Overuse Throwing Injuries in Youth Athletes R. Scott Cook, DO, FAOASM Director, St. Joseph Medical Center Sports Medicine Fellowship Consultant, Pittsburgh Pirates Consultant, Boston Red Sox Commonwealth Orthopaedic Associates
Overuse Throwing Injuries
in Youth Athletes
R. Scott Cook, DO, FAOASMDirector, St. Joseph Medical Center Sports Medicine Fellowship
Consultant, Pittsburgh PiratesConsultant, Boston Red Sox
Commonwealth Orthopaedic Associates
Goals
Identify common Sports Medicine throwing related
injuries in the young athlete.
Discuss Examination findings
Review typical radiographic findings
Discuss non-operative treatment options
Review surgical referral indications
Review return to play considerations
Discuss Issues surrounding Injury Prevention
ELBOW
Lateral Epicondylitis/Extensor Tendonitis
“Tennis Elbow”
Overuse of extensor muscle compartment
Repetitive Dorsiflexion & Supination
Wrist mechanics of throwing play role
Examination:
Lateral Epicondylar/Enthesis Pain to Palpation
“Chair Grip Sign”
Painful resisted wrist extension with handgrip activation
Radiographs
Plain Films typically normal
MRI ?
ELBOW
Lateral Epicondylitis/Extensor Tendonitis
Treatment:
Acute v Chronic v Recurrent
Epicodylar vs Extensor Muscle
NSAIDs
Activity Modification/Mechanical Evaluation
Ice Massage
Bracing – Counterforce
Physical Therapy
Injection Therapy?
Corticosteroid
Regenerative Therapy
Surgical Referral: Refractory cases
ELBOW
Radiocapitellar Osteochondritis
Typically gradual onset lateral throwing related elbow pain
Compressive side force from valgus load to elbow leads to repetitive
stress injury to osteochondral junction.
Physical Exam Findings:
Lateral pain over epicondyle and radial head palpation.
+/- Effusion
+/- Lateral Pain w Valgus Load (? Laxity)
ELBOW
Radiocapitellar Osteochondritis
Radiographic Imaging:
Plain Radiographs: May be inconclusive early on, however
develop capitellar lucency and irregularity late.
MRI: Helpful in determining extent of Osteochondral Injury
and stability of lesion.
ELBOW
Radiocapitellar Osteochondritis
Treatment:
Discontinue throwing.
Often become asymptomatic quickly with cessation of throwing
activity and any loaded full elbow extension.
Surgical Referral with MRI.
ELBOW
Medial Epicondylitis/Flexor Tendonitis
“Golfer’s Elbow”/”Little Leaguer’s Elbow”
Overuse load of valgus elbow stress with repetitive flexion &
pronation
Exam:
Medial Epicondylar/Flexor Tendinous pain to palpation
+/- Ecchymosis
+/- Milking Test
Radiographs:
Adults often normal
Comparison views in pediatric patients useful
MRI ?
ELBOW
Medial Elbow PainDifferential Diagnosis:
UCL Injury
Traction Apophysitis
Ulnar Nerve Injury(Always assess for Radiocapitellar Pain)
Treatment:Adult
NSAIDs, Activity Mod, Injection, Brace, PT/OT
Pediatric
Radiographic Fragmentation:
<5mm Displaced
Posterior Splinting 3-4 weeks
Graduated ROM/ITP 6 weeks
>5mm Displaced
Surgical referral
ELBOW
Medial Traction Apophysitis
Presentation:
Throwing related medial elbow pain; typically
subacute/recurrent
Often asymptomatic unless athlete throws.
Physical Examination:
Palpable pain at medial epicondyle
Valgus stress may or may not result in pain.
+/- Gross asymmetric prominence of medial elbow
ELBOW
Medial Traction Apophysitis
Radiographically:
COMPARISON VIEWS HELPFUL
Widening (asymmetrically) at medial apophysis
MRArthro may be helpful if significant valgus laxity presents.
Treatment:
Radiographic Widening < 5mm
Posterior splinting
Throwing/Activity cessation
Graduated Rehab follwed by ITP/Throw Mod 6-12 weeks
Radiographic Widening > 5mm
Surgical Referral
FOREARM
FOREARM STRESS FRACTURES
Forearm pain with activity.
Develops as overuse injury imparting recurrent excessive force to bone cortical bone.
Patient often lacks report of specific injury.
Softball, Baseball, Crew, Gymnastics, Power Lifting
Examination:
Often vague clinical exam findings
Examination maybe normal in office
Painful cortical fulcrum testing
Soft tissue swelling
Muscular Hypertrophy
Handgrip weakness
FOREARM
FOREARM STRESS FRACTURES
Differential Diagnosis:
Tendinopathy
Vascular Entrapment
Exertional Thrombus
Forearm CECS
Imaging:
Plain Radiographs often normal
Bone Scan
MRI
CT
FOREARM
FOREARM STRESS FRACTURES
Treatment:
Activity Modification/Cessation
Rest often leads to symptom alleviation
Immobilization
Grade of Stress Fracture
Location of Stress Fracture
Activity concerns
Retraining
Guided graduated RTP
Pitching analysis
Serology Workup
FOREARM
Forearm CECS
Presentation:
Vague repetitive throwing related pain.
“Heavy Arm” “Dead Arm”
Burning/Tingling
Difficulty with ball grip/mechanics
Physical Examination:
Often normal.
