Tag Archives: sports injuries

The real Hunger Games

For those unfamiliar with Suzanne Collins’ “Hunger Games” trilogy or its cinematic offshoots, the story revolves around a world where 24 teenagers are selected each year to battle to the death for the entertainment of a wealthy capital that the 12 poorer outlying districts support with their labor once tried to overthrow.

Every part of the tournament is marketed nationwide, the selection of the candidates, the training, the details of their struggles and finally the deaths in the arena and the glorification of the winners. Collins has said part of the idea came from the Roman practice of having gladiators fight for popular entertainment.

Japan’s arena

Collins could also have drawn inspiration from Japan’s summer national high school baseball tournament, creating her dystopian arena as a stand in for Koshien Stadium, Japan’s high school baseball mecca.

There, a sport officially recognized place in the national education system, is showcased, not as education but as mass entertainment.

In Collins’ world the real tragedy is not in the visible arena, but in the less visible system of brutality and authoritarianism that supports it, and the same is true in Japanese baseball. People are riveted to Koshien’s spectacle and care about the winners and losers. To a lesser degree, this is also true for prefectural tournaments, whose champions advance to that national arena.

Behind the scenes

Japan’s tragedy is in the system that supports the arena. At the elementary and junior high levels, competition mimics the Koshien model in the form of knockout tournaments in which a single loss equals heartbreak. Through endless, mind-numbing practice and abuse of pitchers’ arms, boys learn from a young age that the cost of victory is high and the bill often comes due in the form of broken bodies.

At the summer nationals, small adjustments have been made for the potential hazard of playing day after day in sweltering heat, rest days have been added in the final stages and international tiebreak rules were introduced in 2018 from the 13th inning to prevent overlong games. With that, the rule that forced games from 2000 to 2017 to be replayed from the start after 15-inning ties was abandoned.

The challenge

But the Koshien ideal that demands maximum effort and commitment remains ingrained and serves as a beacon informing an entire baseball culture that losing is hateful and mistakes therefore unacceptable in practice or in games from the moment a young child puts on a glove for the first time.

In December, Niigata Prefecture’s high school baseball federation, knowing that too many children were staying away from their sport when there are safer and less burdensome alternatives to baseball, acted to set an example.

For Niigata’s 2019 spring high school tournament, no player would be able to take the mound in a new inning after he’d already thrown 100 pitches in that game. The rule didn’t address practice time, pitching on consecutive days or affect any competition outside of Niigata, but it was a challenge to the status quo and to the idea that high school baseball is some kind of sacred temple that must not be fiddled with.

Niigata’s modest plan generated a tremendous backlash, with almost all of the responses falling into three categories:

  1. Forcing a team to take its best pitcher out of the game will make public schools with fewer good pitchers uncompetitive, making the spectacle less interesting.
  2. Batters will train to foul off more pitches to get the opposing starter out of the game, making games boring.
  3. It would eliminate marathon pitching feats that are a staple of tournament’s lore, crushing — for most pitchers – their lone chance at glory, further reducing the quality of the spectacle.

Some in the public supported the Niigata initiative, but they were drowned out by the chorus – including some from the national federation – that don’t want anyone messing with the ritual human sacrifice.

Japan’s High School Baseball Association authorities didn’t appreciate a local body overstepping its bounds and announcing rules without consulting their betters. In February, the national association instructed Niigata to “reconsider,” and the plan was withdrawn. After Niigata’s bold move drew praise from Japan Sports Agency chief Daichi Suzuki, the national association announced a blue-ribbon panel to study reform and health countermeasures.

A reporter who covered the proceedings told a Tokyo symposium on April 23 about an exchange he had with a national association executive at the time.

“He told me, ‘How do you know throwing more than 100 pitches is harmful? What evidence do you have? We are instituting a day off between games,’” the reporter said. “Is having a rest day between two 150-pitch games really OK? How can we possibly allow that?”

The Cambio Meeting symposium was the third annual meeting of a group dedicated to reinvigorating baseball in Japan from at its lowest levels by promoting education and rules to limit abuses. This year’s principle speaker, Dr. Kozo Furushima, has performed more than 1,200 surgeries on elbows and shoulders – mostly belonging to youth baseball.

Furushima told of a patient in junior high school, who had pitched his youth team to the semifinals of Saitama’s prefectural tournament, and about how his right elbow was deformed with three different injuries in comparison with his normal left elbow.

“Because his team couldn’t win if he didn’t pitch, he pitched every game and had been doing so for four years,” Furushima said. “His pain had started one week earlier. We needed him to extend his arm as far as he could for the X-Ray and he couldn’t. Some with the same injuries can’t bend their elbow.”

