Little League ElbowWhy is this such a persistent problem?

John Alsobrook, MD

Disclosures

• I have no financial interests, relationships, or potential conflicts of interest relative to this presentation

Case 1• 12 yo presents for follow-up of his hand fracture and new onset

elbow pain

• Patient fractured third metacarpal in right hand in October

• Jammed hand on opponent in football game• Non-displaced/Non-angulated neck fracture

• Immobilization in a brace for 4 weeks, with early ROM started at 3 weeks

• Fracture healed, no pain

• Football season was completed, so he rested and started conditioning for basketball

• Mild persistent hand swelling but full pain free ROM and function

Case 1

• Basketball started early in December

• He returned to play without issues or pain

• Started baseball conditioning just before Christmas

• One pitching lesson with coach

• Three weeks later, early January, he returned for another lesson with his coach

• 30-minute lesson threw about 50-60 pitches

• Remembers “developing soreness” in his LEFT throwing arm, medially

• Pain did not stop him from continuing

• Never felt a “pop”

• That evening and next day developed more pain – medial elbow

• Associated swelling

• No associated numbness or tingling

• Had not returned to baseball/throwing, but still plays basketball without pain

• Ice and NSAIDs help

• Presents to my office a week after the pain started with 6/10 persistent pain but at least improved

Little League Elbow,Why is this such a persistent problem?

A plethora of information . . .

• Published research in both scholarly journals and sports/social media

• Coaches have conferences and meetings before seasons

• Websites and training programs

• Relatives, friends, teammates . . . . Very common injury

• So why does little league elbow continue to plague our youth?

Coaches (Dads) “Just Don’t Care” Attitude?Compliance With Injury Prevention Measures in Youth Pitchers: Survey of Coaches in Little League of Puerto Rico Kristian J. Pamias-Velázquez,

MSPT,*† Mariam M. Figueroa-Negrón, MSPT,† Janiliz Tirado-Crespo, MSPT,† and Ana L. Mulero-Portela, PhD, PT† Sport Health: A Multidisciplinary Approach. May • Jun 2016. pp 274-277.

• Background: Because the problem of elbow and shoulder injuries in baseball pitchers between 9 and 14 years of age has led to more recent injuries, the USA Baseball Medical & Safety Advisory Committee and the Department of Recreation and Sports in Puerto Rico developed injury prevention guidelines for pitchers.

• Purpose: to determine the compliance of pitching coaches of 9- to 14-year-old Little League teams in Puerto Rico with the Administrative Order 2006-01 and the USA Baseball guidelines.

• Hypotheses: 1) coaches will have a satisfactory level of compliance with the order, and 2) coach level of education and years of experience will correlate with higher level of compliance.

• Results: • Most coaches (57.14%) do not have a certification as a coach from the Department of Recreation and Sports

• Only 48.57% of the coaches complied with the established guidelines for pitches thrown in a game.

• The number of pitches thrown in a game correlates with development of shoulder and elbow injuries

• The coaches who participated in this study did not demonstrate a satisfactory level of compliance with the USA Baseball guidelines nor with Administrative Order 2006-01.

• The findings of this study reflect the need to reinforce compliance with the guidelines (pitch count restrictions) for the prevention of injuries.

Why are parents so SURPRIED when

the physician uses a four-lettered

word as the initial form of treatment?

R – E – S – T

Is this Little League Elbow?

DifferenceIs Subtle

Elbow: Sport Medicine Discussion• Overview

• Run Through

• Anatomy

• History and Evaluation

• Differential Diagnosis

• Little League (Throwers) Elbow

• Risk Factors

• Treatment/Management

• Prevention

Elbow Injuries Overview

• Injuries to the elbow, forearm, wrist account for more than 25% of all sport-related injuries.

• Acute: falls, abrupt traction injuries

• Chronic: repetitive motion and overuse

• Sport Specific:

• Throwers: baseball, softball, javelin

• Endurance: swimming

• Power grippers: weightlifting, racquet sports

• Weightbearing: gymnastics, cheerleading

Baseball Numbers

• 15 million children and adults play organized baseball annually

• 5.7 million 8th grad or younger

• 17% of all children play baseball

• 500,000 at the high school level

• 1 in 200 senior boys who play interscholastic baseball in US will actually be drafted by the MLB

• Even fewer actually play in the MLB.

Baseball Elbow Injury Rates• Majority non-contact injuries to the dominant arm

• 6-12 yo, elbow pain incidence 1.5 per 1000• >/= 9 years 2.7 x greater risk than <9 yo per year

• 13-18 yo incidence 1.0 per 1000

• Pros incidence 1.7 per 1000

• Wilhelm: increased serious elbow injuries in pros who specialized in baseball before high school.• Coach and to a less extent parents are the reasons for

specialization before high school

• Correlations of these numbers prompt the question: “What are the reliable and valid risk factors?”

