(照片來源：紐時網站)
Arms-Control Breakdown
By RON BERLER
Most baseball pitchers pitch with pain. Alden Manning’s elbow pain began when he was 14, playing for his Greenville, N.C., middle-school baseball team in the spring of 2008. He would throw five or six innings and afterward, at Cubbie’s, a local burger joint, feel the inside of his right forearm near his elbow start to tighten. Back home, his dad, an orthodontist, would massage it with liniments and creams. The pain never worried Alden. He played baseball nearly year-round for four teams. That year, he “always had soreness,” he told me recently. “A lot of kids do.” After several days he would feel well enough to pitch again. But the ache never entirely went away.
The first time the pain really got to Alden was after an outing against E. B. Aycock, a powerhouse middle-school team in Greenville, just a mile and a half from his own school, C. M. Eppes. The schools had a fierce if lopsided baseball rivalry: Eppes hadn’t beaten Aycock in eight years. Alden, who would soon finish eighth grade and graduate, wanted badly to win. So did the Eppes coach, Danny Dally, whose career record against Aycock was 0-16. Ken Manning, Alden’s dad and perhaps the team’s biggest booster, felt the same way.
At Aycock that afternoon, Alden pitched six hard innings on a big-league-size diamond, throwing 80 to 90 pitches — near his limit, according to Dally. By then, Eppes held a 5-1 lead with three outs to go. Dally moved Alden to shortstop. Immediately, the relief pitcher ran into trouble, surrendering two runs, loading the bases and getting only one out. “In the stands,” Ken Manning told me, “we were all just suffering.” Manning climbed down the rickety aluminum bleachers behind third base and approached Dally. “It’s all right to put Alden back in and finish it up,” he said.
“You sure?” Dally asked.
“It’s fine,” Manning insisted.
The coach sent his 5-foot-7, 130-pound ace back to the mound. “I didn’t want to penalize the entire team when we had a chance at victory,” Dally told me this spring. Alden threw perhaps 15 more pitches and saved the game. When he got home, his elbow began to throb, the pain worse than ever. “It hurt just to move it,” he said.
Yet Alden kept pitching. About 10 days later, he asked off the mound in the middle of a game — something he had never done before — because his arm hurt so badly. Dally moved him to second base, believing he would be all right. Alden didn’t protest. Afterward he told his dad, “I was hoping nobody would hit the ball to me because I didn’t think I could throw it to first base.”
Near the end of the season, Alden had a batting lesson with Mike Mullis, his private instructor. Mullis, a former college coach and a part-time scout for the San Francisco Giants, knew about Alden’s elbow pain. When he learned Alden was scheduled to pitch in Eppes’s coming rematch against Aycock on shorter-than-normal rest, he advised against it. Ken Manning reminded him that it was for the conference championship. (More accurately, it was for bragging rights, because the Pitt County Middle School Athletic Conference crowns no champion.) “I know winning championships are great,” Mullis cautioned, “but we’re talking about a middle-school game versus a bright future.”
Driving home, Alden and his dad talked it over. They both loved baseball. Ken Manning, a large, gregarious man, played the sport through college and hoped his son could do the same, perhaps go even further. “Alden said his arm didn’t hurt, and he wanted to pitch,” Ken Manning said. “I said O.K. I thought, It probably won’t hurt him.”
Alden’s mom, Sharon, was nervous, however. That night she sent an e-mail message to Dally, asking him to limit Alden’s pitches. Dally, who had coached middle-school teams for 15 years and was sensitive to parental concerns, took her request seriously. He spent two days searching the Internet for recommendations on pitch-count limits and proper rest, then consulted the head baseball coach at the high school that Alden would attend that fall. While guidelines varied, he told Sharon in an e-mail message, all evidence indicated that pitching a full game would not place Alden at risk.
Three days later, Alden pitched a complete-game victory against Aycock. Eppes won bragging rights; Dally quietly celebrated. That night, Ken Manning tapped on the underside of his son’s forearm, near the elbow. It felt like brick.
