The Throwing Athlete: Conflicts of Interest Managing Upper Extremity Problems in the Adolescent Athlete Orthopediatrics - consultant Dr. Nirav K. Pandya Dr. Nirav K. Pandya Director Pediatric Orthopaedic Sports Medicine Program Director Pediatric Orthopaedic Sports Medicine Program Clinical Assistant Professor, UCSF Nirav.Pandya@ucsf.edu Nirav.Pandya@ucsf.edu Goals Epidemiology • Global Approach to Pediatric Sports Injuries • History and Physical • Prevention Strategies • Common Conditions • • Little League Shoulder • Little League Elbow 1
“You have to throw above 90 mph to get drafted or get a scholarship. The only way to throw 90 mph in high school is to throw a lot and often at too young an age. Only 2% of high school athletes will get a scholarship with an average 4 year award of $11,000. We are ruining arms and wasting money” 2
Epidemiology • 5.5 million children = in-school sports • 30 million children = out of school sports Free Play No Longer Encouraged! This rise has occurred with a concurrent drop in school-based physical education with only 29% of all high school students participating in daily classes 3
Epidemiology 70% By age 13, 70 percent of kids drop out of youth sports. The top three reasons: Adults, Coaches, and Parents The Problem The Problem Starts Young!! 4
We are emphasizing skill development rather than fitness In 1993, Ericsson et al. proposed that in order to achieve expertise as a musician, one must practice 10,000 hours within that specialized field Defining the Problem Single sport specialization = intensive, year round training in a single sport at the exclusion of other sports. 5
Single Sport Specialization Early = Burnout Injury Social Isolation Poor Adult Health “Diversified sport training in early and At the collegiate level, DiFiori et al. examined a cohort of middle adolescence may better foster elite Division I athletes at their institution and found that 88% had participated in 2 -3 sports as children, with the vast majority athletic potential than specialization due to (70%) not specializing until the age of 12. a more positive transfer of skills” In addition, the average age of specialization between collegiate (Abernathy et al) athletes (15.4 years) and non-collegiate athletes (14.2 years) varied significantly. 6
. Putting It All Together Jayanthi et al. examined over 1200 athletes between the ages of 8 and 18, and found that athletes who spend more hours per week playing their sport than their age are 70 percent more likely to experience severe injury!!! Best Way To Keep UE Athletes Injury Free and Playing Sports?? 7
Key Point Pain and Fatigue The vast majority of pediatric upper extremity throwing injuries are due to three factors: Survey of 200 youth baseball pitchers 1. Overuse - 75% = pain / fatigue while throwing 2. Poor Lower Extremity / Core - 80% = pain the day after Strength - 50% = encouraged to stay in game even with pain / fatigue 3. Poor Mechanics Key History Questions Key History Questions • Hours / week, pitches / week, throws / week • Insidious and dull vs. sharp and traumatic pain • Position: pitchers AND catchers • Diffuse vs. localized pain • Pain and persistence of it • Pain before / after throwing vs. during throwing • Number of teams (club, school) • Normal motion vs. locking, instability, stiffness • Breaking balls vs. fastball • Pitching coach vs. parent • Medications / supplements / alternative tx vs. • Prior MSK problems • Family history 8
Very Key History Questions Pitching Limits • DECREASING VELOCITY • LOSS OF CONTROL • INCREASING FATIGUE • KNEE AND HIP PAIN • ELBOW STIFFNESS > 600 pitches a season increases injury risk Pitching Type Limits • 476 pitchers (ages 9 – 14) • 50% had shoulder /elbow pain • Curveball = 52% increased risk shoulder pain • Slider = 86% increased risk of elbow pain • Increased game and season pitches correlated with injury 9
• 95 adolescent pitchers with shoulder /elbow • 481 pitchers (ages 9 – 14) surgery • Injury = elbow surgery, shoulder surgery, • 45 adolescent pitchers with no surgery retirement • Overuse and fatigue associated with injury • 5% overall incidence • High pitch velocity and pitching in • > 100 innings / year = 3.5 times injury risk showcases associated with injury PE: Glenohumeral Internal Identifying the At Risk Athlete Rotation Deficit Common manifestations in the pediatric athlete include: 1. Chronic muscle or joint pain 2. Personality changes 3. Elevated resting heart rate 4. Fatigue 5. Lack of enthusiasm about practice or competition 6. Difficulty with successfully completing usual routines 10
