Regarding “Increased Elbow Valgus Torque During Pitching Is Not a Risk Factor for Medial Elbow Injuries in Young Baseball Pitchers: A Prospective Cohort Study”

We read with great interest the study by Saito et al.1 and commend the authors for addressing an important and clinically relevant question in youth throwing injury prevention. However, we believe that several important aspects were insufficiently addressed, and we respectfully offer the following comments to enrich the discussion. First, the observed association with age may reflect maturational vulnerability more than chronological age itself. Tsutsui et al.2 suggest that forearm-hand inertia peaks before shoulder musculature during the interval surrounding peak height velocity, creating a transient mismatch in distal segment loading and proximal muscular support. Likewise, Tariq et al.3 show that symptomatic throwing-elbow pathology evolves according to skeletal maturity rather than behaving as a single age-defined entity. Accordingly, future prospective models could be strengthened by incorporating peak height velocity, recent growth velocity, bone age or skeletal age, and, when feasible, apophyseal maturation status, rather than relying primarily on calendar age. Two pitchers of the same chronological age may differ substantially in tissue vulnerability if they are at different maturational stages. Second, preseason asymptomatic ultrasonographic abnormalities may represent a clinically meaningful preclinical susceptibility state. Asymptomatic medial elbow abnormalities on ultrasound are independently associated with subsequent elbow injury, and a substantial subset of players with baseline asymptomatic abnormalities later become symptomatic.4, 5 This has an important interpretive implication for the present study: if pitchers with structurally susceptible elbows were pooled with pitchers whose baseline elbows were normal, any relation between torque exposure and later symptoms may have been attenuated. Stratified analyses according to baseline elbow morphology, for example, normal ultrasound versus asymptomatic medial epicondylar abnormality, could help identify whether torque is differentially relevant once structural predisposition is present. From a clinical standpoint, preseason ultrasound may be most useful not as indiscriminate screening but as a risk-enrichment tool when combined with workload and growth data. Again, we sincerely thank the authors for their contributions. The authors (K.Q., Y.X., W.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.