Baseball and Softball abstract

17
POLICY STATEMENT Baseball and Softball abstract Baseball and softball are among the most popular and safest sports in which children and adolescents participate. Nevertheless, traumatic and overuse injuries occur regularly, including occasional catastrophic injury and even death. Safety of the athlete is a constant focus of attention among those responsible for modifying rules. Understanding the stresses placed on the arm, especially while pitching, led to the institution of rules controlling the quantity of pitches thrown in youth baseball and established rest periods between pitching assignments. Similarly, eld maintenance and awareness of environmental conditions as well as equipment mainte- nance and creative prevention strategies are critically important in mini- mizing the risk of injury. This statement serves as a basis for encouraging safe participation in baseball and softball. This statement has been en- dorsed by the Canadian Paediatric Society. Pediatrics 2012;129:e842e856 INTRODUCTION The pediatrician needs to have an understanding of baseball and softball. This will allow the pediatrician to offer appropriate counseling and guidance to the many boys and girls, their parents, and members of the sporting community who participate in baseball and softball each year. Baseball is one of the most popular sports in the United States, with an estimated 8.6 million children ages 6 to 17 participating annually in or- ganized and recreational baseball. 1 Although baseball is a relatively safe sport in comparison with many other athletic activities, highly publicized catastrophic impact injuries from contact with a ball or a bat frequently raise safety concerns. 2,3 These incidents, as well as the high frequency of shoulder and elbow injuries resulting from overload and overuse, pro- vide the impetus for this review and new guidance to reduce injury risk and improve safety in baseball for 5- to 18-year-old participants. This policy statement replaces the previous statement written in 2001. 4 This statement has been endorsed by the Canadian Paediatric Society. Beginning in the early 1990s, epidemiological and injury surveillance research in baseball and softball intensi ed. Data from these scientic efforts paved the way for organized baseball to create medical advisory committees, which generated policies designed to reduce the risks of injury in baseball and softball. Advances in equipment also continue to offer new opportunities to make the game safer for youth athletes; similarly, the dissemination and use of automatic lightning detectors (which produce a clear and loud warning signal) and automated external debrillators (AEDs) provide additional means of reducing catastrophic events on the baseball eld. 5,6 Moreover, organized youth baseball coaches, ofcials, and administrators must remain knowledgeable and COUNCIL ON SPORTS MEDICINE AND FITNESS KEY WORDS balls, bats, commotio cordis, elbow, equipment, helmets, injury, pitch count, safety, shoulder ABBREVIATIONS AEDautomated external debrillator CPSCConsumer Protection Safety Commission NEISSNational Electronic Injury Surveillance System NOCSAENational Operating Committee on Standard for Athletic Equipment UCLulnar collateral ligament This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have led conict of interest statements with the American Academy of Pediatrics. Any conicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reafrmed, revised, or retired at or before that time. www.pediatrics.org/cgi/doi/10.1542/peds.2011-3593 doi:10.1542/peds.2011-3593 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2012 by the American Academy of Pediatrics e842 FROM THE AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Dene the Child Health Care System and/or Improve the Health of all Children by guest on January 28, 2019 www.aappublications.org/news Downloaded from

Transcript of Baseball and Softball abstract

Page 1: Baseball and Softball abstract

POLICY STATEMENT

Baseball and Softball

abstractBaseball and softball are among the most popular and safest sports inwhich children and adolescents participate. Nevertheless, traumatic andoveruse injuries occur regularly, including occasional catastrophic injuryand even death. Safety of the athlete is a constant focus of attentionamong those responsible for modifying rules. Understanding the stressesplaced on the arm, especially while pitching, led to the institution of rulescontrolling the quantity of pitches thrown in youth baseball and establishedrest periods between pitching assignments. Similarly, field maintenanceand awareness of environmental conditions as well as equipment mainte-nance and creative prevention strategies are critically important in mini-mizing the risk of injury. This statement serves as a basis for encouragingsafe participation in baseball and softball. This statement has been en-dorsed by the Canadian Paediatric Society. Pediatrics 2012;129:e842–e856

INTRODUCTION

The pediatrician needs to have an understanding of baseball and softball.This will allow the pediatrician to offer appropriate counseling andguidance to the many boys and girls, their parents, and members of thesporting community who participate in baseball and softball each year.

Baseball is one of the most popular sports in the United States, with anestimated 8.6 million children ages 6 to 17 participating annually in or-ganized and recreational baseball.1 Although baseball is a relatively safesport in comparison with many other athletic activities, highly publicizedcatastrophic impact injuries from contact with a ball or a bat frequentlyraise safety concerns.2,3 These incidents, as well as the high frequency ofshoulder and elbow injuries resulting from overload and overuse, pro-vide the impetus for this review and new guidance to reduce injury riskand improve safety in baseball for 5- to 18-year-old participants. Thispolicy statement replaces the previous statement written in 2001.4 Thisstatement has been endorsed by the Canadian Paediatric Society.

Beginning in the early 1990s, epidemiological and injury surveillanceresearch in baseball and softball intensified. Data from these scientificefforts paved the way for organized baseball to create medical advisorycommittees, which generated policies designed to reduce the risks ofinjury in baseball and softball. Advances in equipment also continue tooffer new opportunities to make the game safer for youth athletes;similarly, the dissemination and use of automatic lightning detectors(which produce a clear and loud warning signal) and automated externaldefibrillators (AEDs) provide additional means of reducing catastrophicevents on the baseball field.5,6 Moreover, organized youth baseballcoaches, officials, and administrators must remain knowledgeable and

COUNCIL ON SPORTS MEDICINE AND FITNESS

KEY WORDSballs, bats, commotio cordis, elbow, equipment, helmets, injury,pitch count, safety, shoulder

ABBREVIATIONSAED—automated external defibrillatorCPSC—Consumer Protection Safety CommissionNEISS—National Electronic Injury Surveillance SystemNOCSAE—National Operating Committee on Standard for AthleticEquipmentUCL—ulnar collateral ligament

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-3593

doi:10.1542/peds.2011-3593

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

e842 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and Define the ChildHealth Care System and/or Improve the Health of all Children

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 2: Baseball and Softball abstract

sensitive to the developmental and skilllevels of young baseball players andcontinue to modify the rules, whennecessary, for the safety of the players.This policy statement focuses princi-pally on baseball, but softball will alsobe considered where relevant literatureis available.

PARTICIPATION

There are over a dozen youth baseballorganizations whose combined annualparticipation is nearly 5 million. LittleLeague Baseball reports baseball par-ticipation at approximately 2.3 millionannually and softball participationat 400 000 per year7; the Babe RuthLeague (and its 12-and-under Cal RipkenBaseball division) has more than 1million youth participants annually.8

Over 2 million girls between the agesof 12 and 18 compete in fast pitchsoftball annually. The National Feder-ation of State High School Associations2009–2010 participation data counted473 503 baseball players (ages 14–18)and 393 578 softball athletes.9

INJURY DATA

There are a variety of sources of datafor injuries in youth baseball, which in-clude hospital emergency departments,insurance claims, national catastrophicinjury reporting system, and indepen-dent researchers.1,10–13 Each of thesesources captures a limited view of to-tal injuries. Taken together, however,a fairly consistent pattern emerges onthe overall injury incidence and rela-tive frequency (prevalence) of baseballinjuries compared with other sports.Comprehensive data also come fromthe high school level reporting systemsusing certified athletic trainers to re-cord the key injury-related informationon this 14- to 18-year-old population.14–16

Prevalence

The US Consumer Product Safety Com-mission (CPSC) maintains the National

Electronic Injury Surveillance Sys-tem (NEISS) through a network ofapproximately 100 participating USemergency departments. From the datacollected from this cross section ofnational emergency departments, theCPSC extrapolates national estimatesof injury prevalence in various agegroups. The overall prevalence of allsports-related injuries in childrenyounger than 15 years seen in anemergency department is just undera million per year; in 2007, the CPSCestimated that 109 202 baseball- andsoftball-related injuries among 5- to14-year-old children were treated inUS emergency departments nation-ally.17 More specifically, in 2007, theCPSC/NEISS recorded exactly 3343baseball injuries among 5- to 18-year-old children from the participating USemergency departments (T.J. Schroeder,MS, personal communication, 2009). Thefrequency distribution of injuries by agefollowed a bell-shaped curve for ages 5to 18 years, with the highest number ofinjuries clustered in children from 11 to14 years of age (more than 300 injuriesper year of age).17 Because 11- to 14-year-old children represent the majorityof participants, valid injury risk com-parisons with other age groups cannotbe directly determined from these rawnumbers alone. Nearly half of the 3343injuries (44%) involved the head (25%to the face, including eyes and nose;14% to the head and neck; and 5% tothe mouth), with the highest frequencyin children 9 to 11 years of age.17 Ac-cording to several years of annual NEISSreports, approximately one-fourth to one-third of all youth baseball injuries are tothe upper extremities, including the fin-gers (10%–13%), wrists (4%–5%), andhands (4%–5%). Just under 20% of in-juries were to the lower extremities, withknees (5%) and ankles (6%–7%) almostequally affected. Injuries to the trunkand pubic area accounted for approx-imately 6% to 10% of all injuries.1,11,17

Also in 2007, the NEISS recorded ex-actly 1188 youth softball injuries in thesame 100 participating emergency de-partments. Girls accounted for 1062injuries, and boys accounted for 126.17

