Three more outs. That's all coach Sam Tropiano needed to advance his Bishop Eustace High School baseball team into the 2018 New Jersey Non-Public South A championship game.

He had just the pitcher to do it, too. Senior infielder Sky Duff had already been through similar situations the season before. He was an effective reliever perfectly suited to protect the 11-9 lead his team had rallied to build against rival St. Augustine in the semfinal on June 1.

"If we didn't have a pitch count, we would have been state champions this year,'' Tropiano said recently as he took a break from the summer camp he runs at the Pennsauken school. "If I bring him in, it's lights out. He's a warrior.''

Ah, but there is a pitch count in high school baseball these days, the offshoot of a study published three years ago by the American Sports Medicine Institute that noted an alarming spike in elbow surgeries performed on players still in the throes of puberty.

Because of that, Duff could not pitch, and St. Augustine rebounded to win that game on a last-inning home run. For Duff, that may have been a lucky break.

According to the study, athletes ages 15 to 19 accounted for 56.8 percent of ulnar collateral ligament reconstruction procedures — Tommy John surgery, as it is popularly known —  from the start of  2011 through 2015. Those findings confirmed what many had suspected. Round-the-calendar participation in a single sport, particularly when it comes to pitching a baseball, is hazardous to your health, especially if you're not fully developed.

>> READ MORE: A look inside the OR during teen's Tommy John surgery

"I used to feel honored that my name was attached to it,'' former major-league pitcher Tommy John, 75, said recently about his 1974 breakthrough surgery performed by Frank Jobe. "It saved my career. But when you hear about kids younger and younger and younger having to go through it, it kind of puts a damper on it.

"I never would have guessed my name would be attached to an operation now more common with kids than pro athletes, thanks to what youth sports have become.''

John also never would have guessed that his eldest son, Tommy John III, 40, would become an advocate for rethinking how people approach youth sports and particularly how children are trained to play them. Published in June, the younger John's book, Minimize Injury, Maximize Performance: A Sports Parent's Survival Guide is a hybrid of warnings and observations, strengthening exercises, and advice culled from 17 years of work as both an instructor and rehab specialist. A former standout at Furman, the younger John saw his own career cut short by injuries that he believes might have been avoided if what he advises now had been applied back then.

"Over 17 years of doing rehab with soft-tissue injury, of seeing 40-, 50- and 60-year-olds,'' he said from his clinic in Southern California, "and then the injuries they were suffering started showing up in my baseball camps and lessons, in our sports performance areas. All sports. Boys and girls, even at 10, 11, 12 years, we were seeing overuse injuries more and more.

"I became obsessed with injuries in general and how to prevent them. It ended up I had to shut down my baseball business and get to the source of it. And that's where I've parlayed this whole thing. That was 10 years ago. And it's gotten worse since.''

Case in point: When the Phillies drafted Mickey Moniak first overall out of high school in 2016, they did so partly because he agreed to sign for less than the slotted signing bonus money for a first pick.

That allowed them to go spend more on a signing bonus to lure their second-round pick, pitcher Kevin Gowdy, away from attending college. Earlier that spring, there was considerable conjecture that the Phillies would use the top pick to draft lefthander Jay Groome of nearby Barnegat (N.J.) High School, who instead was chosen by Boston with the 12th pick.

Both pitchers will miss the entire 2018 season while recovering from Tommy John surgery.

Phillies pitcher Jesen Therrien, who made his major-league debut last summer, will miss this season after undergoing the procedure. Jesse Biddle, the Phillies' first-round pick in 2010 (27thoverall) from Germantown Friends School, underwent Tommy John surgery in 2015 and missed the entire 2016 season. Traded to the Pirates and then waived, he has finally made it to the majors this season as a reliever with the Braves.

In his early teens, Duff played on several traveling AAU teams with Groome and calls him a friend. "When we were younger, his work ethic wasn't great,'' said Duff. "But he got himself into really good shape.''