Risk Factors → Prevention

Elbow Anatomy

Elbow: Articulation Anatomy• Three interrelated joints

• Radiocapitellar joint

• articulation of the capitellum of humerus and radial head

• Ulnohumeral joint

• articulation of the humerus with coronoid process, trochlear notch, olecranon of ulna

• Radioulnar joint

• radial head and radial notch of the ulna: annular ligament

• Landmarks

• Medial epicondyle: origin of wrist and finger flexors and pronators

• Lateral epicondyle: origin of the wrist and finger extensors

• Olecranon process: insertion of the elbow extensors (triceps)

Elbow: Ligament Anatomy• Ulnar Collateral Ligament

• Origin: Medial Epicondyle → Insertion: Sublime Tubercle

• Function: Medial Stability

• Annular Ligament

• Origin: Ulnar Notch → Insertion: Ulnar Notch

• Function: Maintains Contact between proximal radius and ulna

• Radial Collateral Ligament

• Origin: Lateral Epicondyle →Annular Ligament

• Function: Maintains radio-capitellar alignment

• Lateral Ulnar Collateral Ligament

• Origin: Lateral Epicondyle (distal to Radial Collateral) → Supinator tubercle of Ulna

• Function: Maintains Lateral Elbow Stability

Elbow – Musculature Anatomy• Flexion and Extension at the ulnohumeral joint

• Flexion: biceps brachii and brachialis muscles

• Extension: Triceps and anconeus

• ROM arc (children and adolescents):

• -15 to 0 degrees in full extension

• 150 degrees full flexion

• ADLs requires 30 degrees extension and 130 degrees flexion

• Supination and Pronation

• Radius rotating over the stationary ulna at the radiohumeral and proximal radioulnar articulations

• Pronation: pronator quadratus and pronator teres (pronate the wrist)

• Supination: supinator and the biceps brachii

• ROM arc

• 90 degrees supination and pronation

• ADLs requires 50 degrees

Elbow: Neuroanatomy

• Median: medial to biceps tendon/brachial artery, antecubital fossa

• Innervates wrist flexor/pronator, finger flexors, thenar muscles

• Ulnar: posterior and medial, cubital tunnel of humerus

• Innervates the intrinsic muscles of hand and flexor carpi ulnaris

• Radial: anterior to the lateral epicondyle

• Innervates wrist extensors and supinators

• Musculocutaneous: lateral to antecubital fossa

• Innervates the elbow flexors

Elbow: Skeletal Development and Ossification

• Classified according to appearance and fusion of secondary ossification centers• Bone age milestones

• Childhood ends with appearance of all secondary ossification centers• Adolescence ends with fusion of all secondary ossificiation centers• Young adulthood ends with completion of all bone growth

• Girls are 1-2 years ahead of boys both appearance and fusion

• CRITOE (Appearance)• Capitellum(5,7 mos), Radial Head(4,5), Inner (Medial) Epicondyle(5,7),

Trochlea(8,9), Olecranon(9,10), External (Lateral) Epicondyle (11,12)

• TECORI (Fusion)• Trochlea (10,12), External (11,13), Capitellum(12,14), Olecranon (13,15), Radial

Head (14,16), Inner (15,17)

Little League Elbow Relevance

Elbow History and Evaluation

Elbow Pain History• History: Acute vs. Chronic

• Acute/Discrete Event

• Pain/Injury local to elbow vs. radiation from shoulder/neck

• Mechanism (fall, throwing, impact, etc)?

• Subacute or Chronic

• Insidious onset and longer duration of symptoms

• Repetitive activity or start of a new activity

• Frequency, intensity, duration, progression, mechanics of activity

History → Diagnosis

• Age• Throwing History (Acute, Subacute, or Chronic)

• Pain develops insidiously “over time” or “going on for a while”• No pain “until I felt a sharp pain or pop while throwing” • Mild pain for a while and “then it became sharp during or after my tournament

this past weekend”

• Young athletes often try to minimize their symptoms so they can continue playing the sport. . . • Aching, sharp pain, and swelling on the inside of the elbow. • Symptoms may occur only with pitching, but • May progress to the point when any throwing causes pain.

• But they can’t hide the Pain→ Change in Functional Performance• Pain with ADLs causing loss of ROM and/or loss of strength (usually an acute

history)• Pain with throwing causing loss of velocity, loss of control (ball sailing), endurance

fatigue (pain more chronic)

Elbow Evaluation

• Swelling +/- and Tenderness to medial epicondyle.

• Full Range of Motion, but pain may restrict it.• Full ROM varies from −15° to 0° of extension, through 150° of flexion around the ulnohumeral joint.

• Supination and pronation occur by rotation of the radius over the stationary ulna.

• The ulnar collateral ligament (UCL) is an important stabilizer of the elbow.

• Valgus stress testing at 30° of flexion should be performed to evaluate Pain and/or Degree of “functional” UCL instability.

• Any perceived laxity should be compared with the contralateral side and re-evaluated at 0° of extension.

• Neurovascular examination

• Sensation and strength testing in the distribution of the median, ulnar, radial, and musculocutaneous nerves

• Elicitation of the deep tendon reflexes of biceps [C5], brachioradialis [C6], and triceps [C7]

• Palpation of the brachial, radial, and ulnar pulses.

Elbow Diagnostic and Treatment Approach• Acute (acute pain, swelling, deformity) vs. Chronic (insidious onset, longevity of symptoms)

• History (event vs. overuse)

• Physical Exam: Correlate with History and Acuity/Chronicity of the pain

• Differential Diagnosis• Imaging

• Plain Radiographs – contralateral elbow and/or shoulder• CT• MRI• US?

