Prevention of Injury in Overhead Throwers - PowerPoint Presentation

Prevention of Injury in Overhead Throwers Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship MedStar National Rehabilitation Hospital MedStar Georgetown University Hospital Physician, Washington Nationals

Disclosures Nothing to Disclose

Sports At The Beach:Sandy Spring Falcons

Overview Common Throwing Injuries Anatomy Throwing Biomechanics Prevention Pitch Counts Pitch Type HistoryPhysical ExaminationRadiologic Assessment

Overview Common Injuries in the Throwing Shoulder Rotator Cuff Tendinosis/Tear Bicipital Tendinosis/Tear Glenohumeral Instability Glenoid Labral Tear “Little League Shoulder”Proximal Humeral Epophysiolysis

Overview Common Injuries in the Throwing Elbow Ulnar Collateral Ligament Tears Ulnar Neuritis Flexor- Pronator Strain, Tear, or Tendinitis Medial Epicondyle apophysitis or avulsionValgus Extension Overload SyndromeOlecranon Stress Fractures Osteochondritis Dissecans (OCD) of the capitellum Loose Bodies

SHOULDER ANATOMY Topography of Greater Tubercle Three facets Superior Middle Inferior Three muscles SupraspinatusInfraspinatusTeres minor Subscapularis insert on lesser tubercle

SHOULDER ANATOMY Bones Humerus Scapula Clavicule Articulations Glenohumeral AcromioclavicularSternoclavicularScapulothoracic (soft tissue)

SHOULDER ANATOMY Primary Muscles Deltoid Rotator Cuff Supra/Infraspinatus, Subscapularis, Teres Minor Secondary MusclesBicepsTricepsLatissimus Trapezius Rhomboids Levator Serratus

The supraspinatus is approximately 23 mm in width (measured anterior to posterior), of which the anterior 13 mm inserts onto the superior facet and the posterior 10 mm inserts onto the anterior aspect of the middle facet (8). The infraspinatus is approximately 22 mm in width (measured anterior to posterior) and inserts onto the middle facet of the greater tuberosity, superficially overlapping the supraspinatus tendon by 10 mm

Supraspinatus footprint Following the cartilage laterally will encounter a sulcus formed between the humeral head and the greater tubercle Site for articular fibers of the rotator cuff attachment to the greater tuberosity

Bursa of shoulder 5 general bursae S ubacromial-subdeltoid bursa Subscapularis bursa Located between the glenohumeral joint capsule and the subscapularis muscleSubcoracoid bursa Coracoclavicular bursa Located between the trapezoid and conoid parts of the coracoclavicular ligament Supra-acromial bursa

S ubacromial - subdeltoid bursa Subscapularis bursa, located between the glenohumeral joint capsule and the subscapularis muscle Subcoracoid bursa C oracoclavicular bursa , located between the trapezoid and conoid parts of the coracoclavicular ligament Supra -acromial bursa

ELBOW ANATOMY Synovial joint with three articulations Ulnar-trochlear Radiocapitellum Ulnar -radial Fossa Anterior: Radial fossa Posterior: Olecranon fossa Fat pads Ligaments Medial: ulnar collateral ligament Lateral: radial collateral ligament Annular ligament

ELBOW ANATOMY Anterior Brachialis Biceps Posterior Triceps Anconeus MedialCommon flexor tendon: FCR, palmaris longus , FCU, FDS Lateral Common extensor tendon ECRB, ECRL, EDC, EDM, EDU

ELBOW ANATOMY

ELBOW ANATOMY Retinaculum Cubital tunnel retinaculum Arcuate ligament NervesUlnar Radial Median Vessels Brachial a, v Ulnar a, v

ELBOW ANATOMY Three joints in one: Ulnohumeral joint (short black arrow) Radiocapitellar joint (long black arrow) Proximal radioulnar joint (arrowhead)Common joint capsule

