Conflicts of Interest Managing Upper Extremity Problems in the - - PowerPoint PPT Presentation

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The Throwing Athlete: Managing Upper Extremity Problems in the Adolescent Athlete

• Dr. Nirav K. Pandya

Director Pediatric Orthopaedic Sports Medicine Program Clinical Assistant Professor, UCSF Nirav.Pandya@ucsf.edu

Conflicts of Interest

• Dr. Nirav K. Pandya

Director Pediatric Orthopaedic Sports Medicine Program Nirav.Pandya@ucsf.edu

Orthopediatrics - consultant

Goals

• Epidemiology
• Global Approach to Pediatric Sports Injuries
• History and Physical
• Prevention Strategies
• Common Conditions
• Little League Shoulder
• Little League Elbow

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“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

• f $11,000. We are ruining arms and

wasting money”

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Epidemiology

• 5.5 million children = in-school sports
• 30 million children = out of

school sports

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

Free Play No Longer Encouraged!

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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!!

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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

Single sport specialization = intensive, year round training in a single sport at the exclusion of other sports.

Defining the Problem

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Single Sport Specialization Early =

Burnout Injury Social Isolation Poor Adult Health

“Diversified sport training in early and middle adolescence may better foster elite athletic potential than specialization due to a more positive transfer of skills” (Abernathy et al)

At the collegiate level, DiFiori et al. examined a cohort of Division I athletes at their institution and found that 88% had participated in 2 -3 sports as children, with the vast majority (70%) not specializing until the age of 12. In addition, the average age of specialization between collegiate athletes (15.4 years) and non-collegiate athletes (14.2 years) varied significantly.

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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!!!

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Putting It All Together

Best Way To Keep UE Athletes Injury Free and Playing Sports??

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Key Point

The vast majority of pediatric upper extremity throwing injuries are due to three factors:

• 1. Overuse
• 2. Poor Lower Extremity / Core

Strength

• 3. Poor Mechanics

Pain and Fatigue

Survey of 200 youth baseball pitchers

• 75% = pain / fatigue while throwing
• 80% = pain the day after
• 50% = encouraged to stay in game even with

pain / fatigue

Key History Questions

• Insidious and dull vs. sharp and traumatic pain
• Diffuse vs. localized pain
• Pain before / after throwing vs. during throwing
• Normal motion vs. locking, instability, stiffness

vs.

Key History Questions

• Hours / week, pitches / week, throws / week
• Position: pitchers AND catchers
• Pain and persistence of it
• Number of teams (club, school)
• Breaking balls vs. fastball
• Pitching coach vs. parent
• Medications / supplements / alternative tx
• Prior MSK problems
• Family history

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Very Key History Questions

• DECREASING VELOCITY
• LOSS OF CONTROL
• INCREASING FATIGUE
• KNEE AND HIP PAIN
• ELBOW STIFFNESS

Pitching Limits

> 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

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• 95 adolescent pitchers with shoulder /elbow

surgery

• 45 adolescent pitchers with no surgery
• Overuse and fatigue associated with injury
• High pitch velocity and pitching in

showcases associated with injury

• 481 pitchers (ages 9 – 14)
• Injury = elbow surgery, shoulder surgery,

retirement

• 5% overall incidence
• > 100 innings / year = 3.5 times injury risk

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

Identifying the At Risk Athlete

PE: Glenohumeral Internal Rotation Deficit

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PE: Glenohumeral Internal Rotation Deficit Assess Single Leg Squat Assess Popliteal Angles Core Stability

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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

• 1. Linear Lower Body In Relation To Arm = Increased

Rotation For Elbow and Shoulder

Assess Biomechanics

• 1. Horizontal Upper Arm= Increased Torque For Elbow and

Shoulder

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Assess Biomechanics

• 1. Inverted “L”= Increased Torque For Elbow and Shoulder
• 169 pitchers
• Decreased injury:
• Lower internal humeral rotation torque
• Lower elbow valgus load
• More efficiency of movement

Imaging???

Plain film on affected joint If under 14 (approximate), no MRI unless you fail conservative management!!!

Top Cases

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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

Injured Side Normal Side

Case 1: Little League Shoulder

Treatment Options?

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Case 1: Little League Shoulder

• First described by Dotter in 1953
• Injury to the proximal humeral physis
• Due to overuse
• Failure to limit pitch count
• Inadequate rest
• Breaking pitches before skeletal maturity

Little League Shoulder – Key H + P

• Activity-related proximal arm / shoulder pain
• Insidious onset
• Excessive pitching
• Rotator cuff weakness
• Impingment

Little League Shoulder – Differential

• Rotator cuff inflammation
• CHILDREN DO NOT GET TEARS!!!
• More common in older teens
• Glenohumeral instability
• History of dislocation / trauma
• Internal impingement
• Internal rotation deficit
• Neoplasm

Little League Shoulder – Imaging

• Plain films show “separation” of proximal humeral

physis

• Contralateral films
• MRI ONLY if failing conservative tx X 3 months

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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

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Case 2: Little League Elbow - Imaging

Affected Side Normal Side

Treatment Options?

Little League Elbow = Medial 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

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
• Muscle injury = diffuse TTP
• OCD = lateral TTP
• MCL injury = laxity

Assess Biomechanics

Apophysitis from Tension Capitellar OCD from Compression

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Elbow Pain Differential Diagnosis

• Panner’s Disease
• Medial Apophysitis
• OCD of Capitellum
• Olecranon Apophysitis
• Hypertrophy of Ulna
• Neoplastic Process
• Muscle strain
• MCL Injury
• Neuropathy

Little League Elbow – Imaging

• Image both elbows
• Widened apophysis
• If x-rays negative, consider MRI if pain continues or

worried about OCD or MCL injury

Medial Epicondyle Apophysitis - Treatment

• 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

Capitellar OCD ≠ Little League Elbow

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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

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Traumatic Rotator Cuff Tears

• Most cases in the literature lesser tuberosity avulsions (8 cases)
• Reported on 4 cases of discrete tears
• All associated with a history of significant trauma
• Treated with cuff repair

Top 10 Young Athlete Throwing Points

• 1. Youth sports participation at all-time high
• 2. Single sport specialization is increasing
• 3. Limited scholarship and professional opp.
• 4. Encourage diversity and multiple sports
• 5. Poor mechanics, LE strength, and overuse
• 6. Warning = decreased velocity, loss of control,

fatigue, LE pain, elbow stiffness

• 7. Assess GIRD, single leg squat, core
• 8. Little League elbow and shoulder = rest

Top 10 Young Athlete Throwing Points

• 9. OCD is not Little League elbow
• 10. Traumatic rotator cuff tears don’t happen in

kids

Thank You