Still, Alden kept pitching. He pitched for a Babe Ruth League summer team till the pain was too great, then played third base on the Babe Ruth All-Star team just to stay on the field. Finally, in September, he landed in the operating room with a torn ulnar collateral ligament, the stretchy, chicken-gut-like tissue at the elbow that binds the ulna, one of the two main bones in the forearm, to the humerus in the upper arm. The ligament had sheared from the bone — a result, simply, of having thrown too many pitches with too little rest under stressful circumstances. Alden needed what is known as Tommy John surgery, in which a tendon — most commonly the palmaris longus tendon in the forearm — is harvested to take the place of the damaged U.C.L. Holes are drilled in the ulna and humerus, which are then lashed together with the tendon. Alden would be out of baseball for eight months, unable to pitch for almost a year.
Dally told me he was saddened to learn of Alden’s surgery. He tried his best to protect the boy, he said. He mentioned the Internet guideline he followed regarding proper rest — one hour of downtime for each pitch thrown. “I don’t recall where I got it,” he said. Later he admitted, “I just don’t know what’s right.”
Neither did Ken Manning. “One of my main goals in life was to get my kids grown with no athletic injuries,” he said. “Now Alden gets out of school an hour early twice a week for physical therapy. I asked myself a hundred times, How can this happen to my son?”
As for Alden, he didn’t worry about complicated issues. “I just wanted to play,” he said.
THE SURGEON WHO operated on Alden is a folksy 67-year-old with a fondness for McDonald’s and a soft Louisiana twang. “Hey, buddy,” said James Andrews, reaching to shake my hand. He wore a brown-checked sports coat over green scrubs and white rubber boots — the jacket grabbed en route from the O.R. Before our meeting one morning in May, Andrews, the nation’s pre-eminent sports orthopedist, had already completed two operations.
We sat in a comfy V.I.P. lounge in Andrews’s new, $36 million OrthoSports Center on the campus of St. Vincent’s Hospital in Birmingham, Ala. Above us on a large flat-screen TV, ESPN speculated that the star quarterback Brett Favre would soon undergo shoulder surgery in order to return to the N.F.L. In fact, he was due to visit Andrews’s facility the next day. Over more than three decades Andrews has found fame and fortune repairing the joints of our sporting elite, many of them attached to the arms of star big-league pitchers — Roger Clemens’s shoulder, John Smoltz’s elbow, Steve Carlton’s shoulder, Chris Carpenter’s shoulder and elbow, to name a few. But Andrews didn’t want to talk about Favre.
About a dozen years ago Andrews noticed a trend — the number of teenage patients seeing him for shoulder and elbow injuries had begun to rise. In 2001 and 2002, he performed a total of 13 shoulder operations on teenagers. Over the next six years, he did 241 such operations. The surge in the number of Tommy John elbow operations was every bit as drastic: 9 from 1995 to 1998, 65 over the next four years, 224 from 2003 to 2008. Colleagues across the nation reported similar increases. “An epidemic” is how Andrews described the phenomenon to me. Alden’s Tommy John surgery, while successful, left a sour taste in his mouth. “The operation was designed for older, professional athletes,” Andrews said. “Now it’s just the opposite.” In 1996, he decided he wanted to do something about it.
Andrews said he feels sympathy for young, sidelined, high-performance athletes. Like him, they were forced from the playing field early, although in his case it was not because of an injury. Like them, he missed competing. In high school in Homer, La., a rural crossroads near the Arkansas border, Andrews played quarterback and cornerback and helped lead his football team to the state finals. He was a wiry 150-pounder, too small to play college ball but agile enough to land a Louisiana State University track-and-field scholarship. He excelled at pole-vaulting; in 1963, his junior year, he won the Southeastern Conference championship. Then, after his father died of lung cancer at the age of 43, he quit sports abruptly to accelerate his studies. “I had to help support my family,” he said. Andrews had always dreamed of being a physician — his grandfather, a farmer by trade, was an admired, if untrained, local country doctor — and he won early acceptance to L.S.U.’s medical school, skipping his senior year. The transition was difficult. “I’d wake up at night dreaming about pole-vaulting,” he said. “Still do.” He chose sports medicine, an emerging field in the early 1970s, to stay connected to sports.