“Those injuries did not occur one week before. It was obviously not something that occurred suddenly because he was pitching in pain. The lesson from that is that just because you’re not in pain doesn’t mean you’re not hurt and not vulnerable.”

“This young man dreamed of being a pro, and now when I look at these (pictures of his arm), it makes my head hurt.”

Furushima presented research results that indicated, in declining order, four factors for increased injury among young pitchers.

  1. Pitching competitively for eight or more months a year, 5.05 times normal
  2. Frequently pitching with arm fatigue, 4.04 times
  3. 80-plus pitches per game, 3.83 times
  4. Throwing fastballs over 85 miles per hour, 2.58 times

One inspiration for the symposium has been regular travel by Furushima and others to the Dominican Republic, a country with a population of less than 11 million that has produced roughly 150 active players in North America with major league experience. Japan, with a population of nearly 127 million, currently has less than 1,000 players playing professionally around the world.

During his time as Lotte Marines manager, Bobby Valentine was puzzled about why a nation as large as Japan that is so passionate about baseball and has such high levels of economic and educational achievement and public safety does not produce more of the world’s best players. Why, he asked, should America or the Dominican Republic be better at producing baseball players than Japan?

Furushima, who has performed ultrasound examinations on youth players in Japan as well as Japan’s Under-12 team, found one reason: injuries to young players. He examined youngsters in the Dominican and found far fewer injuries than among Japanese players the same age.

What Furushima and his fellow travelers discovered in the Dominican Republic was a youth baseball environment far removed from the highly pressurized Japanese norm.

Future MLB Hall of Famer Albert Pujols, asked in March about his baseball training in the Dominican, contradicted one of Furushima’s assertions that coaches there never yell at players.

“Oh, I got yelled at,” he told Japanese media in Tempe, Arizona. “But the job of the coach is to not give the kids reason to give up on sports. They have to treat the boys as individuals, help them grow, encourage their love for the game.”

Ryunosuke Seno, one of the symposium’s leaders, won national “Boys League” championships in 1999 and 2000 as manager of Osaka’s Sakai Big Boys baseball club. Since then, however, he has gone from an old-school hard-ass coach to reform advocate.

“As manager, I had hard practices, I’d get angry, sometimes use physical punishment. We won a championship and celebrated. It was an exceptionally strong team, and what happened to the players on such a strong team? One would expect players like that to…go on to play pro ball, be good ballplayers. But that wasn’t the case. They quit baseball or got hurt. They were saying, ‘I’m done with baseball. I’m full of it. I’m tired of it.’ Guys were burned out, a lot of them.”

“I thought I’d been coaching correctly. But was carrying out my duties like that right? A lot of the kids on the championship team quit playing in high school. When I looked at kids playing on other teams, this guy hurt his elbow, that guy had surgery or quit. There were an amazing number of those kids. I began to question the purpose of what I was doing.”

Seno and his colleagues are now advocating rules that will, among other things, limit pitches in games and the amount of time teams are allowed to practice and take those decisions out of the hands of coaches who simply don’t know any other way than the old way.

“If you’re limited to two hours practice, that’s the rule, not the coach’s fault,” Seno said. “Tomorrow is the final, but because players can’t pitch on consecutive days, today’s pitcher can’t pitch again. That’s the fault of the rule, not the manager. But if there are no rules, the managers are thinking, ‘We want to win, he can pitch.’ And the child will say, ‘OK.’”

“It’s going to take a real long time before coaches realize you can’t force kids to practice so much. That’s because coaches don’t think what they’re doing is wrong. If a player is fatigued or in pain, the coach will ask if they’re OK. But the boys are trained to tough it out. So asking a player if he’s OK is akin to ordering a soldier in battle to charge.”

Although Niigata’s initiative failed to make concrete headway, it helped push the conversation. In January, the Japan Rubber Baseball Association, which oversees school tournaments for elementary, junior high and girls teams, announced a 70-pitch limit for this year’s national elementary school tourney.

“That is 100 times more important than the Niigata proposal,” Seno said.

That’s because while high school ball is the tip of Japan’s abusive baseball coaching iceberg, and the number of elementary and junior high school players is shrinking more rapidly than the nation’s declining birth rate, and eroding the base that high school and pro ball depend on.

“You’d think playing baseball is cheap for kids, but it isn’t,” a long-time youth coach said. “There is a huge burden on parents to come and provide lunches for the long practices, and the medical bills can be extravagant.”