ELBOW ANATOMY Trochlea Lateral surface (short white arrow) Larger and more distally projecting medial surface (long white arrow) Separated by the trochlear groove (short black arrow) Tip of the olecranon process of the proximal ulna presses into the olecranon fossa

ELBOW ANATOMY Sigmoid notch (long arrow): ellipsoid shaped depression in the proximal ulna between the coronoid process (short arrow) and the tip of the olecranon process (arrowhead) Coronoid fossa (arrow) Radial fossa (arrowhead)

ELBOW ANATOMY Ulnar collateral ligament Composed of three bundles: Anterior bundle primary restraint to valgus force of the elbow from 30° to 120° of flexion Subjected to near-failure tensile stresses during the acceleration phase of the throwing motion Posterior bundle Transverse oblique bundle

Ulnar collateral ligament Three components Anterior bundle M ain stabilizer Orignate inferior surface of the humeral medial epicondyle to the sublimis tubercle of the ulna

ELBOW BIOMECHANICS Examine the forces at the elbow joint during the throwing motion Baseball throwing generates large valgus and extension forces Biomechanical testing Estimated valgus forces as high as 64 Nm at the elbow during the late cocking and early acceleration phases of throwing Compressive forces of 500 N at the lateral radiocapitellar articulation as the elbow moves from approximately 110° to 20° of flexion and velocities as high as 3000 deg/sec. Combination of large valgus loads with rapid elbow extension produces: Tensile stress along the medial compartment restraints UCL, flexor- pronator mass, medial epicondyle apophysis, and ulnar nerve) Shear stress in the posterior compartment (posteromedial tip of the olecranon and trochlea /olecranon fossa) Compression stress is produced laterally (radial head and capitellum). This phenomenon has been termed “valgus extension overload syndrome” and forms the basic pathophysiologic model behind the most common elbow injuries in the throwing athlete.

ELBOW BIOMECHANICS Repetitive near-tensile failure loads applied during throwing Microtrauma to the anterior band of the UCL May eventually lead to ligament attenuation or failure. Continued valgus and extension forces may produce Olecranon tip osteophytes &loose bodies in posterior or radiocapitellar compartment “kissing lesion” Articular damage on the posteromedial trochlea caused by the olecranon osteophyte Chondromalacia on the posteromedial trochlea (olecranon fossa) Subtle laxity may also cause excessive medial soft tissue stretch Resulting in flexor pronator mass tendinitis, ulnar neuritis, or medial epicondyle apophysitis in the skeletally immature athlete. Valgus extension overload forces lesions of the posterior compartment, including olecranon osteophytes & loose bodies Most common diagnoses that require surgery in baseball players However, in all cases of elbow pain in the throwing athlete, valgus laxity from injury to the UCL must be excluded as the underlying cause of more obvious elbow lesions.

Biomechanics of Throwing Patterns with changes in: Velocity Location Frequency Joint Loads Shoulder, Elbow, Hip Pitch TypesFastball, Change-Up, Curveball, Slider, Fork, Knuckle

Adaptations to Throwing Bony Changes Arc of Motion Laxity of throwing arm Soft Tissue

Why Do Throwing Injuries Occur? 1. Mechanics 2. Pitch Type 3. Pitch Volume 4. Rest Periods 5. Physical Make-up 6. Nutrition 7 . Genetics Height, Weight, G-d given ability

Risk Factors Pitching While Fatigued Throwing Too Many Innings over the Course of the Year Not Taking Enough Time off from Baseball Every Year Throwing Too Many Pitches Not Getting Enough RestPitching on Consecutive DaysExcessive Throwing When Not Pitching Playing for Multiple Teams at the Same Time Pitching With Injuries to Other Body Regions Not Following Proper Strength and Conditioning Routines Not Following Safe Practices While at Showcases Throwing Curveballs and Sliders at a Young Age Radar Gun Use http://m.mlb.com/pitchsmart/risk-factors/

