"I'm Going to Alabama to See Dr. Andrews," Part 2
"I'm Going to Alabama to See Dr. Andrews," Part 2
Editor's Note:
James Andrews, MD, orthopaedic surgeon and founding member of the Alabama Sports Medicine and Orthopaedic Center (ASMOC), Birmingham, Alabama, is the avatar of sports medicine orthopaedic surgery.
His roster of patients comprises a who's who of professional athletes from every major sport in America (he recently operated on, for the second time, the throwing shoulder of New York Jets quarterback Chad Pennington).
Dr. Andrews is chairman and medical director of the American Sports Medicine Institute (ASMI) in Birmingham, Alabama, and a fellow of the American Academy of Orthopaedic Surgeons (AAOS).
In this second part of a 2-part interview, Dr. Andrews sat down with Medscape's Pippa Wysong to talk about injuries in young athletes, why the radar gun should be outlawed in the assessment of young baseball pitchers, the role that physicians must play in preserving the health and well-being of young athletes, and much more.
Medscape: What are some of the key areas of research at ASMI?
Dr. Andrews: At ASMI we've really devoted a lot of our research time and research monies during this new decade to trying to figure out what we can do about prevention of injuries in youth sports. We've been at least as interested in prevention as we have been in procedures and techniques.
The problem we have in orthopaedic surgery, and across the board in medicine in general, is that more research money is available for development of techniques and surgical procedures after the injury occurs than is available for prevention. Obviously, the most important prevention category is our kids. An injury early in life means a lifetime of potential problems, both in general health and in terms of orthopaedic problems.
Some orthopaedists don't know this, and there's research to support this, but a kid who has an injury to a major joint has a 5-fold increased risk for the development of degenerative arthritis in that joint regardless of how well we can treat it today. That's from a minor injury as a young athlete -- say, of the shoulder, the elbow, the knee, the hip, the ankle, regardless of how well it's treated. Problems may not show up early, but they show up later in the form of degenerative arthritis, and it comes on prematurely because of the injury.
Medscape: So is prevention as important as treatment? It sounds like you might say that preventing injuries is as leading-edge as any technology or innovation in sports medicine or orthopaedics.
Dr. Andrews: It's so important to try to control injury rates. Our nation has become obsessed with sports. I've talked to sophomore high school classes that visit during a career day. I talk about medicine, then ask how many of them want to be doctors. Most of them, both male and female, say they want to be professional athletes. There's nothing wrong with being a professional athlete, but for most of these kids that's a dream. And it's not worth pushing so hard in sports, before their bodies are mature, that they get a lasting injury.
Medscape: What should doctors tell parents who may be pushing their kids in sports?
Dr. Andrews: Generally, they're not bad parents; they just don't know about the risks. I'll have a 14-year-old kid come to my office who has hurt his elbow. I have a blackboard in the examining room, and I'll ask the kid to write his throwing history on it. Often it's a big bragging event. They talk about when they started playing, and all the leagues they've played in, and the championships they've won. I'll leave the room and give them plenty of time to list everything. When I come back in, I'll look at the parents and say, "Let me ask you all a question. Why do you think he's here seeing me?" And they don't have a clue. Then I'll point to the blackboard, and for the first time they realize what has really happened. And it sinks in. Most parents really want to do what's best for their kids, but they just don't know beforehand.
Medscape: What do you feel is the role of physicians in the area of preventing sports injuries?
Dr. Andrews: What orthopaedists are primarily interested in is what to do when injury occurs, how to fix it. But it's not the latest surgical procedure -- it's more about the prevention area, which is probably more important than surgery. What physicians can do is discuss the risk factors. They can do local interviews with the radio or the newspapers to try to get the message out to families, to grandparents and mothers and dads, and to coaches about what's happening out there.
Medscape: What is some of the research in this area that you've been behind?
Dr. Andrews: Here we've studied the real risk factors in youth sports, particularly the injuries related to youth baseball. Other youth sports have problems too, but baseball is the hot topic around the country right now. When I give lectures at different medical meetings, this is a topic that really gets the attention of doctors. It's about what's really happening out there, why it is happening, and what we can do.
Medscape: Is there an increase in serious injuries across the board in youth sports?
Dr. Andrews: Yes, there is an epidemic of increased injuries in youth sports across the board, with increases in everything from baseball to football, hockey, and more. Our research at ASMI has been primarily focused on the marked increase of injuries in youth sports at all levels of play. Mostly we've been involved with youth baseball -- that is, from high school level on down.
Medscape: Some of your research looking at injuries in young players doesn't bode well for their long-term health. Can you tell Medscape readers more about this?