For girls, the frequency of injuries byage also followed a bell-shaped curvefor ages 5 to 18 years, with the high-est numbers of injuries clustered inchildren from 13 to 16 years of age(more than 130 injuries per year ofage). The distribution of injuries bybody region was more evenly distrib-uted for girls playing softball com-pared with boys playing baseball, with28% of girls’ softball injuries involvingthe head and neck, 35% involving theupper extremities, 31% involving thelower extremities, and 5% involvingthe trunk and pubic area. The 5 mostcommon areas for injury were theface (14%), ankle (14%), finger (13%),knee (11%), and head and neck (11%).17

Thirty-nine percent of injuries wereclassified as contusions, abrasions, lac-erations, or hematomas/hemorrhages;31% were classified as sprains orstrains; 21% were classified as fractures,dislocations, or avulsions; 4% were clas-sified as internal organ injuries; and 4%were classified as concussions.17

Baseball is one of the safest highschool sports in the United States witha reported injury rate of 1.26 injuriesper 1000 athletic exposures.14 Baseballathletes have the third lowest ratesof injury lasting longer than 1 weekamong 18 different sports played inhigh school. However, although theoverall injury rate is low, the degreeof injury severity is relatively high. Inbaseball, fractures represent a largerpercentage of total injuries than inother sports. Baseball also ranks sec-ond highest for the percentage of in-juries resulting in a time loss fromsport participation longer than 7 days.14,15 In high school baseball and softball,as in youth baseball, most injuries tothe head and face (48%) and mouth

PEDIATRICS Volume 129, Number 3, March 2012 e843

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 3: Baseball and Softball abstract

and teeth (16.0%) are attributed tobeing hit by a batted ball.14 More ofthese head and facial injuries also re-quired surgery (18.0%), compared withother baseball-related injuries (6.8%).

USA Baseball, through its Medical andSafety Advisory Committee, sponsoredinjury-surveillance research and pro-duced a report on injury patterns inyouth baseball in 2008 which concludedthat, in younger players, injuries aremore often associated with lack of skill,whereas in older players, the greaterskill, muscle power, and body size be-come injurious forces.13 More detailedstudy findings were as follows:

1. Across all age groups, pitchers,catchers, and fielders have a relativefrequency of injury in a season com-parable to batters and base runners,with one exception: as age increases,the proportion of injuries to catch-ers increases, whereas the propor-tion of injuries to fielders decreases.

2. The younger the age group, the morefrequently injuries occur during prac-tice sessions, not games. Also, inyounger age groups, relatively higherfrequencies of injuries came from“before/after” baseball play, such aswarm-ups or postgame horseplay.

3. Pitcher injuries are also age-related,with noncontact overuse injuries in-creasing in each older age group.Younger pitchers are more likely tobe hit by a batted or thrown ball.

4. Catchers principally are injured incatching a pitch, getting hit by a foultip, or tagging a base runner. Youn-ger catchers are more frequentlyinjured trying to catch the pitchedball, whereas older catchers aremore likely to be injured by foul tips.Although home-plate collisions dur-ing a tag play generate a modest butconstant pattern of injury for catch-ers of all ages, these collisions pro-duce a greater injury risk to theolder catcher.

5. Batters are most frequently injuredby a pitched ball (and by a foul ballas they get older). The younger thebatter, the more likely they are tobe injured by a swung bat of anotherplayer while getting into position. Ap-proximately 10% of batting injuriesamong older batters are of a noncon-tact nature, indicating some form ofoverswinging resulting in an injuryto the muscles, bones, or connectivetissues of the rib cage.

6. Injuries to base runners occurredalmost equally at all bases, withslightly more injuries at home platethan at first base. Two-thirds ofthese injuries occurred from sliding,and one-third occurred from baserunning. Base running injuries arenot related to age, occurring almostequally from collisions, being hit bya thrown ball, or simply running(such as falling, stepping wrong onthe base, or straining a muscle).

7. Fielder injuries occur at the base(33%), in foul territory (10%), andin the field (57%). Younger fieldersare more likely to be hit by a bat-ted ball, whereas older fieldersare more likely to be injured bycolliding with a sliding opponent.

Catastrophic Injuries

Research from the National AmateurBaseball Catastrophic Injury Surveil-lance Program places the rate of cata-strophic injury very low, at approximately1 injury per 1 million participants an-nually. Such injuries may be caused bytrauma related to participating in theskills of the sport, such as contact witha bat, baseball, or softball (direct cata-strophic injury), by a body system failureresulting from exertion while partici-pating in a sport or activity (eg, cardiaccollapse or heat stroke) or by a com-plication that resulted from a nonfatalinjury (indirect catastrophic injury). Ca-tastrophic injuries are further classifiedaccording to outcome as fatal (athlete

died), nonfatal (athlete left with per-manent disability), and serious (athleteexperienced severe injury but recov-ered, to be left with no permanentfunctional disability).12 The NationalAmateur Baseball Catastrophic InjurySurveillance Program data revealed anannual fatality rate of 0.05 per 100 000participants, 0.03 for nonfatal cata-strophic injuries and 0.04 for seriouscatastrophic injuries.18 Between 1996and 2006, deaths in youth baseballaveraged just over 2 per year.18 Thesedeaths occurred from impact to thehead resulting in intracranial bleedingand from blunt chest impact, likelyprompting ventricular fibrillation orasystole (commotio cordis).11,12

Another study based on statisticscompiled by the CPSC11 indicated thatthere were 88 baseball-related deaths(approximately 4 per year) to children5 to 18 years old between 1973 and1995.11,19 The injury causing death in38 cases (43%) was direct-ball impactwith the chest (commotio cordis); in21 cases (24%), the injury causingdeath was direct-ball contact with thehead; in 13 cases (15%), the injurycausing death was from impact frombat contact; in 9 cases (10%), the injurycausing death was from direct contactwith a ball impacting the neck, ears, orthroat; and in 7 (8%), the injury causingdeath was unknown.11,19

Among high school baseball athletes(with approximately 475 000 partici-pating annually), there have been 10“direct” deaths, 14 “indirect” deaths,17 nonfatal catastrophic injuries, and22 serious catastrophic injuries be-tween 1982 and 2008.12 Direct injuryrates are between 2 and 5 timesgreater in high school than in youthbaseball (5–14 years of age) and 4times greater in college than highschool baseball (but still less than 1/100 000 participants annually in any ofthe 3 categories).

e844 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 4: Baseball and Softball abstract

Among high school softball athletes(371 000 annual participants), therehas been 1 direct death, no indirectdeaths, 2 nonfatal catastrophic inju-ries, and 1 serious catastrophic injuryin the 15 seasons from 1993 and2008; these rates are approximatelyone-tenth of those for high schoolbaseball.12

Commotio Cordis

Young baseball and softball playerswho receive direct ball impact to theanterior chest wall over the cardiacsilhouette may develop cardiac arrest.Commotio cordis is the second highestcause of death in athletes youngerthan 14 years and is considered to beonly a pediatric problem because of itsunique occurrence in children, usuallyyounger than 16 years.20–22 Children 5 to14 years of age may be uniquely vul-nerable to this blunt chest impact, be-cause their chest walls are more elasticand more easily compressed.20–24

Although protective gear can be a keypreventive measure, it is not alwayseffective. Research has shown thateven with protective gear, the fatalityrate for commotio cordis is alarminglyhigh at 90%.19–24,25,26 Proper coachingand execution can augment protectiveequipment. Batters who learn to avoidthe ball and turn away from an insidepitch can greatly reduce their risk.This is particularly difficult, however,while bunting and, thus, requiresspecial attention and instruction. Therisk to pitchers can also be reducedby teaching proper fielding positionafter ball release as well as ball avoid-ance when necessary.19 The capac-ity to recognize that a batted ball iscoming at you quickly and the abilityto react to that event before the ballarrives are crucial traits for protect-ing these athletes. Speed of process-ing and reaction time are commonlymeasured during the computer-basedneuropsychological tests given to high

school athletes as a baseline inconcussion management programs.Presumably, these are skills that canbe improved marginally with propertraining and sufficient repetitions. It isestimated that 400 milliseconds is re-quired for a pitcher to complete aprotective movement, such as lifting ahand to the chest or face; this corre-sponds to a batted ball speed of 42 m/second.27 Because balls hit from somemetal bats may exceed 42 m/second,performance standards for compositemetal bats were developed in 2003 tolimit their capacity to transfer force(velocity) to the batted ball.

It is noteworthy that cardiac deathcaused by commotio cordis is poten-tially preventable. If cardiac arrestoccurs, an immediate and appropriateresponse may, in many cases, savea young player’s life. AEDs are be-coming more prevalent in the sportsworld at athletic complexes and cer-tainly in patrol cars and emergencymedical vehicles. The use of thesedevices, along with cardiopulmonaryresuscitation, has become a standardfirst step in treating cardiac arrest.6,28

If no AED is available near the affectedchild, the emergency medical caresystem should be activated by using911 to get an AED to the athlete’s sideas soon as possible (ideally within 3minutes). Baseball coaches should beroutinely reminded to have a localcellular phone and emergency medi-cal numbers at every youth baseballand softball game and practice in theevent of a medical emergency.