Injury Prevention Proper Mechanics Injury Prevention Injury Mechanisms Professional pitchers generate up to 92 N - m of humeral rotation torque, greater than the torsional failure limit in human cadaveric shoulders Greiwe and Ahmad. Management of the Throwing Shoulder: Cuff , Labrum and Internal Impingement. Orthop Clin N Am. 41 (2010) 309–323

Injury Prevention Preventative strategies P reseason conditioning Proper throwing techniqueGradual increase in the number and intensity of pitchesBuilt-in rest periods S trict adherence to pitch count guidelines

Injury Prevention Little League Baseball Recommendations: Age appropriate pitches: Fastball (> 9yrs)Change-Up(>11yrs)Curveball (> 13yrs) Slider , Forkball, Knuckleball (> 15yrs) Screwball (>17yrs )

Little League Baseball Regulation Guidelines: Pitch Count Limits Age Per Game Per Week Per Season Per Year 17-18 105 - - - 13-16 95 - - - 11-12 85 125 1000 3000 9-10 75 100 1000 3000 7-8 50 75 1000 2000

Little League Baseball Regulation Guidelines: Days Rest Between Pitching 15-18 Years Old Pitches Days Rest >76 4 61-75 3 46-50 2 31-45 1 1-30 0 14 Years and Under Pitches Days Rest >66 4 51-65 4 36-50 4 21-35 4 1-20 4

MLB Pitch Smart Guidelines 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+

Pitching with Arm Fatigue Average > 80 pitches = 4x risk of surgery Pitch competitively > 8 months/year = 5x likelihood of injury Pitching regularly with fatigued arm = 36x as likely to have an injury and potentially need surgery! Olsen SJ, et al. AJSM. 2006

Pitch Type Slider 86 % elbow pain Curve ball52% shoulder painChange-up 12 % elbow pain 29 % shoulder pain Lyman et al, AJSM 2002

Pitch Types Change up Slower motions Less force and torque Curveball S imilar to less force & torqueNewer research changing mindset Fleisig Lecture, ISBS 2010 Keynote Lecture

History and Physical Examination History Age Handedness Are you a Pitcher, Catcher, or other? How many teams do you play on? When was the last time you had more than 1-2 weeks off from practice or games pertinent in warm weather climatesHow many games have you played in since January 1 st ?

History and Physical Examination History When and how the injury occurred, but also to know what took place before the injury. Changes in training regimens Prior injuries Changes in accuracy, velocity, stamina, and strength Time of onset of symptoms Phase of throwing

Adults vs Skeletally Immature Skeletally Immature pitchers have: More variability in angles ↓ angular velocity & ball velocity↓ ↓ force & torque Think about a 16 yo skeletally immature pitcher who can throw 90 mph…load/force > resistance INJURY

Adolescent Shoulder & Elbow Shoulder and Elbow pain in the youth and adolescent population is different from adults Due to immature bone structure of the shoulder and elbow region. Growth plates are constantly changing Predisposition to potential injury Relative weakness at the growth plates Decreased resistance to shear and tensile forces compared to the surrounding ligaments, tendons and muscles Important to know maturation of the bone including the closing of ossification centers

Adolescent Elbow Important ages to remember for closure of the ossifications centers of the shoulder and elbow region include: CRITOE Capitellum, Radial head, Internal (medial) epicondyle, Trochlea , Olecranon, External (lateral) epicondyle. Elbow lateral epicondyle (14-16 yrs)medial epicondyle (14-16 yrs)

History Medial Elbow Instability 85% will experience pain during the acceleration phase 25% will experience pain during the deceleration phase Any neurologic or vascular complaints cold intolerance numbness or tingling in the hand or fingertips Shooting pain sensationsTendency to drop objects May be the earliest signs of significant abnormalities.27 lnar Ulnar collateral ligament injuries and associated ulnar neuritis many patients complain of paresthesia that radiates from the medial elbow to the ring and small fingers on the affected side.

