding pitching complete games. Batter up!

Many thanks to Dr. Brandon Erickson for his contributions to this article. ??

I've spent my career in the pursuit of excellence for my patients by pioneering new approaches to shoulder replacement surgery and developing advanced orthopaedic implants and surgical procedures supported by cutting-edge research and patient-focused outcomes. Learn more about my practice and research on my website.