Concussion

Concussion in sports continues togarner ever-increasing public attentionand concern. Data on high school con-cussion rates in baseball and softballwere generated through the ReportingInformation Online system, developedfrom the National High School Sports-Related Injury Surveillance Study, over

the 5-year period from the 2005–2006to 2009–2010 school years. The rate ofconcussions for baseball was 0.2 per1000 athletic exposures, and for soft-ball the rate of concussions was 0.5 per1000 athletic exposures. Of the 9 sportssurveyed (including football, wrestling,soccer, and basketball), baseball hadthe lowest rate, and softball was sev-enth. The top 2 activities associated withconcussion in high school boys playingbaseball were batting (36.7%) and run-ning the bases (21.5%), whereas forgirls playing softball, the top 2 activitieswere catching (33.3%) and fielding(25.0%).29 The most recent concus-sion recommendations, including theAAP Clinical Report published in 2010,stress removing an athlete suspectedof sustaining a concussion from playimmediately with no return to play onthe day of injury. Resting the brain isthe key to the most rapid resolutionof the concussion; such rest includesno physical activity, with minimal cog-nitive and social activity. The concussedathlete should seek prompt medicalattention from an appropriate healthprofessional. Once the athlete isfully free of symptoms and clearedby a physician knowledgeable in thetreatment and management of con-cussion, the athlete should entera graduated return-to-play protocolto ensure a safe return to sportingactivity.30

Summary of Acute Injuries

Although the rates of injury for base-ball and softball are low in comparisonwith other sports, the combination ofrelatively high severity of injuries thatdo occur and the very large number ofparticipants in these sports producesa substantial number of individualswith significant injuries each year.Focused media attention on thesecases often produces a groundswellfor action, even when the scientificevidence for change is lacking.

PEDIATRICS Volume 129, Number 3, March 2012 e845

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 5: Baseball and Softball abstract

OVERLOAD CAUSING OVERUSEINJURY OF THE SHOULDER ANDELBOW IN BASEBALL

Overuse arm injuries in youth baseballprimarily affect pitchers. The repetitivestress of throwing can lead to musclefatigue and then to muscle, tendon,and ligament damage. To control thenumber of these injuries, it is criticalthat pediatricians, coaches, athletes,and parents understand the anatomy,biomechanics, and kinetics of throw-ing a baseball pitch.31–33

In throwing, especially pitching, thearm force and speed generated duringthe full windup motion is astonishinglyhigh (7200 degrees, or 20 revolutions ofa circle, per second for professionalpitchers). At ball release, the rotatorcuff muscles and long head of the bi-ceps contract to decelerate arm motionand prevent the arm from following theball (“throwing one’s arm out”).34

The shoulder girdle (including the cla-vicle [collarbone], scapula [shoulderblade], glenohumeral joint, humerus,and all of the various muscular attach-ments to the thorax and scapula) permitsthe arm to enjoy remarkable freedom ofmovement. Greater joint range of mo-tion sacrifices the inherent joint sta-bility that is usually provided by bonyarticulation or ligamentous limitation.Unlike other joints, such as the kneeand ankle, the glenohumeral joint of theshoulder acquires nearly all of itsstability during activity from the mus-cles of the shoulder with little or noassistance from bones or ligaments.Therefore, when the muscles becomefatigued (and cannot do their jobproperly), the shoulder becomes anunstable joint. Pitchers who continue tothrow when the arm is fatigued riskserious and possibly permanent injuryto their muscles, ligaments, capsules,labra, and bones.35

The scapula plays a critical role in thefunctioning kinetic chain of the upper

extremity. The scapula is attached tothe distal end of the clavicle by thebroad acromioclavicular ligament andthe 2 coracoclavicular ligaments thatarise from the hooklike coracoid. Theclavicle attaches proximally to thesternum at the sternoclavicular joint;the sternoclavicular joint is the onlyjoint connection of the entire upperextremity to the main skeleton of thebody. The scapula rests on the thorax(chest wall) and is connected throughnumerous muscles (scapulothoracicjoint) that permit the shoulder blade torise (shrugging shoulders), to glidearound the body (protraction), and toglide back toward the spinal column(retraction). Strength and enduranceof these extrinsic shoulder girdle mus-cles, especially the serratus anterior,are essential to ensure safe pitching.These muscles must move the scapulato its appropriate position and stabilizeits base before the acceleration phase ofthe throwing motion can proceed. Withexcellent scapular muscular control, theathlete can then use the long lever ofthe upper extremity to throw withpower, speed, and accuracy.36

It also has long been recognized, how-ever, that the source of power (velocity)in throwing is part of a larger kineticchain, which begins in the legs, travelsthrough the pelvis into the torso (“thecore”), and finally comes out throughthe scapula into the upper extremity.Strong legs and especially a strongcore help generate a majority of theforce behind a pitched ball.37

Relative weakness of the serratus an-terior muscle is often responsible forinjuries to the rotator cuff muscles,biceps, and elbow (farther down thekinetic chain). Scapular winging (beingable to slide one’s hand under themedial or inferior edge of the scapulawhen relaxed), scapular depression(inferior pole sits lower than the otherside or below T-7), and protraction(sits farther away from the vertebral

spines than the opposite side) arenoted on inspection. Observing an ath-lete (from behind) performing the armcomponent of a “jumping jack” ap-proximately a dozen times will de-monstrate poor movement patterns, orscapulothoracic dyskinesis. A secondtest entails forward flexing the arm tothe fully overhead position and slowlylowering the arm 180 degrees to itsnatural position. Scapulothoracic dys-kinesis consists of unsmooth or uncon-trolled scapular motion while bringingthe arms up or down, including markedscapular winging during descent. Al-though the athlete may perform thefirst few repetitions well, scapulothoracicdyskinesis may become evident to-ward the end of the set, when fatiguesets in.36,38

The scapula also forms part of the gle-nohumeral joint (true shoulder joint).The scapula’s glenoid is a shallowsocket surrounded by a cuplike rimcalled the labrum, which provides ad-ditional stability. The 2 main ligamentsof the glenohumeral joint perform mostof their stabilizing function when theshoulder is not being used dynamically.During sporting activity and especiallyduring throwing, the 4 rotator cuffmuscles and the long head of the bi-ceps are responsible for keeping thehumeral head in the glenoid socket.The larger muscles (deltoids, trapezius,pectorals, latissimus dorsi, short headof the biceps, and triceps) provide thepowerful dynamic forces to move thearm and generate ball velocity.

The term “Little League shoulder”refers to the widening of the proximalhumeral physis resulting from chronicrecurrent traction stress across thegrowth plate. This lesion is felt to beprimarily the result of throwing a largenumber of pitches or maximum-effortthrows or insufficient rest betweenpitching assignments, but can alsobe related to improper mechanics orpremature attempts with certain pitch

e846 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 6: Baseball and Softball abstract

types. When unrecognized, or whenrecognized in an advanced stage ofoveruse, Little League shoulder canlead to chronic pain with throwing,early shoulder instability, or degen-erative arthritis.39

The term “Little League elbow” refers tomedial elbow pain in skeletally imma-ture athletes resulting from throwingissues similar to those mentioned inthe description of “Little League shoul-der.” Pitchers are most likely to be af-fected by this condition, but it can alsooccur in other players at positions re-quiring frequent and forceful throwing.Traction forces occur on the medialelbow and compression forces laterally.The medial traction forces can causeseparation or avulsion of the humeralmedial epicondyle apophysis and over-use injury to the common flexor ten-don. The compression forces laterallycan cause collapse and deformity ofthe distal humerus (capitulum), alsoknown as osteochondritis dissecans inadolescents and Panner disease inchildren younger than 10 years. Earlyrecognition of symptoms is importantto avoid chronic elbow pain, instability,and arthritis.35 The inability to fullystraighten the elbow is usually an in-dication of an overuse elbow injury.Complete tears of the ulnar collateralligament (UCL) are repaired by “TommyJohn” surgery, which is followed bynearly a year of rehabilitation beforereturn to pitching is allowed. UCL tearshave risen to nearly epidemic pro-portions in the past 5 years amongyouth and high school pitchers, in-creasing almost 20-fold from the pre-vious decade.35,40 When the pitch velocityexceeds 80 miles per hour, the forcesexperienced at the UCL are near thepoint of failure (32 Newton meters).35,41

Prevention of Shoulder and ElbowOveruse Injuries in Baseball

In 2006, the Medical and Safety Advi-sory Committee of USA Baseball set

pitching limits for a season and a cal-endar year, based on age.42 In 2007and 2008, on the basis of extensiveresearch, Little League Baseball re-leased its pitch count regulation guidein an attempt to reduce the risk ofoveruse injuries to elbows and should-ers.43,44 This guide for parents, coaches,and league officials sets a maximumnumber of pitches to be thrown ina day on the basis of age as well asthe number of rest days betweenpitching assignments on the basis ofnumber of pitches thrown and age.It replaces the previous regulations,which set a maximum number ofinnings pitched in a calendar week.Beginning in 2010, Little League tour-nament pitching regulations becamethe same as for regular season play,as shown in Tables 1 and 2.44,45 Itis the responsibility of the coach toknow when an athlete has reached hisor her pitch count limit. When pitch-ers exceed recommended pitch countmaximums for age for an entire sea-son or a full year, the injury rates forshoulders and elbows increase dra-matically.41

Young pitchers should avoid pitch-ing on multiple teams with over-lapping seasons; the guidelines forrest requirements must be enforcedacross all teams. Youth pitchers shouldnot pitch competitively in more than 8months in any 12-month period; 3consecutive months of complete restfrom pitching each year is recom-mended. A pitcher should also not bea catcher for his or her team. Catchersthrow even more frequently thanpitchers, and although the returnthrows are only moderately stressful,catchers also make many hard throwsto the bases during a game. Thus,playing both positions greatly increa-ses the repetitive stress to the arm.35,46

A preseason conditioning program thatincludes strengthening the core, therotator cuff, and the shoulder-stabilizing

muscles (scapular stabilizers) alsomay help reduce throwing injuries. Aprospective epidemiological researchstudy among asymptomatic adoles-cent and preadolescent tennis athletesfound those with decreased scapulastabilizing muscular strength (noted byscapula winging, protraction, and de-pression) demonstrated a higher rateof shoulder injury during the subse-quent season.47