In 1973, Andrews went to work for Jack Hughston, an obscure physician in Columbus, Ga., right next to the Alabama state line. To Andrews, he was a giant, “the modern father of sports medicine.” Back then, most sports doctors catered to professional and college teams. But Hughston, who was the team doctor for Auburn football games on Saturdays, arranged for a platoon of physicians to serve as volunteer team doctors for 30 or so high-school games on Friday nights. It was there that Andrews found his calling. “That’s where the injuries are,” he said. “That’s where kids are most vulnerable to get hurt. They don’t realize how it affects them the rest of their life. The younger they are, the more we need to protect them.”
When Andrews moved to Birmingham in 1986, he set up a practice similar to Hughston’s, with one additional component: a companion research lab that would study the causes of orthopedic sports injuries and how best to fix them. He opened what is now called the American Sports Medicine Institute in 1987 and hired Glenn Fleisig, a biomechanical engineer from M.IT. who had worked at the U.S. Olympic Training Center in Colorado Springs, to run it.
Initially, Fleisig’s research focused on repair and recovery. Then in the mid-1990s, as the number of young arm-injury patients began climbing, he saw Andrews grow increasingly, even visibly, agitated. “It’s the best pitchers who are being abused,” Andrews complained to him. “They’re the ones pitching all the innings.”He told Fleisig, “It’s time to do something about preventing injuries.”
WHEN YOU WIND UP to throw a pitch, Fleisig explained in his biomechanics lab, which is in a building near Andrews’s offices, you start a chain of motions unlike any other. Fleisig picked up a baseball, settled it in his hand. “Think of pitching as the sum of a series of coordinated sequences,” he said. He demonstrated each in slow motion, from windup to follow-through, and accompanied them with lectures on motion theory and physics. It took him 15 minutes. The same motion, replicated by Tim Lincecum, the star pitcher for the San Francisco Giants, who throws 100 miles an hour, takes less than a second. According to Fleisig, Lincecum’s pitching arm rotates at the speed of blur — if it made a circular motion, it would whip around almost 21 times per second. Youth-league pitchers don’t throw that hard, of course, but like big leaguers they push themselves to their bodies’ limits.
“Imagine a slingshot,” Fleisig said, referring to a pitcher’s cocked arm position just before release. “Anything with elastic, if you do it a lot, it starts to get little tears in it. When you have them in your elbow or shoulder, your body starts to say: ‘I feel sore. I better stop.’ That’s your body signaling, ‘We have a little damage, let me go fix it.’ It’s a brilliant system. But if you don’t stop, the tears get too big. They start connecting to each other, till no matter how long you rest, they’re too big for [the body] to repair.”
Stan Conte, the head athletic trainer and director of medical services for the Los Angeles Dodgers, explained it this way: “The biggest key to understanding this is, children are not little adults. They are children, and their bone structure is totally different. Yet we’re asking them to put the same stress in throwing a baseball that a professional does.”
When Andrews began to focus on protecting teenage pitchers back in the mid-1990s, pitching regulations for youth baseball were patchwork at best. There were at least 13 national and regional youth leagues operating under the umbrella of USA Baseball, which oversees all American amateur baseball, from T-ball to the Olympic team. Each had its own set of rules. Little League, for instance, limited pitchers to six innings per week, but that could still mean more than 100 pitches in a game — the same number a major-league starting pitcher typically throws. Bronco League, the division in PONY League Baseball equivalent to Little League, and Dixie Youth Baseball permitted their pitchers to throw a bit more.
