Painful elbow in a rising star

Painful elbow in a rising starSpecialist presentation 25/11/2015Dr. Lucci Lugee Liyeung

Let me tell you Pedros story10 years old right handed Pitcher in a local baseball teamProspect for a baseball scholarship into high school and collegeKeen on a professional career

Noted right medial elbow pain during mid seasonDid not inform parents and coachesDecrease in pitch velocity & distanceEventually pain so severe that his performance deteriorated

Unable to continue playing towards the end of the season

What should have been done to help him?

The Kinetic Chain in Overhand PitchingShane T Seroyer, MD, et alThe Kinetic Chain in Overhand PitchingSports Health. 2010 Mar; 2(2): 135146.

Phases of throwingWindupCockingEarlyLateAccelerationDecelerationFollow-through

WindupGains momentum in forward directionElbow is flexed GHJ is slightly internally rotated.

Lasts 0.5 to 1.0 seconds

CockingBegins with front foot contactEnds with shoulder in maximal external rotation

CockingElbow flexes between 90120Forearm pronates 90GHJ in abduction and reaches maximal external rotation

Lasts 0.1 to 0.15 seconds

AccelerationBegins with Maximal EXTernal rotationEnds with Maximal INTernal rotation (ball release)

AccelerationArm moves to a position of internal rotation and adduction at the shoulder and extension at the elbowLarge valgus and extension forces generated at the elbowLasts a few 100th of a second

Deceleration/Follow-throughBegins with Maximal Internal rotation Ends with hindfoot contact

Deceleration/Follow-throughFollow-through is complete when pitcher achieves abalanced position and is ready to resume play

Overhand pitching

Medial elbow is particularly prone to injury at late cocking and acceleration phasesTremendous valgus strainMaximum valgus stress occurs at 86of elbow flexion in adults and 87 in adolescents, during the late cocking phaseSabick MB, Torry MR, Lawton RL, Hawkins RJ. Valgus torque in youth baseball pitchers: A biomechanical study. J Shoulder Elbow Surg. 2004

LittleLeagueElbow

Little League Elbow

Review article:Medial elbow injury in young throwing athletesBonnie Gregory et alMuscles Ligaments Tendons J. 2013 Apr-Jun; 3(2): 91100. 2013

Little League elbowRepetitive overhand throwingHigh valgus torque of the throwing motionTensile and shearing stress at the medial elbowApophyseal cartilage at the medial epicondyle sustains repetitive trauma at hypertrophic zoneCommon in baseball pitchers 9 - 14 y/o

The medical epicondyleMay arise from >1 ossification centerCommonly the last epiphyseal center to fuse (16+ y/o)Attachment site of the flexor muscle origins and UCLApophysis is the area of highest potential for injury

The medical epicondyle

OssificationFusion

Ulnar Collateral Ligament

Epidemiology~ 30 million children participate in organized sport in USA~ 4.8 million children aged 5-14 participate in baseball/softballincidence of elbow pain in young baseball players:2030% for 812 year oldsapproximately 45% for 1314 year oldsover 50% for high school, college, and professional athletesThe true incidence of sports-related injuries is unknown because a large number of athletes never seek medical care.Relationship between throwing mechanics and elbow valgus in professional baseball pitchers.Werner SL, Murray TA, Hawkins RJ, Gill TJJ Shoulder Elbow Surg. 2002 Mar-Apr; 11(2):151-5.

Risk FactorsAge>80 pitches per month> 8 months per yearPosition played (Pitchers > catchers > infielders > outfielders) involve in multiple baseball leaguesDominant arm Family history of osteochondrosis.

DiagnosisAge and skeletal maturationinjury profile changes with fusion of elbow ossification centers.Overuse vs acute injuriesAcute: sudden onset or a "pop" may indicate an avulsionChronic: decrease strength, active mobility, and enduranceRelationship of the pain with throwing phasesexacerbated during early acceleration/ late cocking

DiagnosisTenderness/swelling/hypertrophy over the medial epicondyleCarrying angle >20: chronic pathologyecchymosis / flexion contracture > 15 - avulsion fractureUCL integrity :Anterior band: valgus stress at 20 elbow flexionPosterior band: valgus torque when the forearm is supinated and the elbow is flexed > 90 (Milking maneuvre)Neurological exam: ulnar nerve injury.

Diagnosis

Milking Maneuvre: UCL integrity

Diagnostic ImagingConfirm diagnoses based on history and physical examinationAid in treatment planning.

Diagnostic imagingPlain X-Raymedial epicondyle avulsion fractures, loose bodies, osteochondritis, bone spurs, ligament calcification, HOStress radiographs Confirm elbow valgus instability with joint opening > 3 mmImaging of sports injuries of the upper extremity in children.Emery KHClin Sports Med. 2006 Jul; 25(3):543-68, viii

Diagnostic imagingwidening of the growth plate or irregularity of the medial epicondyle ossification center

avulsed epicondylar fragmentanterior and posterior fat pads ("sail sign"): effusion

Diagnostic imagingMagnetic Resonance ImagingMarrow edema in the medial epicondyleUCL injuries:100% specificity, 100% sensitivity in identifying full-thickness tears100% specificity, 57% sensitivity for partial-thickness tears

Tuite MJ, Kijowski R. Sports-related injuries of the elbow: an approach to MRI interpretation. Clin Sports Med. 2006;25(3):387408.

