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+

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