At least these leagues had some oversight. The tens of thousands of youths playing for independent travel and all-star teams, competing in a hodgepodge of independently operated tournaments, adhered to few rules at all. In some weekend tournaments, pitchers could throw Saturday and in a doubleheader on Sunday. Stephen Keener, the president and chief executive of Little League International, recalled a tournament in which his son played. “His manager handed me a rule book,” he told me. “He said, ‘Would you look up the pitching rules, just to make sure I have it right?’ I looked through the index, and it said, ‘Pitching Rules.’ I flipped to the page, and it said, ‘There are no pitching rules.’ ”
Charles Blackburn, the executive director of the National Amateur Baseball Federation, which has run youth tournaments since 1944, described the tournament scene to me: “Everybody has their own philosophy on what should or shouldn’t be done. You go to these meetings, and some will say pitchers should be limited to 75 pitches in a game, some say 40 pitches, some say 150. We decided to avoid it. Everybody does their own thing. Basically, our managers will watch a kid, and if they see him struggling, they get him out of there. But some of these little kids have rubber arms.”
Many of these better kids were also playing on multiple teams with overlapping schedules. A 13-year-old might pitch Sunday for his travel team, Monday for his middle-school team and Wednesday for his Babe Ruth League team. Seldom would his two, three or even four separate coaches communicate among themselves; each might blame the others for overworking the player. Sometimes the dimensions of the field differed. One day a 12-year-old pitcher might be throwing from 46 feet for his Little League team, the next day from 60 feet, 6 inches for his middle-school team.
Worse, pitchers like Alden were playing baseball nearly year-round, to the exclusion of all other sports. Parents and their children were chasing the same lotterylike dreams — getting a leg up on peers competing for the high-school team, a chance at a college scholarship, a shot (perhaps) at that multimillion-dollar big-league contract. What parents failed to recognize was that kids need three to four months of recovery time each year — physically as well as mentally — from competitive baseball. The players Andrews operated on had two things in common: they pitched in pain, and their arms were fatigued.
In 1999, with $150,000 in financing and sponsorship by USA Baseball, Andrews and Fleisig began the first in a series of studies on the interlocking relationships between pitch count, pitch type, arm fatigue and pain. That year they collected data from 476 Alabama youth-league pitchers between the ages of 9 and 14. Their findings: Over the course of the season, more than half of the pitchers experienced shoulder or elbow pain. For each increment of 25 pitches thrown after 50 pitches, the percentage of pitchers experiencing pain increased as fatigue set in. Those who threw curveballs were 52 percent more likely to feel shoulder pain. Those who threw sliders were 86 percent more likely to endure elbow pain.
Alden was not part of the study. But he did throw a curve — a hard-breaking one that he learned at 12 and perfected at 14. “I swore my kid would never throw a curve in Little League,” Ken Manning told me. “But when he got to Little League, all the 12-year-olds were throwing curves. Those kids were good. You had to throw one if you wanted to compete.”
It wasn’t the curve, per se, that put Alden at risk. One of Andrews and Fleisig’s later studies proved, counterintuitively, that a properly thrown curveball places no more stress on the arm than a fastball. The problem is throwing it with good mechanics, which becomes increasingly difficult as a pitcher — particularly a teenage pitcher — grows weary. Another of their studies produced this startling figure: By the age of 20, a baseball player who has regularly pitched past the point of fatigue is 36 times as likely to need elbow or shoulder surgery as one who has not. Between his school team, Babe Ruth League team, all-star team and fall and winter travel team, Alden pitched 10 months out of the year — and had done so since he was 13. Andrews and Fleisig recommend lots of throwing, provided it’s in a noncompetitive situation. But Alden was pitching to win. He not only threw while fatigued; he never gave his arm a chance to rest.
In 2002, USA Baseball invited Andrews and Fleisig to its annual meeting in Orlando to present their findings. “For the first time, we had gotten all the youth-baseball programs together in one room,” Andrews said. “We had them sitting in a big circle, the whole bunch of them. I talked to them about trying to come together about rules, getting unified rules.”
But Andrews was received with indifference. “I got nowhere,” he said. “They said their own systems were working just fine.”
Fleisig went next. He presented his fatigue and pitch-count data. One person showed particular interest. “Steve Keener came up to me,” Fleisig said. “I had never met him before. He asked a lot of questions, was very proactive about it, very eager to have scientific knowledge. The other people in the meeting said, ‘That’s interesting.’ But afterward, Little League Baseball was the only one who called.”