Teaching proper pitching mechanicsmay also prevent serious overuseinjuries.35,42,43,48 Allowing sufficient timeduring the early part of the seasonto gradually increase the amount andintensity of throwing may provideyoung arms an opportunity to adaptto the stresses of throwing. Duringthe off-season and preseason, afterallowing for a period of several monthsof complete rest from throwing, dailythrowing of a strictly limited numberof pitches may enhance strength de-velopment (as regular strength train-ing does for other muscle regions)with little risk of overuse injury orfatigue.35,49 A core-stabilizing exerciseprogram will improve strength andshould also be adopted for pitchersand hitters.35,37,47

Four keys to successful pitching withinthe 5- to 14-year age group are (1)the development of a fastball; (2) ac-curacy of locating pitches (control);(3) development of an off-speed pitch(change-up); and (4) changing pitchspeeds and plate locations to keepbatters guessing. Conventional wis-dom has long considered the curveball and slider to be stressful to theyoung elbow, and recommendationsto delay their introduction until lateryears (when the skeletal maturity ismore significantly advanced) werecommon.43 Recent studies challengethose theories and indicate that, whenproperly thrown, the curve ball maynot overly stress the elbow.35,50,51

Nevertheless, on the basis of those

PEDIATRICS Volume 129, Number 3, March 2012 e847

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 7: Baseball and Softball abstract

studies that show increased injuryamong those who throw curve ballsand sliders at early ages, researcherscurrently continue to recommend de-laying introduction of the curve balluntil after age 14 or when pubertaldevelopment has advanced to the stagewhen the athlete has started to shave(sliders should be delayed until age16).41 The American Academy of Pedi-atrics endorses this recommendation.Finally, on the basis of the increasingnumber of elbow ligament surgeries inyounger and younger pitchers, it isclear that players, parents, and coachesrequire more respect for the limits ofthe developing child’s arm to withstandthe forces incurred while pitching andshould understand that the conse-quence of overload causing overuseinjuries which can permanently dam-age anatomic structures.35

OVERUSE INJURY FROM SOFTBALLPITCHING

Data on softball injurieswere included inthe previous sections; in general, these

demonstrate injury patterns similar tobaseball with several minor variations.One unique feature of softball, however,is the nature of pitching; pitchers throwunderhand from a flat mound. Althoughthe softball windmill pitching motionmay be less stressful to the pitcher’sshoulder and elbow than throwinga hardball overhand, there are stillsignificant forces placed on variousbody structures to cause overuse injury.

The same concerns exist for armsafety: do not throw when fatigued. Asof 2011, inning limitations and restdays for softball windmill pitchers inthe various age divisions of LittleLeague apply to tournament play only.Many softball teams rely on fewerpitchers per team than baseball. Be-fore such inning limitations, somepitchers pitched in multiple gamesduring weekend tournaments, runningup pitch counts between 1500 and 2000pitches in a 3-day period.52

The driving force of the windmillsoftball pitch is in the lower body53; 1study reported more than 50% of thetotal kinetic energy of upper extremityduring overhead movements is sup-plied by the trunk and legs.54 Thesoftball pitcher engages the glutealmuscles to achieve stabilization of thepelvis, which in turn helps the scapulaachieve adequate control.

The lower extremity supports the me-chanics of the upper body during the

softball windmill pitch, especially dur-ing the single-leg support component;however, the site of failure (injury) maynot be located where the problemoriginates, but at a more remote site(the weakest link). This kinetic chaintheory produces “culprits” and “vic-tims” in describing injuries. For ex-ample, although 70% of 131 injuries tocollegiate softball pitchers were fromoveruse, only 13% were reported inthe lower extremity.55 The majorityoccurred in the shoulder or elbow.Thus, although the “culprit” may beweak gluteal muscles and lack of pel-vic stabilization, the athlete may pres-ent with shoulder pain, because the“victim” shoulder is inherently “theweakest link.”

The pelvis and torso work to acceleratethe segments of the upper extremity ina sequential manner. Scapular retrac-tion is stimulated by ipsilateral hip ex-tension and trunk extension. A stablescapula is vital for optimal rotator cufffunction that helps to keep the humerusin the glenoid fossa (thus avoiding im-pingement).

Accordingly, examination and treatmentof shoulder pain in softball windmillpitchers should include an assessmentof and rehabilitation for pelvic stabilityand gluteal strength. Scapular stabi-lization must also be evaluated andtreated as well as the affected shoulderor elbow. Off-season and preseasonconditioning programs for softballwindmill pitchers should include glu-teal strengthening and pelvic stabili-zation exercises.

ROLE OF EQUIPMENT IN INJURYRISK AND PREVENTION

Playing Equipment

The game of baseball requires playingequipment (ball, bat, gloves, bases), aswell as equipment to dress and protectthe athlete. Although there are over-arching concerns about equipment

TABLE 1 Little League Baseball 2010Pitching Guidelines: MaximumPitches per Game

10 y and younger 75 pitches per d11–12 y 85 pitcher per d13–16 y 95 pitches per d17–18 y 105 pitches per d

Source: Little League (http://www.littleleague.org/media/newsarchive/2009/Sep-Dec/LLTournamentRegularSeason-PitchingRulesMadeSame.htm).

TABLE 2 Little League Baseball 2010 Pitching Guidelines: Rest Requirements for Pitchers

Pitchers 14 y and younger66 or more pitches in a day Four (4) calendar days51–65 pitches in a day Three (3) calendar days36–50 pitches in a day Two (2) calendar days of rest must be observed21–35 pitches in a day One (1) calendar day of rest must be observed1–20 pitches in a day NO (0) calendar day of rest must be observed

Pitchers 15–18 y76 or more pitches in a day Four (4) calendar days61–75 pitches in a day Three (3) calendar days46–60 pitches in a day Two (2) calendar days of rest must be observed31–45 pitches in a day One (1) calendar day of rest must be observed1–30 pitches in a day NO (0) calendar day of rest must be observed

Source: Little League (http://www.littleleague.org/media/newsarchive/2009/Sep-Dec/LLTournamentRegularSeasonPitching-RulesMadeSame.htm).

e848 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 8: Baseball and Softball abstract

performance and safety that apply toevery athlete who plays baseball, someconcerns typically apply to only a smallsegment of players depending on age,developmental level, and skill.56,57

The ball is the cause of most baseballinjuries, through being hit by a pitchedball, being struck while attempting tofield a batted ball, trying to catcha thrown ball, or being hit by a thrownor batted ball while running the bases.Accordingly, modifications in the hard-ness and compressibility of baseballs(and softballs) were developed byequipment manufacturers several dec-ades ago for use by children of differentages with the intent of reducing theforce of impact by the ball whilemaintaining adequate performancecharacteristics; they were known asreduction-in-force balls. These softerballs, however, are alleged to possessa more “lively” bounce than traditionalbaseballs.56–58 The National OperatingCommittee on Standard for AthleticEquipment (NOCSAE) has developedstandards for these softer baseballs(levels 1, 2, and 3),59,60 and an expertreview panel and other researchershave indicated that softer balls meet-ing the NOCSAE standard are lesslikely to cause injury, specifically se-rious head injury or commotio cordisby impact.22–24,60,61 Children with thelowest skill level (in general, thoseyounger than 10 years) should use thelowest-impact NOCSAE-approved balls(level 1). Level 2 low-impact balls aredesigned for children 10 to 12 years ofage with moderate skill levels. Chil-dren younger than 10 years of agewith moderate skills may use eitherlevel 1 or level 2 balls. Level 3 ballsare designated for youths older than12 years and those 10 to 12 years ofage with advanced skills.61

Baseball has the highest number ofsports-related eye injuries in children,with the highest incidence in 5- to 14-year-olds (T.J. Schroeder, MS, personal

communication, 2009).11,13 Approximatelyone-third of baseball-related eye injuriesresult from being struck by a pitchedball; other common causes of eye inju-ries are attempting to field a batted ballor catch a thrown ball.

The composition of the bat has pro-voked much discussion in recent years,especially for baseball players olderthan 15 years. Composite (metal)bats have largely replaced woodenbats.62 Initially, the introduction ofmetal bats led to an increased velocityof the batted ball, putting fieldersat greater risk of injury, especiallypitchers and third basemen.62 Consid-erable research has been conductedcomparing both types of bats, but noconsensus exists regarding safety ofcomposite metal bats compared withwooden bats in youth baseball.62,63 Allbats, wooden or metal, are momen-tarily deformed upon contact with thebaseball; the recoil or restitutioncharacteristics of the bat to its usualshape result in imparting additionalvelocity to the batted ball. Industryperformance standards for compositemetal bats were developed in 2003through the leadership of the NationalCollegiate Athletic Association andNational Federation of State High SchoolAssociations. These standards limit thedimensions of the bat and its capacityto transfer force (velocity) to the battedball (ball exit speed ratio). Bat compo-sition for National Collegiate AthleticAssociation baseball was required tomeet the Batted Ball Coefficient ofRestitution guidelines in 2011, andhigh school baseball will follow suit in2012.64 For Little League Baseball, themaximum bat length is 33 inches andmaximum barrel diameter may notexceed 2 1/4 inches. Since 2009, allLittle League bats must be labeled witha bat performance factor of 1.15 orlower.65,66 Bat performance factor isa measure of a nonwood bat’s perfor-mance relative to wood bats. For 2011,

Little League International has im-posed a moratorium on the use ofcomposite bats for all baseball divi-sions citing research that found that“composite bats, while they meet thestandard when new, can exceed thatstandard after a break-in process.”67

Although the media continue to reportanecdotal stories of significant headand facial injuries associated withmetal bats, epidemiological injurysurveillance studies do not show anincrease in the rate of such injuriessince metal bats were introduced.62

Equipment-related injuries also in-clude those caused by bases andcleats. Foot and ankle injuries occurregularly in baseball and softball, es-pecially during sliding. Early studiesshowed that at least 35% of all injuriesin softball occurred while sliding feetfirst into a base, and, in one study, 82%of those injuries resulted in anklefractures or dislocations.68,69 Subse-quently, a 2-year study comparingtraditional stationary bases and ba-ses capable of disengaging noted agreater than 95% reduction in footand ankle injuries with breakawaybases.70–74 In 2008, Little League base-ball and softball mandated the use ofbreakaway bases.74 Youth softball lea-gues have also incorporated the useof a separate “runner’s base” at firstbase to avoid collisions; the orange“runner’s base” sits adjacent to thewhite regular base, but in foul terri-tory, providing the runner and fielderseparate, equal-size bases. Metal spikesare dangerous to basemen coveringbases; rubber spikes are preferred foryouth baseball.