PE: Glenohumeral Internal Assess Single Leg Squat Rotation Deficit Assess Popliteal Angles Core Stability 11
Assess Biomechanics Assess Biomechanics 1. Cocking = valgus stress as high as 120N, tension 2. Acceleration = rapid flexion of elbow 90 – 120 degrees 3. Follow-Through = rapid hyperextension, compression Assess Biomechanics Assess Biomechanics 1. Linear Lower Body In Relation To Arm = Increased 1. Horizontal Upper Arm= Increased Torque For Elbow and Rotation For Elbow and Shoulder Shoulder 12
Assess Biomechanics • 169 pitchers • Decreased injury: • Lower internal humeral rotation torque • Lower elbow valgus load • More efficiency of movement 1. Inverted “L”= Increased Torque For Elbow and Shoulder Imaging??? Top Cases Plain film on affected joint If under 14 (approximate), no MRI unless you fail conservative management!!! 13
Case 1: Little League Shoulder Case 1: Little League Shoulder • HPI: • 12 y/o RHD pitcher cc: R shoulder pain X 3 weeks • Parents: “He is going to play in the major league” • Kid: “I like the snacks after the games” • Pitching for 3 different teams • Throws every day of the week including curve balls • PE: • Tender to palpation over anterolateral shoulder • Decreased rotator cuff strength • No instability Case 1: Little League Shoulder Case 1: Little League Shoulder Treatment Options? Injured Side Normal Side 14
Case 1: Little League Shoulder Little League Shoulder – Key H + P • First described by Dotter in 1953 • Activity-related proximal arm / shoulder pain • Injury to the proximal humeral physis • Insidious onset • Due to overuse • Excessive pitching • Failure to limit pitch count • Inadequate rest • Rotator cuff weakness • Breaking pitches before skeletal maturity • Impingment Little League Shoulder – Differential Little League Shoulder – Imaging • Rotator cuff inflammation • Plain films show “separation” of proximal humeral physis • CHILDREN DO NOT GET TEARS!!! • Contralateral films • More common in older teens • MRI ONLY if failing conservative tx X 3 months • Glenohumeral instability • History of dislocation / trauma • Internal impingement • Internal rotation deficit • Neoplasm 15
Little League Shoulder - Treatment • Cessation of ALL throwing X 6 weeks • Physical therapy • After 6 weeks of rest & PT can begin throwing program if pain free • Return to pitching if pain-free after 3 months • Surgery not indicated Case 2: Little League Elbow Case 2: Little League Elbow HPI: • • 12 y/o male cc: R medial elbow pain x 4 weeks • Has been throwing multiple pitches (including curves) • Pitches every day • No trauma although felt a “pop” while pitching recently PE: • • Tender to palpation over medial epicondyle • No tenderness over capitellum • No ligamentous laxity 16
Little League Elbow = Medial Case 2: Little League Elbow - Imaging Epicondyle Apophysitis • Medial epicondyle ossifies between 5 – 7 yrs • Completes ossification between 14 – 17 yrs • Apophysis weaker than muscle, tendon and bone • Traction causes widening / separation and irritation of medial epicondyle apophysis Normal Side Treatment Options? Affected Side Assess Biomechanics Little League Elbow – Key H+P • Insidious onset of pain • History of trauma = worry about medial epic. avulsion • Decreased performance • Loss of motion • Tenderness in the medial elbow over epicondyle Apophysitis Capitellar • Muscle injury = diffuse TTP from Tension OCD from • OCD = lateral TTP Compression • MCL injury = laxity 17
Elbow Pain Little League Elbow – Imaging Differential Diagnosis • Image both elbows • Panner’s Disease • Widened apophysis • Medial Apophysitis • OCD of Capitellum • If x-rays negative, consider MRI if pain continues or • Olecranon Apophysitis worried about OCD or MCL injury • Hypertrophy of Ulna • Neoplastic Process • Muscle strain • MCL Injury • Neuropathy Medial Epicondyle Apophysitis - Capitellar OCD ≠ Little League Treatment Elbow • Rest, ice, NSAIDs • No throwing X 6 weeks • Physical therapy • Return to throw program after 6 weeks if pain free • Consider position change if pain continues • Consider surgery for avulsion fracture 18
Capitellar OCD ≠ Little League Elbow • Good outcome = stable, open growth plate, localized flattening / lucency, good elbow motion • Poor outcome = unstable, closed growth plate, fragmentation, restricted elbow ROM Traumatic Rotator Cuff Tears Traumatic Rotator Cuff Tears • Not common in the pediatric / adolescent population • Most pathology related to overuse and tendonitis • Activity modification, proper pitching mechanics, and PT 19
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