? Muscular/soft tissue hypertrophy/asymmetry
FOREARM
Forearm CECS
Diagnosis:
Imaging: Often negative globally
? Diffusion-weighted MR
CECS Intra-compartmental Pressure Testing:
Require exertional testing plan.
SHOULDER
Scapula Osseous Growth
Body, Spine, Coracoid Process, Acromion Process, Glenoid, Inferior Angle.
Arise from several ossification centers with varies stages of coalescence:
Coracoid: 14-18yo
Acromion: 19-20yo
Os Acromiale
Inferior Angle: 18-20yo
Glenoid Fossa: 20-25yo
SHOULDER
Kinetic Chain
Scapula serves as a link in Proximal-to-Distal sequencing of Velocity, Energy,
and Forces of shoulder function.
Generation, Summation, Transference
Scapula serves as pivotal link of transference of large
forces/high energy from lower body/core to the
arm/hand.
Also allows arm stabilization to absorb force loads through long-
lever dynamics to reduce injury.
SHOULDER
Scapular Anatomic Positioning at Rest:
Anteriorly Rotated (relative to trunk) approx 30°
Medial Border Rotated
Inferior Pole diverged 3-5° from Spine
Anteriorly Tilted 20° in sagittal plane
SHOULDER
Scapular Dyskinesis:
Affects normal Scapulohumeral Rhythm (SHR).
May lead to articular and/or soft tissue shoulder dysfunction.
May result in shoulder pathology and injury.
May result from injury causing inhibition of scapular stabilization.
Often contributes to “Overhead Comensatory Adaptation” in biomechanics and
GIRD.
SHOULDER
Scapular Dyskinesis
Alterations in STATIC scapular position and DYNAMIC scapular motion
resulting in scapular asymmetry in gross postural assessment and function
movement.
SHOULDER
SICK Scapula Factors:
Contracture/Inflexibility
Pectoralis Minor/SH-Biceps
Anterior Tilted Scapula
GIRD
“Wind-Up” Effect
Glenoid and Scapula pulled in forward-inferior direction
May result in ↑ protraction during arm-ADDucted position
SHOULDER
SICK Scapula:
Associated Shoulder Pathology:
Subacromial Impingement
Glenohumeral Instability
Glenoid Labral Injury
Rotator Cuff Injury
SHOULDER
Loss of Kinetic Chain Function
Disruption of transferal of lower extremity and core forces to the upper
extremity.
↓ Strength and Energy Use
↓ Acceleration Velocity
SHOULDER
SICK Scapula:
Treatment:
Activity Modification/Restrictions
Formalized/ Directed PT
Postural Scapular Control
K-Taping
Regular Home Program
Mechanical Evaluation
Imaging:
Case by Case
SHOULDER
Humeral Apophyseal Injury
“Little League Shoulder”
Presentation:
Vague shoulder pain; throwing related
Physical Evaluation:
Tenderness at lateral anterior humeral head/neck
Often examination is vague.
SHOULDER
Humeral Apophyseal Injury
Radiographic Evaluation:
Comparison Films Often needed:
SHOULDER
Humeral Apophyseal Injuries
Treatment:
Arm Rest: cessation of throwing
Rehabilitation: focus on scapular mechanics and RC strength and
develop regular stretching program.
Education
SHOULDER
Exertional Thrombus:
Paget-Schroetter Syndrome
Subclavian/Axillary Vein condition; develops from strenuous
exercise/arm use.
TOS comorbidity
Hyperabduction/external rotation mechanics predispose.
Hypercoagulation Workup considered
SHOULDER
Exertional Thrombus
Presentation:
Vague pain, weakness, fatigue. (Activity Related)
Swelling, Edema, Neuropathic complants
Diagnosis:
Duplex: limited (FPR – 30%)
MRAngio/ContrastCT: enhanced sensitivity/specificity and
anatomic survey of TO.
Catherized Contrast Venography: direct diagnosis and assesses
thrombolytic approach.
SHOULDER
Exertional Thrombus:
Treatment:
Thrombolytic Therapy
Surgical TOS Ressection
Rehabilitation/Mechanical Evalutaton
EDUCATION
Battles/Hurdles:
Multiple Leauges
Coach/Parent Education
Peer Pressure
Misplaced Goals
Ignorance
EDUCATION
MLB Pitch Smart
American Sports Medicine Institute
Little League.org
EDUCATION
MLB Pitch Smart
Global guideline for youth and adolescent pitchers for
organization leagues, travel, and tournament play.
Addresses concerns across multiple age groups specifically.
EDUCATION
MLB Smart Pitch
Address rest periods from throwing sports.
Address position change considerations.
Emphasize conditioning and mechanics development.
Pitch count recommendations.
Pitch style considerations.
Documentaion/Communication.
Education Education Education
EDUCATION
MLB Smart Pitch
AGE DAILY MAX (PITCHES) REQUIRED REST (PITCHES)
0 Days 1 Days 2 Days 3 Days 4 Days
7-8 50 1-20 21-35 36-50 N/A N/A
9-10 75 1-20 21-35 36-50 51-65 66+
11-12 85 1-20 21-35 36-50 51-65 66+
13-14 95 1-20 21-35 36-50 51-65 66+
15-16 95 1-30 31-45 46-60 61-75 76+
17-18 105 1-30 31-45 46-60 61-75 76+
Print PDF version
Questions??