Physical Examination Differ to Drs Martinez and Micheo

History and Physical Examination Physical Examination Shoulder Range of Motion Flexion, Extension, Internal/External Rotation, Abduction, Adduction Tenderness to Palpation Strength Sensation Special TestsSpeed’s, Yergason Neer’s , Hawkin’s , Painful Arc, Empty Can, Lift Off O’Brien’s, Sulcus Cross Arm Adduction

History and Physical Examination Physical Examination Elbow Range of Motion Flexion, Extension, Supination,Pronation Tenderness to Palpation Strength SensationSpecial Tests Cozen’s , Reverse Cozen’s Tinels at the Elbow UCL Laxity on Dynamic Stressing

Physical Examination Inspection Resting position of the elbow Elbow effusion Athlete will often hold the elbow flexed 70° to 80° position that corresponds with the greatest capsular volume. Carrying angle Angle between line drawn along the axis of the humerus & line drawn along axis of forearm. Normal carrying angle is 11° of valgus in men and 13° of valgus in women Increase in the carrying angle, when compared with the opposite side may be due to previous trauma or developmental abnormality However, in throwing athletes, it is not uncommon to find increased valgus in the throwing elbow due to adaptive changes to repetitive stress. Pro throwers Not uncommon to find valgus angles greater than 15°.51 Bony landmarks olecranon tip, medial and lateral epicondyles Antecubital fossa Inspected for ecchymosis May be present in cases of fracture, dislocation, or tendon rupture Lateral recess between the olecranon tip, the radial head, and the lateral epicondyle inspected for fullness to identify any effusion.

Physical Examination Inspection Asymmetry, Atrophy Shoulder Range of motion Actively and passive Note any crepitus, pain, or other mechanical symptoms Indication of chondral irregularity or loose bodies Periscapular EvaluationTenderness to Palpation

Physical Examination Elbow Range of motion Actively and passive Normal motion in the sagittal plane includes flexion from 0° to 140° +/-10° and forearm rotation of 80° to 90° in both supination and pronation Elbow is flexed, the carrying angle progresses into more of a varus alignment Makes evaluation of the carrying angle difficult in the setting of elbow contracture. Any attempt to compensate for a loss of elbow motion by rotating or elevating the shoulder should be documented. Note any crepitus , pain, or other mechanical symptoms Indication of chondral irregularity or loose bodies End-feel to range of motion testing Very important in examining the thrower’s elbow Normal end-feel in extension Should be the firm sensation of bone contacting bone as the olecranon tip contacts the distal humerus in the olecranon fossa End-feel to range of motion testing in flexion Soft tissue contacting soft tissue as the musculature of the upper arm comes into contact with the musculature of the forearm.

Physical Examination Loss of motion in the thrower’s elbow can be due to several causes. Elbow flexion contracture has been seen in up to 50% of professional throwers Should not be considered indicative of injury Throwers rarely possess elbow hyperextension Should consider an injury Bony end-feel in terminal flexion Consider a bony osteophyte or loose body

Physical Examination Palpation Bony landmarks Pain with bony palpation may indicate fracture, stress fracture, or insertional tendinitis. Specific attention should be paid to palpation of the medial epicondyle, the radial head, and the proximal olecranon. Medial epicondyle pain May indicate an avulsion fracture or growth plate injury in the immature athlete. Proximal olecranon pain Especially pain noted with palpation of the lateral border May indicate an olecranon stress fracture. Olecranon (posteromedial tip) Important aspect of the physical examination of the thrower’s elbow. Valgus stress is applied to the flexed elbow, the medial aspect of the olecranon tip may impinge on the medial wall of the olecranon fossa. Hallmark of valgus extension overload Radial Head Performed while the forearm is rotated passively. Pain with palpation of the radial head may indicate a fracture, dislocation, OCD of the capitellum, or annular ligament injury.

