The big question in many aspects of medicine is whether there is more of something or if it is simply better diagnosis than in the past.

In youth baseball programs, throwing injuries seem to have gone up despite pitching limits that weren't evident in the past. Professional baseball once used a four-man rotation and there was no consideration at all about pitching for kids.

But a multicenter, national research study says serious pitching injuries requiring surgery have skyrocketed, with one estimate reporting serious throwing injuries are occurring 16 times more often today than just 30 years ago.

Some of the findings conclude that, contrary to national guidelines limiting pitches thrown, 13.3 percent of pitchers pitched competitively for more than 8 months of the year, 40 percent pitched in a league without pitch counts or limits, 56.6 percent pitched on back-to-back days, and 19 percent pitched more than one game in the same day. 

Nearly one-third of these pitchers pitched for more than one team during the same season; one-third played only baseball and 10 percent also played catcher on the same team, another high-volume throwing position. 

Still, that is not different from 30 years ago, though surgeries are, leaving open the possibility that some injuries requiring surgery didn't get surgery then, so either pitchers stopped pitching (perhaps due to decreased effectiveness) or they healed without surgery.

A total of 754 pitchers between the ages of 9 and 18 participated in this national youth baseball study where all regions of the United States were represented. The average age of the pitchers was 14.1. The average age of first throwing curve balls was 12.2. The boys pitched on average 5.2 months per year, and when in-season, threw 5.4 innings per week. More than half pitched for a travel club, and 41.9 percent attended a pitching camp. Most importantly, one-third of the pitchers reported having a pitching-related injury in the past 12 months, seven out of 10 reported significant arm tiredness in the past 12 months, and nearly 40 percent reported significant arm pain within the past 12 months.

"Our research team and colleagues from around the country, saw several recurring themes," says Beaumont orthopedic surgeon and sports medicine specialist Joseph Guettler, M.D. . "It became very clear that dangerous pitching behavior is occurring among pitchers as young as little league all the way through their high school years. And, the blame doesn't usually lie with the leagues or coaches. Most were found to be adhering to nationally recognized guidelines for pitch limits and rest. It seems much of the blame lies with behavior of parents and their kids.

"The most prevalent reasons for arm pain and tiredness can be boiled down to five major issues. The following behaviors can lead to arm pain and tiredness which can then lead to the most significant shoulder and elbow injuries."

1. Pitching for more than one team during the same season

2. Pitching more than one game during the same day

3. Pitching on back-to-back days

4. Pitching in a league without pitch counts or playing year-round

5. Throwing curve balls before high school

That last one would seem to be the biggest problem compared to the past. Before the advent of 24-hour television and the Internet, younger players were not learning a curveball, coaches would not teach it. Arm strength was developed by throwing fastballs. 

In a curveball, the arm speed will be just as fast as a fastball but the grip and the position of the hand on the ball is different - and potentially more damaging if done improperly. 

To date, this is the largest study of its kind. It is also the first study to include all regions of the United States. The American Orthopedic Society for Sports Medicine sponsored the study.

Guettler says that the first step to bringing down the number of pitching injuries can be remembered with a simple, newly coined "Rule of Ones."

It means one game a day, one day of pitching then rest, one position at a time during a pitched game, one team at a time, only one pitch before high school, and at least one season of some other organized sport. And parents, if your young pitcher mentions that his arm is 'sore' or 'tired' – let him take some time off. One complaint of arm soreness or tiredness equals one week off.