Protective Equipment

Protective equipment should always beproperly fitted, well maintained, andclean; equipment hygiene is importantto prevent infections, such as methicillin-resistant Staphylococcus aureus. Al-though not all equipment adaptationshave been tested scientifically for

PEDIATRICS Volume 129, Number 3, March 2012 e849

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 9: Baseball and Softball abstract

efficacy, experts believe those mentionedin this article will help reduce injuries insoftball and baseball players.24

Padded sliding pants worn underneaththe baseball pants provide good pro-tection against contusions and abra-sions to the hips and thigh whenathletes slide feet first into a base. Forathletes who slide head and handsfirst, wearing gloves can reduce handabrasions; similarly, use of battinggloves improves the grip on the batand reduces the risk of blisters. Head-first sliding creates the risk of headinjuries from collisions with the fielderor from being hit by a thrown ball;upper-extremity injuries can occurfrom the contact and decelerationforces that occur when the hands ofthe diving body encounter the sta-tionary base. According to currentLittle League Baseball rules, a runnermay not slide head-first except whenretreating to a previously held base.75

Chest protectors for batters were in-troduced in the 1990s to protect theheart from ball impact, which cancause commotio cordis.19 However,this protective barrier has not beenshown to be reliable in either thehuman experience or in animal labo-ratory studies.22–25,28,63 More study isrequired to develop and target equip-ment that will better prevent commotiocordis.24 Recent design modificationsindicate that progress is being made,but these advances have not beenvalidated in evidence-based peer-reviewed scientific journal articles orabstracts presented at professionalmeetings.76 Even the chest protectorsfor catchers, which are effective forblunting the usual forces encounteredfrom pitches, foul tips, throws, andcollisions do not reliably prevent com-motio cordis.24,77

Hard plastic shell batting helmets havelong been an integral part of pro-tecting baseball and softball playersfrom head injuries while batting and

running the bases. The NOCSAE de-veloped standards for helmets andtheir testing decades ago.59 Their de-sign and characteristics have beenmodified over the years to betterprotect the eyes, ears, face, mouth,and nose.78 In 2009, a new battinghelmet was introduced with the ca-pacity to withstand the impact of a100-mph fastball; it has a layer ofexpanded polypropylene, the hard,foamlike material used in bicyclehelmets.79,80

Face and eye protection can be ach-ieved by securing additional protectionto the batting helmet, such as a poly-carbonate plastic face guard, metalcage, or a polycarbonate full-faceshield. Although full plastic face shieldshave been demonstrated to reduce in-jury risk significantly, their acceptanceby players and league officials has beenmixed, primarily because of compro-mised visibility through the shield overtime.56 More recent epidemiologicalresearch among high school baseballathletes has led to a call for infieldersand pitchers to wear face shields.14

Eye protection may be worn to reducethe risk for eye injury.81–84 This pro-tection may be particularly importantfor young athletes who have un-dergone eye surgery or experienceda previous serious eye injury.85 Poly-carbonate face guards and shieldsmust meet the F910 standard of theAmerican Society of Testing and Ma-terials.84,86 Face guards cover thelower part of the face from the tip ofthe nose to below the chin, directlyprotecting the teeth and facial bones;the space between the top of theguard and the brim of the helmet isless than the diameter of a baseball,thereby indirectly protecting the eyeswithout impairing vision. Functionallyone-eyed athletes (best corrected vi-sion in the worse eye of less than 20/50) must use one of these protectorswhen batting and also must protect

their good eye when fielding the ballby using polycarbonate sports gog-gles that meet American Society ofTesting and Materials standard F803.86

Some parents may also prefer the useof a face guard or eye goggles whentheir children are in the field. All ath-letes who wear glasses or sunglasseswhile playing baseball or softball shouldmake sure that the lenses and framesmeet appropriate safety standards, thusminimizing the risk of breaking orshattering on contact with a baseballor softball.86

An essential piece of equipment for allboys playing baseball or softball is useof a hard plastic athletic cup to protectthe testicles. Although catchers, pitch-ers, and infielders are at the greatestrisk, testicular injuries can occur to anyplayer while in the field, batting, orrunning the bases.

The development of triangular-shapedfoam pads (“knee savers”) for catch-ers is another advance in safety equip-ment that has enjoyed widespread usesince its introduction.87 These pads fitinto the popliteal fossa behind theknee and are designed to minimizethe strain on the knee joint while thecatcher is in the crouched position.Some batters opt for shin guards toprotect their medial distal tibia; an-other innovation gaining notice is theelbow protective pad for batters.

ENVIRONMENTAL RISKS

Environmental risks include weather-related concerns and field conditionsand boundaries (perimeters).

Baseball and softball players are atrisk for injury from weather-relatedfactors, including lightning, sun, andheat. Recreational facilities managers,coaches, and umpires need to be well-versed in lightning safety guidelines5,88

and prepare an emergency actionprevention plan in advance. In par-ticular, lightning presents a uniquechallenge because of the difficulty in

e850 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 10: Baseball and Softball abstract

predicting and appreciating the pres-ence of electrical storms. More andmore facilities are installing auto-matic lightning detectors and alarmsystems to ensure that everyone re-sponds appropriately to the pres-ence of lightning. In the absence of anautomated warning system, estimatingthe distance of the storm from thefields can be accomplished by countingthe number of seconds between seeinglightning and hearing thunder. Dividethe number of seconds by 5 to estimatethe distance in miles. A “flash-to-bang”of 30 seconds or less is an indication tomove athletes and spectators to asafe area. A preassigned individualshould be responsible for the decisionto evacuate. In general, a period of 30minutes should elapse from the lastsound of thunder and from the lastvisible lightning flash before playshould be resumed.

Hot and/or humid weather conditionspose significant risk for heat-relatedillness in children and adolescents.Ambient temperature, relative humid-ity, wind speed, and solar radiant heatall affect risk for heat illness.89,90 Theability to dissipate body heat into thesurrounding environment decreasesas the ambient temperature risescloser to body temperature. Similarly,as the humidity rises and the airbecomes more saturated with water,the ability to cool oneself throughevaporation decreases. Wind and sunexposure can damage the skin andeyes. Being acclimatized to the envi-ronment, ensuring adequate hydration,wearing a baseball cap, and havinga covered dugout are important fea-tures of minimizing the risk of sun- andheat-related illness. Recommendationsregarding sunscreen, sunglasses, andproper uniforms for practice and gamesare appropriate for players of all ages.Similarly, in cold weather, athletes needto be properly dressed. When neces-sary, games should be postponed or

game times altered when weather con-ditions are extreme.

Fields need to be inspected regularlyfor hazards, including problems withsprinkler heads, gopher holes in theoutfield, or rocky infields. A warningtrack (usually 15 feet wide) shouldsurround the entire grass or artifi-cial turf playing surface and shouldmeet all recommended specifications;the change in surface texture servesto alert fielders that they are nearingthe perimeter barriers, such as whenoutfielders are going back on long hitsto the fence. All fences should be ingood repair, especially the backstopand the fence along both foul lines. Ifa chain-link fence is curled up and thegrass becomes high, an athlete mayreceive a laceration when reachingdown to pick up the ball (not noticingthe hazard produced by the defectivefencing).

Elimination of the on-deck circle,placing dugouts behind a fence, andthe wearing of batting helmets by thefirst-base and third-base coaches havefurther reduced the risk of injury onthe playing field.

DEVELOPMENTALCONSIDERATIONS

The pediatrician needs to have anunderstanding of developmental con-siderations as they apply to baseballand softball participation at variousages. This will allow the pediatrician tooffer appropriate counseling and guid-ance to the many boys and girls, theirparents, and members of the sportingcommunity who participate in baseballand softball each year.

Compared with older players, childrenbetween 5 and 10 years often have lesscoordination, slower reaction times,a reduced ability to pitch accurately,and a greater fear of being struckby the ball.91,92 Some developmentallyappropriate rule modifications, there-fore, are advisable for this age group,

including the use of batting tee, apitching machine, or an adult pitcher.The avoidance of head-first sliding forchildren younger than 10 years isespecially important, because therehave been anecdotal reports of rarebut serious cervical spine injuriesoccurring when a young player slideshead-first, hitting an opponent withthe top of the helmet. This injury issimilar to that caused by “spearing”(using the head as the lead object) infootball. Feet-first sliding should betaught consistently (as players be-come developmentally ready) so thatall players become comfortable withthis key technique of the game. Theuse of softer balls, as described ina previous section of this statement,is also recommended in this agegroup to reduce serious impact injury.