STEPHEN KEENER IS a Little League lifer. As a child, he played Little League baseball in Williamsport, Pa., the organization’s international headquarters. He interned for Little League during college and stayed on after graduation. He has never worked anywhere else. Slender and intense at age 52, he is fiercely protective of the league’s image. And in August 2002, a year after Keener ascended to president and chief executive of Little League International, its image needed protection.
During the 2002 Little League World Series, millions watched on TV as Aaron Alvey from Louisville, Ky., threw 129 pitches and his opponent from Fort Worth, Walker Kelly, threw 118 in a national semifinal game. They each went 9 innings in an 11-inning game. Little League had relaxed its regular-season pitching rules for the tournament, so the additional three innings were permissible. But the league, which built its reputation on attention to safety (it was the first to introduce batting helmets, oversize chest protectors and throat guards), was widely criticized. In a marketplace crowded with youth leagues and travel teams, it couldn’t afford a stained image. Keener stepped up his correspondence with Andrews and Fleisig about pitch counts. Finally, in 2005, after seeing an episode on HBO’s “Real Sports” about an overworked 12-year-old pitcher who had Tommy John surgery, Keener decided to act.
“I took to a board meeting a video of that segment,” he told me in June. “There was a moment in that piece that was very revealing. The boy’s father had pushed him hard in travel ball. He said if he knew then what he knows now, he wouldn’t have done any of this. But he didn’t know.
“I remember saying to our board: They don’t know. This is the problem. Parents don’t know, coaches don’t know. They don’t have the expertise. They’re volunteers. Many of them think they’re doing the right thing. We know better.”
That spring, Little League became the first youth league to implement a pilot pitch-count program. Fifty of its member leagues took part. Following Andrews and Fleisig’s lead, 11- and 12-year-olds were limited to 75 pitches per game. Four days of rest were required for those who threw 61 pitches or more.
Almost from the start, though, Little League began to water down the recommendations. In 2006, the second year of the test program, Little League increased its pitch-count limit to 85. Although Little League’s Web site identifies Andrews as “the world’s foremost authority on pitching injuries,” he was not consulted beforehand. “We’re responding to our membership,” Keener told the doctor after the decision. “They’re telling us 75 is just too few to give a pitcher a chance to pitch a complete game.” The next year, when Little League rolled out the program to its more than 7,000 member leagues and 2.2 million players worldwide, Keener and his staff introduced a new adjustment — they sliced the four-day rest period for those who threw 61 or more pitches to three. Again, Andrews was not consulted. The member leagues and volunteer coaches wanted to make it easier for pitchers to pitch more than one game per week, Keener said.
Even so, Keener asked Andrews to endorse the changes. The doctor didn’t have much choice but to go along. No other youth-baseball organizations had adopted his pitch-count system or any other recommendations from him and Fleisig. “Anything they did was a step forward,” he told me. “You’ve got to have a starting point.”
Then Little League relaxed its guidelines even further for its annual 10-day, 32-game Little League World Series tournament, shortening rest requirements between outings.
CALEB DUHAY, a slender 12-year-old wearing braces on his teeth, strode to the pitcher’s mound in Williamsport last August before a crowd of 28,500 and took a deep breath. It was the championship game of the 2008 Little League World Series, and the prospects for his team, from Waipahu, Hawaii, depended largely on him. Duhay wasn’t nervous. According to his dad, Billy Duhay, he had already played this game a thousand times in his head.
Employing his entire repertory — four-seam fastball, two-seam fastball, slider, split-finger fastball, cut fastball and change-up, all taught to him by his dad — the 5-foot-6, 111-pound pitcher had held his opponent, Matamoros, Mexico, to three runs when manager Timo Donahue relieved him in the sixth inning with two outs left in the game. The rules required that Donahue remove him. Caleb Duhay had thrown 89 pitches. After 85 pitches, he was not allowed to face a fresh batter.
Waipahu won, 12-3. At the news conference afterward, Duhay seemed pooped. He should have been. In a space of 10 days, he pitched in four games and threw 288 pitches — all within league rules. To place this in perspective, last month, over the same time period, the Red Sox star Josh Beckett pitched twice and threw 201 pitches; C. C. Sabathia threw 214 in two games for the Yankees.
