So thank you for having us today. This is more of making an argument for this group of athletes because I think this has been up until recently a largely ignored group of athletes. This is my disclosure, nothing relevant to this talk. So fast pitch softball is one of the fastest growing sports and most popular youth female sports in the United States and in the most recent publication up to two million players are registered with USA Softball and this has grown exponentially over the last ten years. So this is a very popular sport with a lot of athletes and the dogma has always been that the windmill pitch is safe. The problem is that there's a paucity of research that looks at the long term risks associated with the windmill pitch, particularly in comparison to the baseball pitch. So as a result there's an unregulated pitch count and games pitched in these athletes and I'll make the argument today that we need to be looking at this more. So if you look at the pitch count provided by ASMI, a seventeen to eighteen year old should pitch no more than a hundred and five pitches maximum of two games per week. That's about two hundred and ten pitches per week is the recommendation. If we look at fast pitch softball, tournament weekends, anywhere from nine to twelve games, three to four days per tournament and often these teams have one or two pitchers available for pitching, sometimes these athletes can throw up to nine hundred pitches in one weekend. Significant difference. And we looked at this at just a single study looking at tournament fatigue and pain scores and over the course of a single tournament, so when we measured their strength and fatigue and pain levels the first day, at the beginning of the day to the end of the day, the second day we measured them they did not recover their strength and their pain scores were higher. The third day they had stepwise progressed lower and if we assume that fatigue and pain is a precursor to injury then these patients or these athletes are at risk and we need to be looking a little bit better at how do we protect them. And as we know from other studies that fatigue changes the throwing kinematics and also puts them at risk for further injury. So looking at biomechanics, the arm speed of a windmill pitch is approximately twelve hundred and fifty degrees per second. The shoulder distraction stress averages about eighty percent of body weight with the maximum bicep activation at the nine o'clock position during the throwing motion and these forces are comparable to pitchers, baseball pitchers. If we look at the injury rates across all the softball players looking at high school versus college and shoulder and elbow injuries, if you look at these numbers it's pretty consistent that high school softball injury rates are similar to high school baseball injury rates and college injury rates between softball and baseball are very similar as well. But we're also seeing that the rates of injury are a little bit higher in the higher level athletes. Recently looking at all the literature we have a couple residents who just did this for us. The higher injury rates happen during competition rather than during participation in practice but practice volume also contributes. The injury rate in high school pitchers is over twice that of position players so the pitchers are getting injured at a higher rate. Looking at the injury rates, this first study, sixteen percent injury rate in pitchers compared to six percent in position players. Across all players those shoulder injuries accounted for about thirty percent, thirty-eight percent of all injuries. We looked at a group of select, single season select high school pitchers and position players and found that thirty-eight percent of the pitchers reported injury in a single select season and sixty-one percent of those were shoulder injuries. And this actually matches the data seen in the college literature with thirty-eight percent roughly of college pitchers reported injury during a single college season. So this is pretty consistent data. We went to look at some of these athletes and we tried to find normal scapular mechanics. We looked at about a hundred and fifty athletes at a pitching academy and the picture on the left is what we found most common. So very few of these athletes have normal scapular mechanics. We also have to look for other unusual injuries like the ulnar stress fracture. It's not uncommon to see stress fractures that look like nightstick fractures from the repetitive stress on the forearm. Next slide please. So this is a table taken from our paper in 2015 looking at injuries in pitchers. So if you notice on the left the majority of the injuries were shoulder pain. We did have a few back injuries, a few hip injuries, but the majority of the injuries were shoulder. If you also look at the time missed, some were not much time missed, but we had a fair number of kids who missed more than three weeks and a couple that missed the entire season. Next slide please. Whereas if you look at the position players, on the left the injury reported is much, much more diverse. You have wrist and back and thumb and hip and ankles and most of these injuries are occurring from base running, hitting, or fielding, not as many from throwing. Next slide please. When we look at the return to play in high school, so of all the injuries that have been reported in some of the studies, it is a pretty high return rate to play. So up to 90% to 93% no time lost. If you look at accumulation of some of the data, returning in less than one week was anywhere from 40% to 49%. Returning one to three weeks ranged from 33% to 40%. Longer than three weeks was 5% to 10%. And season ending injuries was anywhere from 2% to 13% depending on the study you looked at. And we're trying to focus on how do we prevent the season ending injuries or more importantly even the three weeks or longer injuries because that's not an insignificant loss of time for these athletes. So the current recommendations were recently published by AOSSM and the recommendations are that no more than 100 pitches per game or 140 pitches per day, no more than three consecutive days of pitching with two days of rest in between outings when possible. A lot of these tournaments don't allow that to happen. And unfortunately these recommendations have not universally been adopted by the competitive leagues and as of now there are not very good studies that show that it makes a big difference but this is where I ask the people in the audience who take care of these athletes that let's see if we can do a better job of getting these athletes safer. Thank you.

windmill pitching

fast pitch softball

long-term risks

pitch count limitations

shoulder injuries