• Diagnosis• Treat according

• Activity Modification and rest• Immobilization (splint, cast, sling)• Medications (Tylenol vs. NSAIDs)• Modalities: Heat/Ice, • Physical Therapy• Graduated Return to play/throwing

• Prevention

Differential Diagnosis in the Throwing Athlete(Relevant to Age, Acute vs. Chronic, and Medial Elbow Pain)

Youth or Open Physes

• Acute Little League Elbow• Medial epicondyle avulsion

fracture

• Medial Epicondyle Traction Apophysitis

• Chronic Little League Elbow

Adolescent/Adult or Closed Physes

• Acute• Ulnar Collateral Ligament tear

• Subacute or Chronic • Medial Epicondylitis

• Ulnar Neuritis

• Radiculopathy C8,T1

• Remember: throwers can develop pain other than medial• OCDs and Panners are common injuries/conditions in throwers• Scope of this talk is the more common medial elbow pain seen in throwers

Little League Elbow• Spectrum of medial epicondylar apophyseal injury in skeletally immature athletes

• Ranges from microtrauma to the physis to fracture and displacement of the medial epicondyle through the apophysis

• Valgus overload and Tensile overstress to the medial elbow → PAIN.

• Baseball players: • Arm cocking and Acceleration phase of throwing a baseball causes greatest stress• Repetitive stress →microtraumatic physis injury

• Potential for fragmentation, hypertrophy, separation of the epiphysis, or avulsion of the medial epicondyle :

• Growing bones easily injured because the physis is much weaker than the ligaments and muscles that attach to it.

Kinetic Chain of events – pitcher rotates pelvis then upper trunk to face target while abducted arm externally rotates at the shoulder

Peak values of shoulder IR torque and elbow varus torque are produced near time of maximal external rotation to decelerate shoulder external rotation

Tension in UCL absorbs half the maximum varustorque in this position

Repetitive pitching can lead to UCL injury

Although youth pitchers produce significantly less torque than adults, youth pitchers have more compliant connective tissue, open physes, underdeveloped muscles

Repetitive pitching → bony avulsion at the growth plate near the origin or insertion of anterior bundle of UCL

Elbow valgus torque is generated by both tension at medial elbow but also compression on lateral elbow

Compression of radial head and humeral capitellum can lead to OCD, osteochondral chip fractures, and AVN

From that arm cocked → elbow rapidly extends & shoulder rapidly internally rotates

Combination of elbow varus torque and elbow extension can cause posteromedial elbow impingement → osteophytes, loose bodies, chondromalacia at tip of olecranon

Throwing is a Bad Thing!• Throwing →medial traction and lateral

compression of the elbow

• Elbow Weakest Link in kinetic chain –connection of joints from 1st MTP to and through arm used to throw an object

• Biomechanical change anywhere in the body but especially in the shoulder and scapula caused by an injury• → abnormal throwing mechanics

• → secondary stress on elbow

• Throwing incorrectly, over and over:

BAD THINGME

INJURY (really bad)

Radiographic Findings• X-rays

• Physis open?

• Physis widened?

• Other: osteophytes, loose bone chips, or early arthritis.

• X-rays in patients with Little League elbow may show nothing abnormal, but the athlete may still have pain.

• Note: it is expected that a repetitive thrower with NO PAIN will still have a “widened” growth plate in the throwing elbow.

• Pain distinguishes the “normal” elbow from the “Little League Elbow”

• Advanced stages of the chronic disorder may include:• small fractures of the physis,

• loose bodies or bone chips, or

• early arthritis and bone spurs.

APOPHYSIS

Who gets Little League elbow?

• Most common between the ages of 8 to 15 years• Up to 17 years if the growth plate has not fused.

• Pitchers• Other at-risk athletes include high-volume throwing positions• Catcher, shortstop, outfielders are also susceptible.

• Studies (and common sense) link volume of throwing to elbow pain• number of pitches (pitch counts) thrown• number of games in which a young player pitches.• extra throwing associated with playing other positions (catcher)• extra throwing done outside of practice.

• This problem is seen much more commonly in baseball players who:• play year-round• Play pitcher and catcher• pitch for more than one team

Little League Elbow

• An INJURY that results in PAIN at the medial epicondyle in skeletally immature athletes which compromises their athletic performance

PAIN INJURY

(play through)PAIN (time loss) INJURY

RISK FACTORSModifiable vs Non-Modifiable

Volume Mechanicsheight

weight

ability

pressure

expectationstraining

focus range of motion

strength

NMC

stamina

experience

teaching

Tissue genetics?

growth rate

# years pitching

STRESS

Modifiable Risk Factors: Two Issues

1) Volume of Throwing

2) Quality of Throwing Mechanics

3) Both (well really 3 issues)

Risk Factors predispose Elbow pain in Baseball

Determining Risk → Impacts Treatment and Prevention

• PROBLEM: Accuracy in determining Risk

• Randomized controlled trials and Prospective Cohort Studies

• Preferred study design to provide direct and accurate estimates of incidence and risk

• Game vs. Lab

• Data Collection without bias

• No prospective studies exist linking specific mechanical patterns to injury incidence

• Need longitudinal tests necessary to determine what mechanics, if any, are critical to train and monitor in order to reduce injury rates

Risk Factors for Little League Elbow

• Independent factors• Age• Skeletal maturity• Growth/Weight changes and rates of change

• Genetics ??• Talent ??