Youth baseball has long recognizedthat the game must be modified tomeet the developmental level andskills of its players. The distance be-tween bases begins at 45 feet for TeeBall, moves to 60 feet for Minor Leagueand Little League (Majors) for ages 10to 12 years, goes to 70 to 75 feet forages 13 to 15 years, and eventuallyadvances to 90 feet for boys 16 to 18years of age; similarly, the pitcher’smound increases from 46 feet, to 50feet, to 60.5 feet from home plate,respectively. The distances of theoutfield fences also grow as the fieldenlarges. The length and weight ofbats is another variable that changesas the youth grow in size, strength,and ability.

Some children are able to track ballmovement at early ages and can ac-curately move to and catch a fly ball orhit live pitching as early as 5 years old;most children, however, do not achievethese capabilities until ages 8 or 9.91

Therefore, it is appropriate to beginintroduction to baseball batting for5- to 7-year-olds using a ball that isnot moving but placed on a tee. For

PEDIATRICS Volume 129, Number 3, March 2012 e851

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 11: Baseball and Softball abstract

children who are capable of hittinga thrown pitched ball, however, beingforced to hit the tee ball may not en-hance their skill development.

Coaches who are not knowledgeable inchild development may become frus-trated trying to teach basic skills toyoung boys and girls who are simplynot ready to acquire these skills, nomatter how many balls are pitched tothem or how many fly balls they areasked to catch during practice. Forthese reasons, Little League baseballtracks its athletes into the minors andthe majors for boys 10 through 12,separating those children who aredevelopmentally advanced from thosewho are developing at the typical rate.It must be remembered, however, that“late bloomers” may ultimately turnout to be the finest athletes of all,despite their slower beginning. Properinstruction and persistent repetition inthe fundamentals of baseball are es-sential for youth to develop the talentand skills required to perform pro-ficiently at a high level during lateadolescence and adulthood.

RECOMMENDATIONS

The American Academy of Pediatricsrecommends the following:

1. Because baseball and softball forchildren 5 through 18 years ofage are relatively safe sports,participation should be encour-aged by pediatricians.

2. Preventive measures should beused to protect young baseballpitchers from throwing injuries.Adequate core strength and scapu-lar muscle strength provide a crit-ical foundation; proper instructionin throwing mechanics, condition-ing, and training is another essen-tial component. Delay introductionof the curve ball until after age 14and the slider until age 16. Threekey elements in preventing overuseinjuries in pitchers include: (a) age

guidelines regarding the numberof pitches thrown daily; (b) restrequirements between pitchingassignments; and (c) season andyearly total pitch limits.38,42,44 Youngpitchers should avoid pitching onmultiple teams with overlappingseasons; the guidelines for restrequirements must be enforcedacross all teams. Youth pitchersshould not pitch competitively inmore than 8 months in any 12-month period; 3 months of restfrom pitching are recommendedeach year. A pitcher should alsonot be a catcher for his or herteam.

3. Parents, coaches, and playersshould be educated about theearly warning signs of elbowand shoulder overuse injuries aswell as the importance of para-scapular muscle strength. Athletesshould cease pitching immediatelywhen signs of arm fatigue or painoccur; they should be encouragedto seek timely and appropriatetreatment of significant or persis-tent pain.35

4. Serious and potentially catastrophicbaseball injuries can be minimizedby the proper use of availablesafety equipment. This safety equip-ment includes: (a) for hitters, ap-proved batting helmets with faceprotection; (b) for catchers, hel-mets, masks with throat guards,chest protectors, and shin guards;(c) for all male players, hard plasticathletic cup; and (d) for all baseballand softball players, rubber-spikedsoles. In light of the relatively highpercentage and severity of head,face, and mouth injuries in baseball,strong consideration should begiven to head and facial protec-tion for pitchers and infielders,especially in younger age groupsand for less-skilled players. Pro-tective equipment should always

be properly fitted, well maintained,and clean.

5. Current data show that chest bar-riers or protection are not suffi-ciently effective in preventingcommotio cordis; thus, the rou-tine use of these heart protectorsis not recommended for baseballplayers at this time. Catchersmust continue to wear approvedchest protectors.

6. Coaches and officials must be pre-pared to activate the emergencyresponse system (call 911) andto obtain rapid access to an AED,ideally in less than 3 minutes, toassist young baseball or softballplayers who are experiencing car-diac arrest or another medicalemergency. Coaches should havea local cellular phone and emer-gency medical phone numbersavailable for use at all times.

7. Coaches, parents, umpires, andleague officials need to be knowl-edgeable regarding the cause, pre-vention, recognition, and responseto concussion. New policies existwith excellent free educational andprevention materials, especiallyfrom the Centers for Disease Con-trol and Prevention. Furthermore,free on-line trainings are availablethrough the Centers for DiseaseControl and Prevention (http://www.cdc.gov/concussion/) and the Na-tional Federation of State HighSchool Associations (www.nfhs.org).

8. Youth baseball and softball play-ers should wear polycarbonateeye protection guards or shieldsor metal cages on their battinghelmets to reduce the risk ofeye injury. For functionally one-eyed athletes (best corrected vi-sion in the worse eye of less than20/50) and those who have under-gone eye surgery or experiencedprevious severe eye injuries, eyeprotection (one of the 3 types of

e852 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 12: Baseball and Softball abstract

face shields or polycarbonatesports goggles) should be requiredat all times while the athlete is bat-ting or fielding.

9. Children with the lowest skill level(in general, those younger than10 years of age) should use thelowest-impact NOCSAE-approvedballs (level 1). Level 2 low-impactballs are recommended for chil-dren 10 to 12 years of age withmoderate skill levels. Childrenyounger than 10 years with mod-erate skills may use either level 1or level 2 balls. Level 3 balls aredesignated for youths older than12 years and those 10 to 12 yearsof age with advanced skills.

10. Continued research into the rela-tive safety of composite metal ver-sus wooden bats is appropriateand necessary.

11. Awareness of heat and lightningsafety is essential for all coachesand officials of Little League base-ball and softball. The Web sitehttp://www.lightningsafety.noaa.gov/outdoors.htm88 and weatherforecasts are critical resourcesfor prevention of lightning injuries.

When necessary, games or practi-ces should be postponed or gametimes altered when weather condi-tions are extreme.

12. Protective fencing of dugouts andbenches and the elimination of theon-deck circle are recommendedduring games and practices in or-ganized and informal participation.Proper field maintenance is re-quired to minimize injury risks.

13. New developmentally appropriaterule modifications should con-tinue to be implemented when in-dicated.

14. Surveillance of baseball and soft-ball injuries should be continued.Continual strong support of re-search is essential to developother new, improved, and effica-cious safety equipment and rulemodifications.

LEAD AUTHORSStephen G. Rice, MD, PhD, MPHJoseph A. Congeni, MD

COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE COMMITTEE,2010-2011Teri M. McCambridge, MD, ChairpersonJoel S. Brenner, MD, MPH, Chairperson-Elect

Holly J. Benjamin, MDCharles T. Cappetta, MDRebecca A. Demorest, MDMark E. Halstead, MDChris G. Koutures, MDCynthia R. LaBella, MDMichele Labotz, MDKeith J. Loud, MDCM, MScStephanie S. Martin, MDAmanda K. Weiss Kelly, MD

PAST COUNCIL EXECUTIVECOMMITTEE MEMBERSJoseph A. Congeni, MDAndrew J. M. Gregory, MDStephen G. Rice, MD, PhD, MPH

LIAISONSLisa K. Kluchurosky, MEd, ATC – National AthleticTrainers AssociationJohn F. Philpot, MD – Canadian Paediatric So-cietyKevin D. Walter, MD – National Federation ofState High School Associations

PAST COUNCIL EXECUTIVE LIAISONClaire M. A. LeBlanc, MD – Canadian PaediatricSociety

CONSULTANTSMichael F. Bergeron, PhDRobert Cordes, MDJames Raynor, MS, ATC

STAFFAnjie Emanuel, MPH

REFERENCES

1. Lawson BR, Comstock RD, Smith GA.Baseball-related injuries to children trea-ted in hospital emergency departments inthe United States, 1994-2006. Pediatrics.2009;123(6). Available at: www.pediatrics.org/cgi/content/full/123/6/e1028

2. Henson S. Pitcher head injuries to triggercries for protection. Yahoo! Sports. May 28,2010. Available at: http://sports.yahoo.com/mlb/news;_ylt=Ashw9AFXDSrC4iQ6Md2d-WA85nYcB?slug=sh-headinjuries052710.Accessed December 19, 2010

3. Killion A. Viewpoint: California proposesban on metal bats after kid suffers headinjury. SI.com. May 25, 2010. Available at:http://sportsillustrated.cnn.com/2010/writers/ann_killion/05/25/sandberg/index.html?xid=

shareFB&hpt=Sbin Accessed December 19,2010

4. Committee on Sports Medicine and Fitness;American Academy of Pediatrics. Risk ofinjury from baseball and softball in chil-dren. Pediatrics. 2001;107(4):782–784

5. Baseball USA, Medical and Safety Advi-sory Committee. Lightning at the Ballpark.February 28, 2002. Available at: http://web.usabaseball.com/news/article.jsp?ymd=20090813&content_id=6408814&vkey=news_usab&gid. Accessed December 19,2010

6. Baseball USA, Medical and Safety AdvisoryCommittee. AEDs at the Ballpark. December2008. Available at: http://web.usabaseball.com/news/article.jsp?ymd=20090813&

content_id=6407404&vkey=news_usab&gid.Accessed February 28, 2010

7. Little League Baseball Inc. Participation inLittle League Reaches 3-Year High. Availableat: www.littleleague.org/media/newsarchive/03_2006/06participation.htm. Accessed De-cember 19, 2010