Physical Examination: Palpation Soft tissues Deltoid Rotator Cuff Common with throwers Peri -scapular Muscles-Lat /Trap/ Levator /Rhomboids Myofascial changes Biceps and triceps muscles Medial flexor-pronator mass Pain with palpation of the flexor- pronator mass is common in throwers Due to valgus stresses across the elbow joint during the throwing motion If the underlying ligamentous structures become lax Medial muscle mass will undergo increased stress Pain in the flexor-pronator muscle mass does not confirm definite underlying instability But pain in this area should alert the examiner to possible deeper abnormalilty . Lateral Extensor mass

Physical Examination Palpation Ulnar collateral ligament Performed with the elbow in approximately 50° to 70° of flexion Moves overlying medial muscle mass anterior to fibers of UCL Palpated along its entire course Begin at origin from the inferior aspect of the medial epicondyle Progress distally to its insertion onto sublime tubercle of proximal medial ulna. Pain with palpation along the ligament May indicate abnormalities ranging from partial intrasubstance injury and attenuation to complete rupture.

Physical Examination Neurovascular structures about the elbow Ulnar nerve Gentle palpation/percussion should not cause any pain or discomfort Above the medial epicondyle Palpating UN above the cubital tunnelPalpate the distal medial aspect of the triceps tendon. Anomalous bands of the distal triceps insertion have been described as a cause of ulnar nerve impingement and may cause a “snapping” sensation as they move across the medial epicondyle. Through the cubital tunnel Exert gentle pressure on the nerve above the medial epicondyle Ensure nerve will not subluxate out of the cubital tunnel. Subluxation of the ulnar nerve may cause significant discomfort or paresthesia , or both Unstable ulnar nerve will dislocate anterior to the medial epicondyle as the elbow is moved from extension to flexion. Distally as far as possible into the flexor carpi ulnaris muscle mass.

Physical Examination Neurovascular structures about the elbow Distal pulses and sensation in all nerve distributions of the upper extremity should be assessed. Any alteration in sensation or capillary refill in the fingertips should be documented. Alterations in the color or temperature of the digits should also be noted. Any neurovascular symptoms may indicate proximal arterial flow abnormality with distal embolization and vessel occlusion

Physical Examination Strength testing Deltoid Rotator Cuff Biceps Triceps Pronation/supination Wrist flexion and extensionStrength should be compared with the strength in the opposite, nonaffected extremity

Physical Examination Stability Elbow stability Assessed with patient supine & shoulder in maximal external rotation Although been demonstrated that greater degrees of valgus instability will be apparent at higher flexion angles (70° to 90°), Difficult to adequately stabilize the humerus at flexion angles greater than 30° Manual valgus stress test Elbow flexed 20° to 30° to unlock olecranon tip from olecranon fossa while stabilizing humerus. Valgus stress is applied to the elbow with maximal forearm pronation. Less than 1 mm of medial opening should be noted in the normal elbow. Any increased opening or reproduction of the patient’s pain with valgus stress is abnormal May indicate medial ligament injury. However, valgus instability is difficult to elicit on manual testing Calloway et al. reported in a cadaveric cutting study Complete sectioning of anterior bundle of UCL Only minimal increase in valgus opening that may not be clinically detectable.

Physical Examination Instability of lateral ligament complex is distinctly uncommon in throwing athletes In the absence of elbow dislocation Lateral instability or posterolateral rotatory instability is uncommon. If complete dislocation is suspected Tests for integrity of the lateral ligamentous complex and the lateral UCL

Physical Examination Valgus extension overload test Patient Seated & shoulder in slight forward flexion Examiner Repeatedly forces the slightly flexed elbow rapidly into full extension while applying a valgus stress Goarl Reproduce pain with impingement of the posteromedial tip of the olecranon on the medial wall of the olecranon fossa Positive finding Indicates the presence of a posteromedial olecranon osteophyte , which may occasionally be palpable at the time of physical examination.

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