• Sport(s), Position(s)

• Conditioning, Training, Practicing• Hours per practice, Practices per week, Weeks per year• Time Off, Activity during time off• Seasons or Years of experience

• Type of Training

• Sport specific• Cross training

• Strength training• NMC Training ??• Changes in skill training – “pitching coach”• Core and flexibility training

• Competition • Season or seasons (per year)

• Team or Teams (per season)

• Injury History

• Elbow (Posterolateral elbow impingement)• Shoulder (GIRD)• Other (lower half or core injury, tightness, flexibility deficit)

• Shoulder Specific • ROM (Arc, end ROM, Body Position)

• Symptoms• “Tightness”

• Strength• Scapular Dyskinesis

• Pitching History• Throwing when fatigued

• Physical• Mental (“stress pitching”)

• Number of pitches per game• Pitch count per inning• Pitching/throwing months in a row (8)• Fast Ball/speed variation vs. other pitch types• Pitching on more than one team per season• Number of positions/innings played per game outside of

pitching• Number of games played per day/weekend

• Pitching Symptoms• Soreness• Pain• Pain that affects performance• “The Will” to play through pain• Pain in other body parts that may affect

mechanics/performance

Flesig Glen S, Andrews, James R. Prevention of Elbow Injuries in Youth Baseball Pitchers. Sports Health. Sep Oct 4(5) 2012: 419-424

• Compilation review of epidemiologic, biomechanical, clinical studies of elbow injuries in baseball from January 2000 – April 2012.

• Strongest Correlation• Amount of pitching

• More months in a year (8)• More innings per year (100)• More innings per game• More pitches per game (80)

• Arm fatigue and regular pitching (36x likely to be surgical)• Travel team pitching or showcases

• Previous generations had same passion, parents, and temptation to throw hard and breaking pitches → but not opportunity for extensive schedules• Not uncommon for kids to play 70+ games (way more in this area) and play >8 consecutive months (more like 11)• Warm weather states vs cold weather states

• Pitcher/catcher combination (2.7x)

• Physical conditioning, nutrition, hydration, playing environment

• General fitness and athleticism vs sport specialization

• Early developers – bigger, faster, stronger – may be more at risk and less likely for Dad-the-coach to correct deficits in pitching mechanics because it may “worsen” performance

Glenohumeral Internal Rotation Deficit and Risk of Upper Extremity Injury in Overhead Athletes: A Meta-Analysis and Systemic Review. Keller, RA, DeGiacomo AF, Neumann JA, Limpisvasti OR, Tibone JE. Sports Health. 2018 March April; 10(2): 125-132

• No statistical significance in this pooled systemic review and meta-analysis found shoulder motion to be correlated to shoulder or elbow injury.

• GIRD was favored as a cause but not found significant

• Study however included handball, tennis, and softball players. High School and Collegiate ages, and focus more on shoulder injuries vs. elbow injuries

Risk Factors for Shoulder and Elbow Injuries in High School Baseball Pitchers: The Role of Preseason Strength and Range of Motion, Timothy F Tyler, Michael J Mullaney, Michael R Mirabella, Stephen J Nicholas, Malachy P McHugh. Am J Sports Med. 2014 Aug;42(8):1993-9.

• Absence of IR ROM loss (GIRD) in the shoulder may indicate inadequate prior exposure to pitching, resulting in increased injury risk

• Pre-season supraspinatus weakness associated with increased risk for major injury

The Effect of a High Pitch Volume on Musculoskeletal Adaptations in High School Baseball Pitchers. McHugh MP, Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ. Am J Sports Med. 2016;44(9):2246-54.

• Cohort Study: High pitch volume was associated with in-season supraspinatus weakness and diminished strength gains from year to year.

• High pitch volume appeared to have a catabolic effect on supraspinatus strength

Relationship Between Glenohumeral Internal Rotation Deficit and Medial Elbow Torque in High School Baseball Pitchers. Smith DG, Swantek AJ, Gulledge CM, Lizzio VA, Bermudez A, Schulz BM, Makhni EC. Am J Sports Med. 2019;47(12):2821-2826.

• Lab Study, 23 males (14-18 yo): HS pitchers with GIRD, no increased risk for increased medial elbow torque during throwing motion

• Authors suggest that ball velocity may have more impact on medial elbow torque

Correlation of Shoulder and Elbow Kinetics with Ball Velocity in Collegiate Baseball Pitchers. Post EG, Laudner KG, McLoda TA, Wong R, Meister K. Journal of Athletic Training. 2015;50(6):629-633.

• No significant association between ball velocity and• shoulder-distraction force• elbow-valgus torque• shoulder external-rotation torque

Sakata J, Nakamura E, Suzukawa M, Akaike A, Shimizu K. Physical Risk Factors for a Medical Elbow Injury in Junior Baseball Players: A Prospective Cohort Study of 353 Players. Am J Sports Med. 2017;45(1):135-143.