He did so by pitching. And pitching some more. With  high school, the travel teams that take up his summer, a lighter fall schedule of games, and winter training,  Duff figures he is involved in some baseball activity for at least 250 days a year. But he is also more responsible than many of his peers, Tropiano said. Duff opts out of participating in any infield throws on the days after a mound appearance and uses exercise bands in lieu of weights.

An only child, Duff also employs a trainer. So does teammate Matt Orlando, who is headed to Maryland in the fall. Still, both are only 18 and thus capable of getting caught up in the moment.

"You fought me tooth and nail any time I tried to take you out,'' Tropiano reminded Duff when the player tried to argue against the rule that kept him from pitching that final inning against St. Augustine last month.

Three days before, Duff had thrown 103 pitches over six innings in a 10-4 quarterfinal victory over St. John Vianney. New Jersey rules, established two years ago, state that any pitch count that exceeds 91 requires four calendar days of rest.

Those rules are based on standards established by the National Federation of State High School Associations after the publication of the ASMI findings. The Pennsylvania Interscholastic Athletic Association also installed similar pitch-count limits in the wake of these findings that  mandate that home teams supply an approved monitor for both teams who files a report after every game.

It's all meant to take the decision making — and temptation — away from overzealous players and coaches. Tropiano admits that had it been three seasons ago, Duff might have been on the mound for that final inning. He also agrees that "it's a good rule. It's a great rule.''

"I've been doing this for 31 years,'' said Tropiano. "Until about four or five years ago, a freshman coming into high school never, ever, ever could make it up to varsity. Just wasn't skilled enough. Wasn't ready. Now, over the last five years, one, two, three kids make it up to varsity as freshmen. Because of the advent of AAU ball, the advent of weight training, kids come to be so advanced. Their skills are so advanced that they make an immediate impact.''

Orlando was one such player, pitching and playing every day as a freshman. "Before him it was Chris Jones," Tropiano said. "Before him it was Nicky Brown. I could go on. That's all attributable to training, to the amount of games they play. What's gone by the wayside is the three-sport athlete. And so what else gets accelerated? Arm injuries. Now they're getting hurt sooner and sooner and sooner.

"So it's a great rule. It's going to save a lot of arms. I think we're going to see the residue of it in five, six, seven years. Because kids will stay healthier longer.''

Ah, but there's the rub. There are no limits or counts for AAU teams, and that allowed one of Tropiano's players to recently pitch three innings in one game and come back the next day for three more.

And one implied reason the Phillies wanted to lure Gowdy from college was to protect him from the possibility of overuse at that level. In the championship game of the  recently concluded College World Series, Oregon State freshman pitcher Kevin Abel threw 129 pitches in a 5-0 shutout of Arkansas. The day before, the 19-year-old Abel threw 23 pitches in a relief role.

Over a 10-day stretch culminating in the championship game, Abel threw 305 pitches.

"I was going to give everything I have, and I really appreciate them letting me go out there," Abel told ESPN.

Oregon supporters were quick to come to the defense of the coach who did so, pointing out that Abel had been underutilized for most of the season. Those who study and repair elbow injuries say that matters less than the arm trauma induced by so many pitches over so little time, especially when thrown at maximum velocity.

"This is the first generation of the year-round, one-sport athletes,'' said Glenn Fleisig, a physician and one of the authors of the ASMI study. "So today's young pro pitcher shows up with more damage in his ligaments and tendons because he didn't play multiple sports. He just pitched, and he's been getting little, microscopic, undetected injuries. Once he becomes a pro, it's already slightly torn.''

Reversing that, said the younger Tommy John, is going to take some doing. As Tropiano noted, more players are coming to him varsity-ready but with still-developing bodies.

"No parents want to intentionally hurt their kid,'' the younger Tommy John said. "It's that fear of missing out. You want to do what's best for them. To put the genie back in the bottle, we need to get the message across that what they think is the best might actually be the worst.''