Dr. Andrews: We published some studies on young baseball players who I performed the so-called "Tommy John operation" on -- ulnar collateral ligament reconstruction of the elbow. We studied players who were high-school-age and younger. We reviewed the follow-up of those players to see how well they did with having to undergo such major reconstruction at such a young age. These kids were also at a young development age for baseball, and there was the question of whether the procedure really worked at that young age, and whether or not these kids could get back to their sport and go up the ladder and play college -- or perhaps professional -- baseball.
Medscape: Are these young players able to get back into the game after such a major procedure?
Dr. Andrews: The big thing that we learned was that there's been a 5-fold increase in these injuries to the shoulder and elbow in high-school-age and younger baseball players since the year 2000. At least that's what our statistics show. We used to worry about the players -- primarily in what we called the Sunshine State -- in youth sports at all levels because the warm weather meant they could play year-round. But now it's not only Florida, California, Texas, Louisiana, Alabama, Georgia -- it's happening across the entire country. Even in areas with colder climates -- because kids can play sports indoors year-round. They're actually playing indoor baseball in small gyms, where the pitchers actually pitch and batters hit into nets. So now we're seeing the overuse problem occur in all of the states.
Medscape: What are the key risk factors for injuries?
Dr. Andrews: When we studied the risk factors associated with these increased injuries in youth baseball, guess what the number-one risk factor is? Year-round baseball. The second risk factor is seasonal overuse, which is often caused by kids playing more than one position during the season. Sometimes they get into a championship series and the best pitcher pitches a complete game on Friday night, then he pitches again on Sunday afternoon because it's the championship final game, so he's pitching back-to-back games with very little rest. Or they might play more than one position. What does this mean? That means your best pitchers, your best athletes, are the ones that are coming out incurring major injuries -- because of overuse.
The third risk factor -- believe it or not -- is the radar gun. There's so much emphasis now on velocity and throwing hard that these kids are hurting their elbows and their shoulders because they're trying to throw a 90-mile-per-hour fastball. There's too much emphasis on the radar gun and not nearly enough emphasis (as my good friend Hank Aaron with the Atlanta Braves has preached for years) on learning how to pitch safely. The safest throws for young kids to learn is strikes, as well as how to pitch around a batter. You need to decrease the importance of radar guns, or outlaw their use in high school and younger baseball events.
The fourth risk factor is throwing breaking balls at an early age. That is, throwing curve balls at an early age when bone structures are not mature. That risk factor is significant for both shoulder and elbow injuries. The fifth risk factor is poor mechanics. Young kids need to be taught proper mechanics.
Showcases are a problem too, and I've published on that. Injuries happen when kids go out to throw for professional scouts and maybe just had a big game the night before and are tired or just not in shape. They throw them off the mound as hard as they can. And there are a number of injuries that we are seeing associated with these 1-day events.
Medscape: Do these risk factors relate to anything that doctors can do?
Dr. Andrews: Prevention gets to be pretty easy once you understand the risk factors. We have recommendations, not only through ASMI but also through USA Baseball's Medical and Safety Advisory Committee (the governing body for all amateur baseball across the United States). Kids involved in an overhead-throwing sport need a minimum of 3 months during the year when they do not overhead throw. The idea is to prevent overuse. And to prevent seasonal overuse, we advise using pitch counts. We have more detailed recommendations from USA Baseball posted on our ASMI Web site: http://www.cstv.com/auto_pdf/p_hotos/s_chools/usab/genrel/auto_pdf/youth-injuries
Another issue is the breaking balls. Orthopaedic surgeons know that breaking balls should not be thrown until kids have gone through puberty and the bone structures are complete. Orthopaedic surgeons need to tell parents that kids shouldn't throw like this until they shave -- at least for the boys. That's a pretty simple recommendation for doctors to make.
When kids do start throwing breaking balls, and curve balls, they need to learn proper mechanics. Suggest to parents that they find a good, professional pitching coach and get special instruction, even video instruction, to learn proper mechanics. But advise them to be careful that any special instruction doesn't add on to what the kids are already doing -- you don't want overuse injuries arising as a result. A pitching coach needs to be smart enough to protect these kids from overuse. Coaches should be aware of the basic throwing-arm exercises that we use to prevent overuse and to keep the arm flexible and strong. Use the Throwers' Ten Exercises which are designed for the throwing arm. These exercises are good for both high-school and younger kids. They are listed on the ASMI Web site: http://www.asmi.org/SportsMed/throwing/thrower10.html
Orthopaedic surgeons and primary-care sports medicine doctors should have this information on hand and be an authoritative source. They have a lot of influence on these kids and their parents.
Medscape: You've trained quite a number of surgeons over the years -- over 250 surgeons, right? Are there any key messages for surgeons in the field, in addition to the prevention aspect?
Dr. Andrews: Education continues forever. Every month new things are coming out -- new devices, new types of instrumentation, new techniques. The problem we all have as orthopaedic surgeons is trying to keep up with the evolution of the technical advances. Postgraduate education is so very, very important for all orthopaedic surgeons at all levels and at all ages.