• Baseball players, 6-12, no hx of elbow pain (353 players, 325 boys); case-controlled study• Incidence of medial elbow injury 22.1%• Older age (>9), pitcher position, number throws/day (>100), thoracic kyphosis angle (>/=30 degrees),

elbow extension deficit (>/=5 degrees) associated with medial elbow injury

Risk Factors for Baseball-Related Arm Injuries: A Systematic Review, Cristine E Agresta, Kevin Krieg, Michael T Freehill. Orthop J Sports Med. 2019 Feb; 7(2): 1-13.

Youth

• Pitching > 100 innings per year

• Age 9-11 years

• Pitcher or catcher position

• Training >16 hours per week

Professional

• Elbow varus torque and shoulder ER torque during maximal external rotation during pitching

• Passive shoulder rotational and flexion range of motion deficits

• High pitch velocity

• Systematic Review of prospective cohort studies and randomized controlled trials

• Risk Factors differ among different skill levels (i.e. age)

VOLUME ROM = MECHANICS?

(play through)PAIN (time loss) INJURY

RISK FACTORSModifiable vs Non-Modifiable

Volume Mechanicsheight

weight

ability

pressure

expectationstraining

focus Range of Motion

strength

NMC

stamina

experience

teaching

Tissue genetics?

growth rate

# years pitching

STRESS

We identify the risk factors . . .

How should we really treat it . . .?Reactive Medicine vs. Preventative Medicine

Stop making it worse! Do it right next time!

ReduceVolume

ImproveMechanics

How do we treat Little League ElBow?

Is it as simple as just teaching it in the classroom?

Or should we learn “on the field?”

Are these injuries life or death?• Long Term Value of Baseball

• Fun

• Competitive Enjoyment

• Exercise

• Socialization

• Open doors to Education/Job

• Establish routine for regular activity

Treatment

• Treatment of Little League elbow involves 3 stages: rest, rehab, and return to pitching.

• Rest: complete rest from all throwing activities• Ice may relieve pain and swelling• NSAIDs but may (should) not be necessary if athlete is not throwing.

• Rehab. Individualized physical therapy programs• Elbow and shoulder range of motion work as well• Strength exercises. • Progress to include strengthening of the forearm, upper arm, shoulder, back, and core.

• Return to pitching. Return to throwing when pain-free, full ROM, and full strength. • Gradual progression from nonthrowing positions (like designated hitter), to • Less throwing positions (like first and second base), to • Full effort throwing positions• Return to pitching program: Outlines a progression of the number and the distance of throws

• Most cases clear with rest and conservative management• Timeline for recovery different for every athlete. • Returning “too soon” → recurrence of injury and/or long-term disability or deformity

• Fracture• Chronic disability• Early osteoarthritis.

The program should include elbow and shoulder range of motion work as well as and strength

exercises. Progress to include strengthening of the forearm, upper arm, shoulder, back, and core.

What is Neuromuscular Control?“Where am I in Space?”

• NMC level up from ROM and PRE’s

• Three components of NMC:• Proprioceptive retraining• Balance retraining• Stabilization retraining

• Mastering NMC →foundation for Functional Strength

• Elbow Functional Strength• Improved innate technique• Improved performance• Decreased Fatigue

• Functional Strength → foundation for Sport Success

Practice makes Perfect

Guide to elbow injury treatment and prevention (or visa versa)

• Understand the risk factors

• Recognize that “physical therapy” can improve performance

• Recover from injury, and

• Pitch “better”

• Incorporate Core Activation in daily life

• Warm up/Cool Down

• Focus on technique → performance follows

• Condition to be an athlete vs early sport specialization

Generic Elbow Rehabilitation Program

• Absence of an avulsion: Rehabilitation program similar to non-operative UCL:

• Reduction of pain and inflammation

• Restoration of motion and strength• Strengthening is gradual

• Isometrics prior to light isotonic exercises

• Core, legs, and shoulder strengthening encouraged• Often the youth has poor core and scapular control and weakness in shoulder musculature

• Stretching to normalize shoulder ROM – especially Shoulder IR and horizontal adduction

• Neuromuscular and sport specific training• No heavy lifting for 12-14 weeks

• Interval throwing program initiated when symptoms subside (8-12 weeks)

Phase 1: Immediate Motion:Minimizes Effects of Immobilization

• Early ROM nourishes articular cartilage and assists in synthesis, alignment, and organization of collagen tissue• functional tissue is better than scar tissue, and early ROM encourages

formation of functional tissue over scar tissue.

• Low-load long-duration stretching – helps to improve elbow extension

• Modalities to reduce pain and inflammation

• Voluntary muscle activation to retard atrophy• Sub-painful and submaximal isometrics: elbow and shoulder

• Scapular strengthening: safe and engaged when patient returns to throwing

• Alternating muscle strengthening → re-establish proprioception and neuromuscular control

Phase 2: Intermediate

• Initiated when following achieved• Full throwing ROM• Minimal pain and tenderness• Good 4/5 manual muscle test of elbow flexor and extensor musculature

• Goals• Maintain and enhance elbow and upper extremity mobility

• Shoulder flexibility emphasis – ER and IR

• Improving muscular strength and endurance• Isotonic contractions, concentric and then progressing to eccentric (Throwers Ten)

• Reestablishing neuromuscular control of elbow complex – prevents fatigue• Proprioceptive neuromuscular facilitation with rhythmic stabilizations and manual

resistance elbow/wrist flexion drills.