Diagnostic imaging

Marrow edema in the medial epicondyle and adjacent bone

Diagnostic ImagingPartial thickness tear: Increased T2-weighted signal within the anterior bundle of UCL ligamentEdema-like signal changes in the proximal pronator muscle strainEdema in the sublime tubercle

Diagnostic ImagingOsteochondritis DissecansJunior high school > high school and collegiate playersMCL injuriesHigh school and collegiate > junior high school playersPitchers and outfielders > infielders.The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging.Han KJ, Kim YK, Lim SK, Park JY, Oh KSClin J Sport Med. 2009 Jul; 19(4):271-6.

Diagnostic ImagingDynamic ultrasonographyUCL injuryoperator-dependentCT arthrography 86% sensitive and 91% specific for UCL injury

TreatmentREST: 4-6 weeksrestriction from throwingWrist and Elbow strengthening exercisesGradual return to throwing if asymptomaticAvoid aggravating pitches, restrict pitch countsChange position that involves less throwing, such as first baseConservative treatment:full recovery rates in 4050% of overhead throwing athletes, 100% in non-throwing athletes

Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: a variant of Little League elbow.Osbahr DC, Chalmers PN, Frank JS, Williams RJ 3rd, Widmann RF, Green DWJ Shoulder Elbow Surg. 2010 Oct; 19(7):951-7

Fixation of medial epicondyleSignificantly displaced medial epicondyle avulsion fracturesYounger children: K-wiresNear Skeletal maturation: Screw fixation

Operative treatment affords a significantly higher union rate over the non-operative managementThere was no difference in pain at final follow-upOperative versus non-operative management of pediatric medial epicondyle fractures: a systematic reviewAtul K Kamath, et alJ Child Orthop. 2009 Oct; 3(5): 345357

Fixation of medial epicondyle

Fixation of medial epicondyleGreat care is needed to ensure a smooth surface over which the ulnar nerve will lie

UCL reconstructionfavored over primary surgical repair (only yield 50% return to previous level)Tommy John Surgeryfirst baseball player to undergo the surgery, MLB pitcher Tommy JohnUCL disruption and insufficiencyRestore medial stability of the elbow

UCL reconstruction

Common site of donar tendon graft:Palmaris LongusHamstringToe extensorAllograft

UCL Reconstruction

Review article:Elbow medial collateral ligament injuriesRaKerry K. Rahman, et alCurr Rev Musculoskelet Med (2008) 1:197204

UCL reconstruction

Jobes TechniqueDetachment of the flexor-pronator massTransposition of the ulnar nerveBone tunnels directed posterior on the humeral epicondyleGraft in a figure of 8Technically demanding High complication rate, ulnar nerve palsy in 21%

UCL reconstruction

Docking TechniqueGraft is passed through the proximal ulnar bone tunnel and medial epicondyleGraft is tensioned with the elbow flexed with an applied varus stressThe proximal limb of the graft is sutured to the medial intermuscular septum outside the drill hole on the superior surface of the epicondyle

UCL reconstructionThe native ligament repaired over the graft with simple suturesGraft fashioned to an exact length to fit inside the humeral tunnelThe free ends of the graft are controlled with sutures that are passed through the two exiting tunnels and tied over a bony bridge.

RehabilitationImmediate post-op: elbow immobilized in a splint to allow skin and soft tissues healing. At 10 days: active wrist, elbow and shoulder range of motion exercisesAt 46weeks: strengthening exercises, avoiding valgus stress At 4months: begin throwing program with gradual increase in pitch count18 months may be needed to regain pre-op level with accurate ball control

Platelet-rich plasma injectionPeripheral blood from the patient is centrifuged Autologous activated platelets retained in fibrin matricesSource of molecular signals to control cell growth + differentiationsynthesis of functional proteins.PRP injected to the injured ligament to stimulate healingWidely in treatment in different sports injuriesACL repair and tendon surgeryNo report of usage in Little League elbowlack of good evidence

PreventionWarm up properly by stretching, running, and gradual throwing Develop skills that are age appropriateDont pitch with elbow or shoulder painDont pitch on consecutive daysAdhere to pitch count guidelinesRotate playing different positionsDont play year-round

PreventionPitches in a game (Ages < 14)Pitches in a game (Ages 15-18)Required rest days after game66+76+4 days51-6561-753 days36-5046-602 days21-3531-451 day1-201-30none

Source : Little League BaseballRequired Rest days after a game

PreventionPitch limit9-10 y/o11-12 y/o13-14 y/oPer game507575Per week75100125Per season100010001000Per year200030003000

Pitch Count Recommendations by AgeThe American Sports Medicine Institute 2006http://www.asmi.org/asmiweb/usabaseball.htm#Counts

Thank you!