Editor's Note:
James Andrews, MD, orthopaedic surgeon and founding member of the Alabama Sports Medicine and Orthopaedic Center (ASMOC), Birmingham, Alabama, is the avatar of sports medicine orthopaedic surgery.
His roster of patients comprises a who's who of professional athletes from every major sport in America (he recently operated on, for the second time, the throwing shoulder of New York Jets quarterback Chad Pennington).
Dr. Andrews is chairman and medical director of the American Sports Medicine Institute (ASMI) in Birmingham, Alabama, and a fellow of the American Academy of Orthopaedic Surgeons (AAOS).
In this second part of a 2-part interview, Dr. Andrews sat down with Medscape's Pippa Wysong to talk about injuries in young athletes, why the radar gun should be outlawed in the assessment of young baseball pitchers, the role that physicians must play in preserving the health and well-being of young athletes, and much more.
Medscape: What are some of the key areas of research at ASMI?
Dr. Andrews: At ASMI we've really devoted a lot of our research time and research monies during this new decade to trying to figure out what we can do about prevention of injuries in youth sports. We've been at least as interested in prevention as we have been in procedures and techniques.
The problem we have in orthopaedic surgery, and across the board in medicine in general, is that more research money is available for development of techniques and surgical procedures after the injury occurs than is available for prevention. Obviously, the most important prevention category is our kids. An injury early in life means a lifetime of potential problems, both in general health and in terms of orthopaedic problems.
Some orthopaedists don't know this, and there's research to support this, but a kid who has an injury to a major joint has a 5-fold increased risk for the development of degenerative arthritis in that joint regardless of how well we can treat it today. That's from a minor injury as a young athlete -- say, of the shoulder, the elbow, the knee, the hip, the ankle, regardless of how well it's treated. Problems may not show up early, but they show up later in the form of degenerative arthritis, and it comes on prematurely because of the injury.
Medscape: So is prevention as important as treatment? It sounds like you might say that preventing injuries is as leading-edge as any technology or innovation in sports medicine or orthopaedics.
Dr. Andrews: It's so important to try to control injury rates. Our nation has become obsessed with sports. I've talked to sophomore high school classes that visit during a career day. I talk about medicine, then ask how many of them want to be doctors. Most of them, both male and female, say they want to be professional athletes. There's nothing wrong with being a professional athlete, but for most of these kids that's a dream. And it's not worth pushing so hard in sports, before their bodies are mature, that they get a lasting injury.
Medscape: What should doctors tell parents who may be pushing their kids in sports?
Dr. Andrews: Generally, they're not bad parents; they just don't know about the risks. I'll have a 14-year-old kid come to my office who has hurt his elbow. I have a blackboard in the examining room, and I'll ask the kid to write his throwing history on it. Often it's a big bragging event. They talk about when they started playing, and all the leagues they've played in, and the championships they've won. I'll leave the room and give them plenty of time to list everything. When I come back in, I'll look at the parents and say, "Let me ask you all a question. Why do you think he's here seeing me?" And they don't have a clue. Then I'll point to the blackboard, and for the first time they realize what has really happened. And it sinks in. Most parents really want to do what's best for their kids, but they just don't know beforehand.
Medscape: What do you feel is the role of physicians in the area of preventing sports injuries?
Dr. Andrews: What orthopaedists are primarily interested in is what to do when injury occurs, how to fix it. But it's not the latest surgical procedure -- it's more about the prevention area, which is probably more important than surgery. What physicians can do is discuss the risk factors. They can do local interviews with the radio or the newspapers to try to get the message out to families, to grandparents and mothers and dads, and to coaches about what's happening out there.
Medscape: What is some of the research in this area that you've been behind?
Dr. Andrews: Here we've studied the real risk factors in youth sports, particularly the injuries related to youth baseball. Other youth sports have problems too, but baseball is the hot topic around the country right now. When I give lectures at different medical meetings, this is a topic that really gets the attention of doctors. It's about what's really happening out there, why it is happening, and what we can do.
Medscape: Is there an increase in serious injuries across the board in youth sports?
Dr. Andrews: Yes, there is an epidemic of increased injuries in youth sports across the board, with increases in everything from baseball to football, hockey, and more. Our research at ASMI has been primarily focused on the marked increase of injuries in youth sports at all levels of play. Mostly we've been involved with youth baseball -- that is, from high school level on down.
Medscape: Some of your research looking at injuries in young players doesn't bode well for their long-term health. Can you tell Medscape readers more about this?
Dr. Andrews: We published some studies on young baseball players who I performed the so-called "Tommy John operation" on -- ulnar collateral ligament reconstruction of the elbow. We studied players who were high-school-age and younger. We reviewed the follow-up of those players to see how well they did with having to undergo such major reconstruction at such a young age. These kids were also at a young development age for baseball, and there was the question of whether the procedure really worked at that young age, and whether or not these kids could get back to their sport and go up the ladder and play college -- or perhaps professional -- baseball.