Phase 3: Advancing Strengthening

• Progression of activities to prepare the athlete for sport participation

• Prerequisite:• Full non-painful ER and IR• No pain or tenderness• Strength is 70% of the contralateral extremity

• Goals:• To gradually increase strength, power, endurance, and NMT to prepare for gradual

return to sport• Higher resistance, functional movements, eccentric contraction, plyometric activities• Elbow flexion is now eccentric, and light weights may be introduced• Advanced Throwers Ten (done on a stability ball)• Plyometric drills with weighted medicine balls

Phase 4: Return to Activity• Progress to competition • Prerequisite

• Exhibit full pain free throwing ROM• No pain or tenderness• Satisfactory isokinetic test• Medical clearance

• Interval throwing program• Long toss interval throwing program at 45 feet → progress to 120 or 180 feet• No pain or significant increase in symptoms• As intensity and distance increase → stressors on anterior shoulder and medial elbow increase• Warm-up (abbreviated Throwers Ten) and Cool Down (stretching)

• Throwing off a Mound• Increase number, intensity and pitch type• 50% intensity → 75% → 90% → 100% over a 4-6 week period• Initiate breaking balls once pitcher can throw 40-50 pitches at a minimum of 80% without

symptoms

Prevention• Year-round fitness and conditioning.

• Resistance training • Core, Rotator Cuff, Scapular Stabilizers• Aerobic Conditioning

• Active rest.• No throwing and play other sports• 3 to 6 months long to give the body time to rest and recover.

• Pitching guidelines.• Guidelines have been updated, researched, and summarized in a publication titled “Protecting Young Pitching

Arms.” • All young pitchers, parents, and coaches should be familiar with them• www.littleleague.org or ASMI Position Statement for Youth Baseball Pitchers.

• Control, command, and speed.• Focus on control (getting the ball in the strike zone). • Command (being able to place the pitch in certain areas of the strike zone). • Changing pitch speed. • (Although evidence is suspect) Guidelines:

• <14 yo fast balls and changeups. • >14 yo Curveballs • >16 yo sliders

Prevention

• Avoiding maximum effort throws.• Young pitchers need to avoid other high-demand throwing positions (catcher, short-stop, third base)

on days they have pitched. • They should also rest from pitching for 24 to 48 hours after an outing, including backyard practice.

• Avoiding further injury.• Avoid pitching through pain. • No pitching if athlete has pain around the elbow or shoulder, popping, or discomfort with throwing

until pain-free• Gradual return to throwing includes

• Warm-up and throws that are less than maximum effort• Pitching with less than maximum throws• Maximum effort pitches

• Proper mechanics.• Correct pitching and throwing mechanics stressed at a young age. • Poor mechanics can lead to injury (not necessarily proven for youth). • Biomechanic evaluation can be obtained from a qualified pitching coach or in a biomechanics

laboratory.

Prevention

• Committee on Sports Medicine and Fitness of the American Academy of Pediatrics and Little League Baseball • Preventative measures to prevent injuries in young pitchers

• Restrictions on amount of pitching

• Limit pitches per game

• Months per year spent pitching

• Instruction in proper throwing techniques

• Avoidance of pitching when arm hurts or is fatigued

• Education of coaches, parents, children

• Warm-up exercises, dynamic mobility, strength, post activity stretching

• Rotator cuff strengthening/scapular stabilization – closed chain vs open chain

• Maximize ROM – prevention of GIRD

• What about a PREVENTION PROGRAM?

Sakata J, Nakamura E, Suzuki T, Suzukawa M, Akaike A, Shimizu K, Hirose N. Efficacy of a Prevention Program for Medial Elbow Injuries in Youth Baseball Players. Am J Sports Med. 2018 Feb;46(2):460-469.

• Cohort Study that was not randomized

• YKB-9: 9 stretching and 9 strengthening exercises; 20 minutes, 1 x a week• Reduced medial elbow injury• Improved physical factors associated with medial elbow injury (TROM, Hip IR ROM,

Thoracic Kyphosis angle)• Also claimed that improving ROM/strength (physical function) had more impact on

injury reduction than volume/pitch count

• Limited study:• Not randomized nor blinded• Confounding variable: mechanics not evaluated• Quality of doing the program not monitored• Prior injured players not included.

Sakata J, Nakamura E, Suzuki T, Suzukawa M, Akeda M, Yamazaki T, Ellenbecker T, Hirose N. Throwing Injuries in Youth Baseball Players: Can a Prevention Program Help? A Randomized Controlled Trial. Am J Sports Med. 2019 Sep;47(11):2709-2716.

• Randomized Controlled Trial

• Program (mYKB-9) reduced to 9 exercises (from 18): 5 stretching, 2 dynamic mobility, 2 balance training; 10 minutes, 1 x a week

• 1.2 per 1000 AEs intervention vs. 2.1 per 1000 AEs: 42.8% reduction• Compliance improved (73.4%) and Self reported compliance

improved outcomes• Ball speed and ROM measures improved in the intervention group

• Limitation:• Not blinded

ASMI Position Statement

• Competitive pitching and pitching while fatigued are strongly linked to injury.