Duhay wasn’t the only workhorse pitcher in the 2008 Little League World Series. Over eight days, Takumi Ozeki of Tokyo threw 261 pitches. Over four days, Andrew Yacyk of Hagerstown, Md., threw 178 pitches; Ellis Drew of Jefferson, Ind., threw 170; and Chris Beyers from Saudi Arabia threw 161.
I asked Keener in June if he thought Duhay had thrown too many pitches. Keener was adamant. “He pitched less this way than he would have under the old, number-of-innings rule. That’s my answer. I’m not going to debate it. Is he throwing too many pitches? That’s what you’re asking. No.”
Billy Duhay was on Keener’s side. “People can criticize all they want,” he said by phone from Hawaii, “but what we’re doing is working. I’m a health consultant; I sell nutritional supplements. I know how the body works. Caleb has never had an arm injury, has no soreness. He has never iced his arm. Our next goal is for him to do well in high school, get a college scholarship and hopefully get to the pros. It has always been his dream to pitch in the big leagues.”
Others aren’t so sure he’ll make it. During spring training, I read off Duhay’s pitch counts — 89 pitches on Aug. 15, 2008; 20 more on Aug. 18; 90 pitches on Aug. 20; 89 on Aug. 24 — to Stan Conte, the Dodgers’ head athletic trainer. “How does that compare with what your pitchers do?” I asked. Conte looked at me with surprise. “Well, we wouldn’t do that,” he said. “We just wouldn’t do it. A manager or coach or trainer would lose his job if he did that. We look at a starting pitcher pitching once every five days — an older guy whose mechanics are good and, when everything’s right, throwing 100 to 110 pitches per week. And this is with years of training.”
Jamie Reed, the Texas Rangers’ head trainer, was more succinct. “I would tell you that I hope he has Dr. Keith Meister’s phone number,” he said, referring to the team physician, “because he’s probably going to need it sooner or later.”
As for Andrews, he dropped his head and sighed. Little League “came to me after the board had met and asked me if I’d endorse what they had agreed upon,” he said, referring to the relaxed tournament pitching rules. “And I said, ‘Absolutely.’ ” He went on to say: “At least we got something on paper where we could see if it would fulfill the bill to help decrease injury patterns and not destroy the flavor of the sport. We gotta go back and look at it. That needs to be done.”
Andrews says the biggest problem he faces is a marketing one. The information is out there — on his American Sports Medicine Institute Web site, on Little League’s Web site, on USA Baseball’s Web site, in countless other places — but it’s not being absorbed.
Last year, Andrews joined Little League’s board. And later this year he will spearhead a national campaign for the prevention of injuries in youth sports that he says he hopes is on a scale not seen since John F. Kennedy established the President’s Council on Physical Fitness. He is raising $50 million for the effort and plans to enlist as volunteers many of the sports stars whose careers he saved.
“We’re going to try to have a national education day simultaneously, throughout the country, on a Saturday, on radio, TV and the Internet,” he said. “It’ll be a three- or four-hour program. We’ll put on forums in all the major cities and smaller towns and utilize the members of our society,” the American Orthopedic Society for Sports Medicine, of which Andrews is the incoming president. “President Obama is an athlete, and I want to get him involved. We’ve got to make it so kids can stay out of the operating room and on the playing field, and let them grow up in a healthy environment.” It’s a lofty goal. His hope is to organize annual teach-ins over the next five years, each time concentrating on a different sport. Baseball will be first, because it’s the richest in available health research.
As for Alden Manning, it has been almost a year since his operation. Last month he returned to the mound for the first time, in a practice game for his Babe Ruth League team. “Alden pitched six innings and gave up a home run and retired all of the others,” Ken Manning told me in an e-mail message. His son’s fastball is faster than before. So Alden, at least, is all the way back — one of the lucky 80 percent who fully recover from Andrews’s Tommy John operations — as long as he doesn’t abuse his arm again.
Ron Berler has written for Wired, Men’s Journal and ESPN.com. This is his first article for the magazine.
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