One of the nation’s more progressive teams is the Tokyo Aoyama Club, which has one national little senior hardball championships for junior high school boys. Tokyo Aoyama leases its own grounds with a dormitory an hour drive from Tokyo, where kids practice virtually every day they aren’t in school. But when they play in tournaments, game experience rather than victory at all costs is the focus. Pitchers are not allowed to pitch on consecutive days and their pitch counts are monitored.

Still, the training is Spartan, with lots of running and strength training and the rules strict.

“They had a 1-kilogram bento rule,” said a woman whose son played with the club five years earlier. “The wanted you to eat so they could grow stronger. They would weigh the lunch boxes and if they weren’t heavy enough, the kids would get sent home.”

“Everyone was forced to eat that huge meal. My son was big, so it was no problem. But you’d see smaller boys crying because they couldn’t and then throwing up when they tried.”

At the Cambio Meeting symposium, one speaker who works for an NPB team, cited rapidly falling numbers of elementary and junior high school players across the country and predicted that even more high schools would soon find it difficult to field teams.

“One problem is that Japanese youth baseball is not fun,” he said. “Grounds are hard to secure, so little time is actually spent playing. Mostly kids are running. It is demanding and considered hard, and there are lots of hurdles to entry at the lowest level.”

“It needs to be made something the kids will want to come back and do more of. It needs to be fun.”

Dr. Furushima, however, said fun is not the old-school Japanese way.

“The old way is to shout at the boys and even hit them when they don’t do something the right way. But little boys who’ve never really played aren’t good at it when they start, so of course they make lots of mistakes, so many coaches who think they’re helping and doing the right thing will yell at them.”

“In high schools, if a pitcher gives up a lot of hits, there are cases where he is sent to the sidelines to throw a 250-pitch bullpen as punishment.”

“It really drives home the idea of how little hold the concept of human rights has in Japan.”

Getting to the root of the problem

This is the second part of a series centering around my interview with a leading Tommy John surgeon in Japan, Dr. Kozo Furushima.

Dr. Furushima
Dr. Kozo Furushima

Amid all the talk of the first pitch limits in Japan’s high school baseball world, Japan’s national elementary school tournament quietly received a 70-pitch limit this year. Working with the reform-minded head of the Japan Rubber Baseball Federation, Toyomi Munakata, Furushima assisted in the drive for change in Japan’s dogma-driven baseball world.

In this part, Furushima discusses the changes to this year’s system and gets down to the nuts and bolts of Japan’s problem — endless practice among players at the youngest ages that lead to more serious injuries as players grow older.

“I’ve been studying this issue for 12 or 13 years, in different sports but mainly baseball,” Furushima said. “I’ve examined the injuries of 6,000 to 7,000 baseball players, with more than 2,000 surgeries on baseball players alone. Why is it that junior high school and high school kids have to have surgery? I was thinking that for a long time.”

In the interview, Dr. Furushima explains avulsion fractures, caused when the pull from a ligament yanks the part of the bone it is attached to free from its surrounding bone.

Avulsion fracture X-Rays

These medial elbow avulsion fractures, if allowed to rest, will heal naturally, he said.

“Compared to adults, kids recover more quickly,” Furushima said. “For example, if a child breaks a bone, it will heal about a week faster than that of an adult. Adult bones take a month to regrow, children take about three weeks.”

Unfortunately, with kids practicing their sports year round, the time required to rest is very difficult to get. Compounding this, he said, is that the fractures only cause pain when under extreme stress. They don’t hurt in day-to-day activities so sufferers may not even realize the need for rest and treatment.

Dr. Furushima believes that about half the kids playing youth baseball between the fifth and seventh grades may have suffered from medial elbow avulsion fractures. His facility performed a study, with coaches alert to the problem bringing in their teams for examination. Of the 406 players examined, 167 showed signs of the injury.

“We had 406 children come for tests as part of a study. They didn’t particularly want to come,” Furushima said. “Of them, 167 had a history of pain in their inner elbow, 41.1 percent. These players came with their teams, whose coaches had a good awareness of the situation. These were good teams and even then, 40 percent had a history of pain. I have to think that among the teams that would never participate, the percentage would be higher than the teams whose coaches would willingly take part.”

Youth player survey

Although the consequences of these injuries are not overwhelming when the kids are young, as their bones become mature and more rigid, the fractures that have not healed are going to be a problem, particularly for ballplayers who have to throw hard using joints in which the ligament is loose and not properly attached to the bone.

In the MRIs below, the loose ligaments in the previously injured elbow can be seen as a squiggly line.

Injury consequences

Find the full story on Kyodo News HERE.

The introduction to the series was posted on Feb. 17.

All graphics courtesy of Dr. Furushima, Keiyu Orthopaedic Hospital Sports Medical Center.