• Other risk factors may include:• pitching on multiple teams

• pitching year-round

• playing catcher when not pitching

• poor pitching mechanics

• poor physical conditioning.

Little League ElbowWhy is this such a persistent problem?

• Challenging to Identify Risk Factors• Variability in Coaching (affects volume and mechanics)• Perceived Risk/Reward – “injury not that bad”• Common Sense does not always prevail• Incorporate Prevention Measures/Program in Training

(play through)PAIN (time loss) INJURY

Volume MechanicsSTRESS

Prevention ProgramStrength, ROM, NMC

ROM

Youth Professional

• Increased throwing/pitching volumes and poor throwing/pitching mechanics have been shown to increase the risk of elbow pain/injury in baseball

athletes.

• However, appears that volume tends to have more of an effect on the youth, and poor throwing

techniques that increase shoulder external rotation and elbow varus torque may have more of an effect

on professional pitchers.

• Even if volume is minimized, youth pitchers who develop poor pitching techniques and ignore other

injury prevention strategies (incl. shoulder ROM stretching) may be at higher risk of elbow injuries if

they pursue pitching at the professional level.

Case 2

• HM is a 13 yo baseball and football player injured medial right elbow on 9/3/20. • During first throw in a football game, he felt a pop in his elbow.

• Noted to have some soreness 6 weeks prior to the acute injury. • Seen by another physician who ordered and MRI and by patient report it showed medial

epicondylitis.

• Ice, Motrin and Rested for 3 weeks, and “gradually progressed” back to regular activity.

• No pain until “pop” yesterday on 9/3/20.

• He had been working with a throwing coach to clean up his mechanics

• Exam

• Pain and swelling over the medial epicondyle, limited ROM, 3/5 elbow strength (pain driven)

• Xrays – 1.5 cm separation of the medial epicondyle avulsion fragment.

9/3/20

Case 2

• Assessment• Avulsion fracture – medial epicondyle

• Plan• Casted for 4 weeks

• 9/18/20 (week 2) re-x-ray in cast

• 10/2/20 cast removed and x-rays. Healing noted, transferred to a splint to start ROM.

• 10/16/20 – d/c splint and was using just the sling• Exam showed full extension and flexion loses only about 15 degrees• Started PT for 4 weeks. No throwing or batting yet

• 11/13/20 – doing better and able to bear weight• Now has full ROM• Allowed him to start training and throwing.• December he will be able to work with pitching coach on mechanics and

warm-ups• Start batting now – tee → light toss → progress to cage• Upper body workouts in January – but start pushups and band work now.

9/18/20

10/2/20

10/16/20

11/13/20

Case 3 - Zebra

• HK, 17 yo volleyballer presents in November with medial elbow pain• Started 3 months prior in August during HS season

• Pain with passing or any full elbow extension activity

• Played through pain, managing with NSAIDs

• Beach season has started and pain significantly worse• 7-8/10 but only when she bumps the ball

• Sore briefly after each bump, no n/t in her fingers

• Tender posterior and medial • Cubital tunnel is + for pain and + Tinel's

• Pain over medial epicondyle

• No pain over UCL with Valgus stress at 30 or 0 degrees extension

• Full elbow extension – but painful. Shoulder no deficits

• DDx: Ulnar Neuritis vs UCL Sprain

• Plan: Rest and PT

• 2 weeks later – PT/rest not helping. MRI ordered

Anconeus Epitrochlearis

Ulnar Nerve

Anconeus Epitrochlearis

• Variant – replaces Osborne’s Ligament

• Prevalence 1-34%

• Hypertrophied can cause dynamic Cubital Tunnel Syndrome

• Typical symptoms are with activity

• Baseball: symptoms with repetitive extension

• Welder and vocal artist: symptoms with prolonged flexion

• 10% decrease in Pre- and post-exercise measurements (after symptoms develop)

• pinch and grip strength

• nerve conduction velocity

• MRI shows anconeus epitrochlearis and/or other pathology

• Dynamic US may show: ulnar nerve subluxation, Anomalous head of the triceps, Snapping triceps syndrome

• Treatment:

• Activity modification and/or rest

• Persistent symptoms: Excise the muscle and decompression of the nerve

Anconeus Epitrochlearis References

• Morgenstein A, Lourie G, Miller B. Anconeus Epitrochlearis Muscle Causing Dynamic Cubital Tunnel Syndrome: A Case Series. The Journal of Hand Surgery. 2014; XXE(X):1-2.

• Nascimento SRR, Ruiz CR. A Study on the Prevalence of the Anconeus Epitrochlearis Muscle by Magnetic Resonance Imaging. Rev Bras Ortop. 2018;53(3):373-377.

• Von Bergen TN, Lourie GM. Etiology, Diagnosis, and Treatment of Dynamic Nerve Compression Syndromes of the Elbow Among High-Level Pitchers. The Orthopedic Journal of Sports Medicine. 2018;6(11):1-5.