8. Wikipedia. List of Organized Baseball League– Youth Leagues. Available at: http://en.wikipedia.org/wiki/List_of_organized_ba-seball_leagues#Youth_leagues. AccessedDecember 19, 2010

9. National Federation of State High SchoolAthletic Associations. 2009–2010 High SchoolAthletics Participation Data. Available at:www.nfhs.org/participation. Accessed Decem-ber 19, 2010

PEDIATRICS Volume 129, Number 3, March 2012 e853

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 13: Baseball and Softball abstract

10. US Consumer Product Safety Commission.National Electronic Injury SurveillanceSystem. CPSC Document 3002. Available at:www.cpsc.gov/cpscpub/pubs/3002.html.Accessed December 19, 2010

11. Kyle SB. Youth Baseball Protective Equip-ment Project: Final Report. Washington, DC:US Consumer Product Safety Commission;1996

12. Mueller FO, Cantu RC. National Center forCatastrophic Injury Research. 26th AnnualReport. Available at: www.unc.edu/depts/nccsi/. Accessed December 19, 2010

13. Clarke KK. Patterns of Injury in YouthBaseball. November 30, 2008. Available at:http://web.usabaseball.com/news/article.jsp?ymd=20090810&content_id=6354562&vkey=news_usab&gid. Accessed December 19, 2010

14. Collins CL, Comstock RD. Epidemiologicalfeatures of high school baseball injuries inthe United States, 2005-2007. Pediatrics.2008;121(6):1181–1187

15. Powell JW, Barber-Foss KD. Sex-related in-jury patterns among selected high schoolsports. Am J Sports Med. 2000;28(3):385–391

16. Krajnik S, Fogarty KJ, Yard EE, Comstock RD.Shoulder injuries in US high school base-ball and softball athletes, 2005-2008. Pedi-atrics. 2010;125(3):497–501

17. US Consumer Product Safety Commission.NEISS Data Highlights – 2007. Available at:www.cpsc.gov/library/neiss.html. AccessedDecember 19, 2010

18. Baseball USA, Medical and Safety AdvisoryCommittee. National Amateur Baseball Cata-strophic Injury Surveillance Program (NAB-CISP). August 13, 2009. Available at: http://web.usabaseball.com/news/article.jsp?ymd=20090813&comtent_id=6409874&vkey=news_usab&gid. Accessed December 19,2010

19. Baseball USA, Medical and Safety AdvisoryCommittee. What is Commotio Cordis inBaseball? November 30, 2008. Available at:http://web.usabaseball.com/news/article.jsp?ymd=20090813&content_id=6410334&vkey=news_usab&gid. Accessed December19, 2010

20. Link MS, Wang PJ, Maron BJ, Estes NA. Whatis commotio cordis? Cardiol Rev. 1999;7(5):265–269

21. Link MS, Maron BJ, VanderBrink BA, et al.Impact directly over the cardiac silhouetteis necessary to produce ventricular fibrilla-tion in an experimental model of commotiocordis. J Am Coll Cardiol. 2001;37(2):649–654

22. Janda DH, Bir CA, Viano DC, Cassatta SJ.Blunt chest impacts: assessing the relativerisk of fatal cardiac injury from variousbaseballs. J Trauma. 1998;44(2):298–303

23. Link MS, Maron BJ, Wang PJ, Pandian NG,VanderBrink BA, Estes NA III. Reduced riskof sudden death from chest wall blows(commotio cordis) with safety baseballs.Pediatrics. 2002;109(5):873–877

24. Link MS, Bir C, Dau N, Madias C, Estes NA, III,Maron BJ. Protecting our children from theconsequences of chest blows on the play-ing field: a time for science over marketing.Pediatrics. 2008;122(2):437–439

25. Janda DH, Viano DC, Andrzejak DV, HensingerRN. An analysis of preventive methods forbaseball-induced chest impact injuries. ClinJ Sport Med. 1992;2(3):172–179

26. Weinstock J, Maron BJ, Song C, Mane PP,Estes NA, III, Link MS. Failure of commer-cially available chest wall protectors toprevent sudden cardiac death induced bychest wall blows in an experimental modelof commotio cordis. Pediatrics. 2006;117(4). Available at: www.pediatrics.org/cgi/content/full/117/4/e656

27. Nicholls RL, Elliott BC, Miller K. Impactinjuries in baseball : prevalence, aetiologyand the role of equipment performance.Sports Med. 2004;34(1):17–25

28. Haskell SE, Kenney MA, Patel S, et al.Awareness of guidelines for use of auto-mated external defibrillators in childrenwithin emergency medical services. Re-suscitation. 2008;76(3):354–359

29. Comstock RD. High School RIO: The NationalHigh School Sports Injury SurveillanceStudy. Paper presented at: American Acad-emy of Pediatrics National Conference andExhibition; San Francisco, CA; October 4,2010

30. Halstead ME, Walter KD; Council on SportsMedicine and Fitness. American Academyof Pediatrics. Clinical report–sport-relatedconcussion in children and adolescents.Pediatrics. 2010;126(3):597–615

31. Fleisig GS. The Biomechanics of BaseballPitching [dissertation]. Birmingham, AL:University of Alabama at Birmingham; 1994

32. Fleisig GS, Andrews JR, Dillman CJ, Esca-milla RF. Kinetics of baseball pitching withimplications about injury mechanisms. AmJ Sports Med. 1995;23(2):233–239

33. Fleisig GS, Barrentine SW, Zheng N, EscamillaRF, Andrews JR. Kinematic and kineticcomparison of baseball pitching amongvarious levels of development. J Biomech.1999;32(12):1371–1375

34. Nissen CW, Westwell M, Ounpuu S, et al.Adolescent baseball pitching technique:a detailed three-dimensional biomechanicalanalysis. Med Sci Sports Exerc. 2007;39(8):1347–1357

35. Fleisig GS, Weber A, Hassell N, Andrews JR.Prevention of elbow injuries in youth baseball

pitchers. Curr Sports Med Rep. 2009;8(5):250–254

36. Sciascia A, Kibler WB. The pediatric over-head athlete: what is the real problem? ClinJ Sport Med. 2006;16(6):471–477

37. Seroyer ST, Nho SJ, Bach BR, Bush-JosephCA, Nicholson GP, Romeo AA. Shoulder painin the overhead throwing athlete. SportsHealth. 2009;1(2):108–120

38. Putnam CA. Sequential motions of bodysegments in striking and throwing skills:descriptions and explanations. J Biomech.1993;26(suppl 1):125–135

39. Sabick MB, Kim YK, Torry MR, Keirns MA,Hawkins RJ. Biomechanics of the shoulderin youth baseball pitchers: implications forthe development of proximal humeral epi-physiolysis and humeral retrotorsion. Am JSports Med. 2005;33(11):1716–1722

40. Petty DH, Andrews JR, Fleisig GS, Cain EL.Ulnar collateral ligament reconstruction inhigh school baseball players: clinical re-sults and injury risk factors. Am J SportsMed. 2004;32(5):1158–1164

41. Andrews JR. Young throwers. Presented at:American Medical Society for Sports Med-icine Annual Meeting; Albuquerque, NM;April 2007

42. Baseball USA, Medical and Safety AdvisoryCommittee. Youth Baseball Pitching Injuries.November 30, 2008. Available at: http://web.usabaseball.com/news/article.jsp?ymd=20090813&content_id=6409508&vkey=news_usab&gid. Accessed December 19, 2010

43. Lyman S, Fleisig GS, Andrews JR, OsinskiED. Effect of pitch type, pitch count, andpitching mechanics on risk of elbow andshoulder pain in youth baseball pitchers.Am J Sports Med. 2002;30(4):463–468

44. Little League Baseball Inc. Protecting youngpitching arms. The Little League Pitch CountRegulation Guide for Parents, Coaches andLeague Officials. Updated for 2008. Availableat: www.littleleague.org/Assets/old_assets/media/Pitch_Count_Publication_2008.pdf.Accessed December 19, 2010

45. Little League Tournament and Regular SeasonPitching Rules Made the Same by Adoption ofNew Rule. November 24, 2009. Available at:www.littleleague.org/media/newsarchive/2009/Sep-Dec/LLTournamentRegularSeasonPitch-ingRulesMadeSame.htm. Accessed Decem-ber 19, 2010

46. Fleisig GS, Andrews JR, Cutter GR, et al.Risk of serious injury for young baseballpitchers: a 10-year prospective study. Am JSports Med. 2011;39(2):253–257

47. Kibler WB, McQueen C, Uhl T. Fitness eval-uations and fitness findings in competitivejunior tennis players. Clin Sports Med.1988;7(2):403–416

e854 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 14: Baseball and Softball abstract

48. Keeley DW, Hackett T, Keirns M, Sabick MB,Torry MR. A biomechanical analysis ofyouth pitching mechanics. J Pediatr Orthop.2008;28(4):452–459

49. Axe M, Hurd W, Snyder-Mackler L. Data-based interval throwing programs forbaseball players. Sports Health. 2009;1(2):145–153

50. Dun S, Loftice J, Fleisig GS, Kingsley D,Andrews JR. A biomechanical comparisonof youth baseball pitches: is the curveballpotentially harmful? Am J Sports Med.2008;36(4):686–692

51. Nissen CW, Westwell M, Ounpuu S, Patel M,Solomito M, Tate J. A biomechanical com-parison of the fastball and curveball inadolescent baseball pitchers. Am J SportsMed. 2009;37(8):1492–1498