Medscape: Are these young players able to get back into the game after such a major procedure?
Dr. Andrews: The big thing that we learned was that there's been a 5-fold increase in these injuries to the shoulder and elbow in high-school-age and younger baseball players since the year 2000. At least that's what our statistics show. We used to worry about the players -- primarily in what we called the Sunshine State -- in youth sports at all levels because the warm weather meant they could play year-round. But now it's not only Florida, California, Texas, Louisiana, Alabama, Georgia -- it's happening across the entire country. Even in areas with colder climates -- because kids can play sports indoors year-round. They're actually playing indoor baseball in small gyms, where the pitchers actually pitch and batters hit into nets. So now we're seeing the overuse problem occur in all of the states.
Medscape: What are the key risk factors for injuries?
Dr. Andrews: When we studied the risk factors associated with these increased injuries in youth baseball, guess what the number-one risk factor is? Year-round baseball. The second risk factor is seasonal overuse, which is often caused by kids playing more than one position during the season. Sometimes they get into a championship series and the best pitcher pitches a complete game on Friday night, then he pitches again on Sunday afternoon because it's the championship final game, so he's pitching back-to-back games with very little rest. Or they might play more than one position. What does this mean? That means your best pitchers, your best athletes, are the ones that are coming out incurring major injuries -- because of overuse.
The third risk factor -- believe it or not -- is the radar gun. There's so much emphasis now on velocity and throwing hard that these kids are hurting their elbows and their shoulders because they're trying to throw a 90-mile-per-hour fastball. There's too much emphasis on the radar gun and not nearly enough emphasis (as my good friend Hank Aaron with the Atlanta Braves has preached for years) on learning how to pitch safely. The safest throws for young kids to learn is strikes, as well as how to pitch around a batter. You need to decrease the importance of radar guns, or outlaw their use in high school and younger baseball events.
The fourth risk factor is throwing breaking balls at an early age. That is, throwing curve balls at an early age when bone structures are not mature. That risk factor is significant for both shoulder and elbow injuries. The fifth risk factor is poor mechanics. Young kids need to be taught proper mechanics.
Showcases are a problem too, and I've published on that. Injuries happen when kids go out to throw for professional scouts and maybe just had a big game the night before and are tired or just not in shape. They throw them off the mound as hard as they can. And there are a number of injuries that we are seeing associated with these 1-day events.
Medscape: Do these risk factors relate to anything that doctors can do?
Dr. Andrews: Prevention gets to be pretty easy once you understand the risk factors. We have recommendations, not only through ASMI but also through USA Baseball's Medical and Safety Advisory Committee (the governing body for all amateur baseball across the United States). Kids involved in an overhead-throwing sport need a minimum of 3 months during the year when they do not overhead throw. The idea is to prevent overuse. And to prevent seasonal overuse, we advise using pitch counts. We have more detailed recommendations from USA Baseball posted on our ASMI Web site: http://www.cstv.com/auto_pdf/p_hotos/s_chools/usab/genrel/auto_pdf/youth-injuries
Another issue is the breaking balls. Orthopaedic surgeons know that breaking balls should not be thrown until kids have gone through puberty and the bone structures are complete. Orthopaedic surgeons need to tell parents that kids shouldn't throw like this until they shave -- at least for the boys. That's a pretty simple recommendation for doctors to make.
When kids do start throwing breaking balls, and curve balls, they need to learn proper mechanics. Suggest to parents that they find a good, professional pitching coach and get special instruction, even video instruction, to learn proper mechanics. But advise them to be careful that any special instruction doesn't add on to what the kids are already doing -- you don't want overuse injuries arising as a result. A pitching coach needs to be smart enough to protect these kids from overuse. Coaches should be aware of the basic throwing-arm exercises that we use to prevent overuse and to keep the arm flexible and strong. Use the Throwers' Ten Exercises which are designed for the throwing arm. These exercises are good for both high-school and younger kids. They are listed on the ASMI Web site: http://www.asmi.org/SportsMed/throwing/thrower10.html
Orthopaedic surgeons and primary-care sports medicine doctors should have this information on hand and be an authoritative source. They have a lot of influence on these kids and their parents.
Medscape: You've trained quite a number of surgeons over the years -- over 250 surgeons, right? Are there any key messages for surgeons in the field, in addition to the prevention aspect?
Dr. Andrews: Education continues forever. Every month new things are coming out -- new devices, new types of instrumentation, new techniques. The problem we all have as orthopaedic surgeons is trying to keep up with the evolution of the technical advances. Postgraduate education is so very, very important for all orthopaedic surgeons at all levels and at all ages.