References

❖ Agresta C, Krieg K, Freehill M. Risk Factors for Baseball-Related Arm Injuries: A Systematic Review. Orthop J Sports Med. 2019 Feb;7(2):1-13.

❖ Anz, AW, Bushnell BD, Griffin LP, Noonan TJ, Torry MR, Hawkins RJ. Correlation of torque and elbow injury in professional baseball pitchers. AM J Sports Med. 2010;38(7):1368–1374.

❖ Arnold, A, Thigpen C, Beattie P, Kissenberth M, Shanley. Overuse Physeal Injuries in Youth Athletes: Risk Factors, Prevention, and Treatment Strategies. Sports Health. 2017;9(2):139-147.

❖ Bushnell, B. D., Anz, A. W., Noonan, T. J., Torry, M. R., & Hawkins, R. J. (2010). Association of maximum pitch velocity and elbow injury in professional baseball pitchers. Am J Sports Med. 2010;38(4):728–732.

❖ Chorley J. Elbow Injuries in Active Children or Skeletally Immature Adolescents: Approach. Up-To-Date. 2020.

❖ Dwek JR. A Segmental Approach to Imaging of Sports-Related Injuries of the Pediatric Elbow. Sports Health. 2012;4(5):442-452.

References

References

❖Fehr S, Damrow D, Kilian C, Lyon R, Liu XC. Elbow Biomechanics of Pitching: Does Age or Experience Make a Difference? Sports Health. 2016;8(5):444-450.

❖Fleisig GS, Andrews JR. Prevention of Elbow Injuries in Youth Baseball Pitchers. Sports Health. 2012;4(5):419-424.

❖Fleisig GS, Andrews JR, Cutter GR, et al. Risk for serious injury for young baseball pitchers: a 10-year prospective study. Am J Sports Med. 2011;39(2):253-257

❖Keller RA, DeGiacomo AF, Neumann JA, Limpisvasti OR, Tibone JE. Glenohumeral Internal Rotation Deficit and Risk of Upper Extremity Injury in Overhead Athletes: A Meta-Analysis and Systemic Review. Sports Health. 2018 March April;10(2):125-132.

❖Matsuura T, Imame T, Suzue N, Arisawa K, Sairyo K. Risk factors for shoulder and elbow pain in youth baseball players. Phys Sportsmed. 2017;45(2):140-144.

❖McHugh MP, Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ. The Effect of a High Pitch Volume on Musculoskeletal Adaptations in High School Baseball Pitchers. Am J Sports Med. 2016 Sep;44(9):2246-2254.

References

References

❖Norton R, Honstad C, Joshi R, Silvis M, Chinchilli V, Dhawan A. Risk Factors for Elbow and Shoulder Injuries in Adolescent Baseball Players: A Systematic Review. Am J Sports Med. 2019 Mar;47(4):982-990.

❖Pamias-Velazquez K, Figueroa-Negron MM, Tirado-Crespo J, Mulero-Portela AL. Compliance with Injury Prevention Measures in Youth Pitchers: Survey of Coaches in Little League of Puerto Rico. Sports Health. 2016;8(3):274-277.

❖Post EG, Laudner KG, McLoda TA, Wong R, Meister K. Correlation of Shoulder and Elbow Kinetics with Ball Velocity in Collegiate Baseball Pitchers. Journal of Athletic Training. 2015;50(6):629-633.

❖Smith DG, Swantek AJ , Gulledge CM, Lizzio VA, Bermudez A, Schulz BM, MakhniEC. Relationship Between Glenohumeral Internal Rotation Deficit and Medial Elbow Torque in High School Baseball Pitchers. Am J Sports Med. 2019;47(12): 2821-2826.

❖Sakata J, Nakamura E, Suzukawa M, Akaike A, Shimizu K. Physical Risk Factors for a Medical Elbow Injury in Junior Baseball Players: A Prospective Cohort Study of 353 Players. Am J Sports Med. 2017;45(1):135-143.

❖Sakata J, Nakamura E, Suzuki T, Suzukawa M, Akaike A, Shimizu K, Hirose N. Efficacy of a Prevention Program for Medial Elbow Injuries in Youth Baseball Players. Am J Sports Med. 2018 Feb;46(2):460-469.

References

References

❖Sakata J, Nakamura E, Suzuki T, Suzukawa M, Akeda M, Yamazaki T, Ellenbecker T, Hirose N. Throwing Injuries in Youth Baseball Players: Can a Prevention Program Help? A Randomized Controlled Trial. Am J Sports Med. 2019 Sep;47(11):2709-2716.

❖Thompson, SF. Youth Baseball Pitching Mechanics: A Systemic Review. Sports Health. 2018 March April;10(2):133-140.

❖Tyler T, Mullaney M, Mirabella M, Nicholas S, McHugh M. Risk Factors for Shoulder and Elbow Injuries in High School Baseball Pitchers: The Role of Preseason Strength and Range of Motion. Am J Sports Med. 2014 Aug;42(8):1993-1999.

❖Wilhelm A, Choi C, Deitch J. Early sport specialization: Effectiveness and Risk of Injury in Professional Baseball Players. Orthop J Sports Med. 2017;5(9):1-5.

❖Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: a prospective study. Am J Sports Med. 2014;49(9):2075-2081.

References

Thank you!