52. Oliver GD, Dwelly PM, Kwon Y-H. Kinematicmotion of the windmill softball pitch in pre-pubescent and pubescent girls. J StrengthCond Res. 2010;24(9):2400–2407

53. Oliver GD. Powering the windmill: lowerbody mechanics of softball pitching. LowerExtremity Review. 2011;3(6):18–22

54. Kibler WB. Biomechanical analysis of theshoulder during tennis activities. ClinSports Med. 1995;14(1):79–85

55. Hill JL, Humphries B, Weidner T, Newton RU.Female collegiate windmill pitchers: influ-ences to injury incidence. J Strength CondRes. 2004;18(3):426–431

56. Mueller FO, Marshall SW; Baseball USA,Medical and Safety Advisory Committee.Safety equipment used in little leaguebaseball. June 2000; Updated August 11,2009. Available at: http://web.usabaseball.com/news/article.jsp?ymd=20090811&con-tent_id=6371824&vkey=news_usab&gid.Accessed December 19, 2010

57. Crisco JJT, Greenwald R; National Institutefor Sports Science and Safety; USA Base-ball, Medical and Safety Advisory Commit-tee. The why and how of bat and ballregulation. June 2000. Available at: http://web.usabaseball.com/news/article.jsp?ymd=20090810&content_id=6354586&vkey=news_usab&gid. Accessed December 19,2010

58. USA Baseball Medical/Safety Advisory Com-mittee. Use of the reduced impact ball inyouth baseball, ages 5–12. Available at:http://web.usabaseball.com/news/article.jsp?ymd=20090813&content_id=6410310&vkey=news_usab&gid= November 2008. AccessedFebruary 28, 2010

59. National Operating Committee on Stand-ards for Athletic Equipment, Baseball Hel-met Task Force. Standard Method ofImpact Test Performance Requirements forBaseball/Softball Batters: Helmets, Baseballs,

and Softballs. Kansas City, MO: NationalOperating Committee on Standards forAthletic Equipment; 1991

60. National Operating Committee on Stand-ards for Athletic Equipment. StandardPerformance Specification for Newly Man-ufactured Youth Baseballs. NOCSAE Docu-ment No. 027. Kansas City, MO: NationalOperating Committee on Standards forAthletic Equipment; April 2006; modifiedDecember 2006

61. Marshall SW, Mueller FO, Kirby DP, Yang J.Evaluation of safety balls and faceguardsfor prevention of injuries in youth baseball.JAMA. 2003;289(5):568–574

62. Wilson D. Effort to get metal to act likewood. The New York Times. October 18,2008. Available at: www.nytimes.com/2008/10/18/sports/baseball/18bats.html.Accessed December 19, 2010

63. Baseball USA, Medical and Safety AdvisoryCommittee. Wood and metal bats. March27, 2007. Available at: http://mlb.mlb.com/usa_baseball/article.jsp?story=medsafety10.Accessed December 19, 2010

64. The NCAA News and NCAA.com. Bat-testing regulations modified. October 8,2008. Available at: http://fs.ncaa.org/Docs/NCAANewsArchive/2008/association-wide/bat-testing%2Bregulations%2Bmodified%2B-%2B10-08-08%2B-%2Bncaa%2Bnews.html.Accessed December 19, 2010

65. Little League Online. Statement on non-wood bats. Available at: www.littleleague.org/media/newsarchive/Unknown_Dates/bats.htm. Accessed December 19, 2010

66. Little League Online. Little League Inter-national issues update regarding compos-ite bats: moratorium imposed immediately.December 30, 2010. Available at: www.littleleague.org/media/newsarchive/2010/Sep-Dec/CompositeBatMoratorium.htmAccessed January 4, 2011

67. Youth-Athlete’s Sports Blog. Bat rule changesfor 2009 season. Available at: www.youth-athlete.org/blog/post/2009/02/26/Bat-Rule-Changes-for-2009-Season.aspx. AccessedDecember 19, 2010

68. Wheeler BR. Slow-pitch softball injuries. AmJ Sports Med. 1984;12(3):237–240

69. Nadeau MT, Brown T, Boatman J, HoustonWT. The prevention of softball injuries: theexperience at Yokota. Mil Med. 1990;155(1):3–5

70. Janda DH, Bir C, Kedroske B. A comparisonof standard vs. breakaway bases: an anal-ysis of a preventative intervention forsoftball and baseball foot and ankle inju-ries. Foot Ankle Int. 2001;22(10):810–816

71. Janda DH, Maguire R, Mackesy D, HawkinsRJ, Fowler P, Boyd J. Sliding injuries in

college and professional baseball—aprospective study comparing stationary andbreak-away bases. Clin J Sport Med. 1993;3(2):78–81

72. Janda DH, Wojtys EM, Hankin FM, BenedictME. Softball sliding injuries. A prospectivestudy comparing standard and modifiedbases. JAMA. 1988;259(12):1848–1850

73. Little League Online. Disengage-able baserule. Available at: www.littleleague.org/learn/rules/Disengage-Able_Base_Rule.htm. Accessed December 19, 2010

74. Consumer Product Safety Commission.Baseball safety. CPSC Publication No. 329.Available at: www.cpsc.gov/cpscpub/pubs/329.pdf. Accessed December 19, 2010

75. Little League Playing Rules and Regulations.Rule 7.08 (a)(4). Available at: www.wad4llb.org/wp-content/uploads/2009/01/ll_safe-ty_rules.pdf. Accessed December 19, 2010

76. Pro Vest, Inc. Pro Vest baseball battingsafety vest test results. Available at: www.pro-vest.com/testresults.cfm Accessed January19, 2011

77. Berkson D, Queller H, Holmes N, Yun DS,Sandella B, Sargent T. Commotio cordis ina 17-year-old baseball catcher. PediatrCardiol. 2010;31(5):689–692

78. National Operating Committee on Stand-ards for Athletic Equipment. Standard testmethod and equipment used in evaluatingthe performance characteristics of pro-tective headgear/equipment. NOCSAE Doc.001-08m08b. Modified December 2008. Avail-able at: www.nocsae.org/standards/pdfs/Standards%20%2709/ND001-08m08b-Drop%20Impact%20Test%20Method.pdf. AccessedDecember 19, 2010

79. Waldstein D. Building a better batting hel-met. The New York Times. August 12, 2009:B11–B12

80. Rawlings Inc. S100 batting helmet. Availableat: www.rawlings.com. Accessed December19, 2010

81. Grin TR, Nelson LB, Jeffers JB. Eye injuriesin childhood. Pediatrics. 1987;80(1):13–17

82. Caveness LS. Ocular and facial injuries inbaseball. Int Ophthalmol Clin. 1988;28(3):238–241

83. Nelson LB, Wilson TW, Jeffers JB. Eye inju-ries in childhood: demography, etiology,and prevention. Pediatrics. 1989;84(3):438–441

84. American Society for Testing Materials.Standard F910-04. Standard specificationsfor face guards for youth baseball. Avail-able at: www.astm.org/Standards/F910.htm. Accessed December 19, 2010

85. American Society for Testing Materials.Standard F803-03. Standard specificationsfor eye protectors for selected sports.

PEDIATRICS Volume 129, Number 3, March 2012 e855

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 15: Baseball and Softball abstract

Available at: www.astm.org/Standards/F803.htm. Accessed December 19, 2010

86. Rice SG; American Academy of PediatricsCouncil on Sports Medicine and Fitness.Medical conditions affecting sports partic-ipation. Pediatrics. 2008;121(4):841–848

87. United States International Trade Commis-sion Rulings and Harmonized Tariff Sched-ule. NY G82707. Available at: www.faqs.org/rulings/rulings2000NYG82707.html.Accessed December 19, 2010

88. Coaches and sports officials guide tolightning safety. Available at: www.light-ningsafety.noaa.gov/resources/CoachGuide.pdf. Accessed December 19, 2010

89. Centers for Disease Control and Pre-vention. Heat illness among high schoolathletes—United States 2005–2009. MMWRMorb Mortal Wkly Rep. 2010:59(32);1009–1013

90. Bergeron MF, Rice SG, Devore CD; Councilon Sports Medicine and Fitness and

Council on School Health. Climatic heatstress and exercising children and ado-lescents. Pediatrics. 2011;128(3). Availableat: www.pediatrics.org/cgi/content/full/128/3/e741

91. Malina RM. 1988 C.H. McCloy research lec-ture: children in the exercise sciences. ResQ Exerc Sport. 1989;60(4):305–317

92. Malina RM, Bouchard C. Growth, Matura-tion and Physical Activity. Champaign, IL:Human Kinetics; 1991

e856 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 16: Baseball and Softball abstract

DOI: 10.1542/peds.2011-3593 originally published online February 27, 2012; 2012;129;e842Pediatrics 

COUNCIL ON SPORTS MEDICINE AND FITNESSBaseball and Softball

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/129/3/e842including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/129/3/e842#BIBLThis article cites 49 articles, 12 of which you can access for free at:

Subspecialty Collections

cal_fitness_subhttp://www.aappublications.org/cgi/collection/sports_medicine:physiSports Medicine/Physical Fitnessdicine_and_fitnesshttp://www.aappublications.org/cgi/collection/council_on_sports_meCouncil on Sports Medicine and Fitnesshttp://www.aappublications.org/cgi/collection/current_policyCurrent Policyfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

Page 17: Baseball and Softball abstract

DOI: 10.1542/peds.2011-3593 originally published online February 27, 2012; 2012;129;e842Pediatrics 

COUNCIL ON SPORTS MEDICINE AND FITNESSBaseball and Softball

http://pediatrics.aappublications.org/content/129/3/e842located on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1073-0397. 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on January 28, 2019www.aappublications.org/newsDownloaded from