Little League Elbow
- 1. Painful elbow in a rising star Specialist presentation 25/11/2015 Dr. Lucci Lugee Liyeung
- 2. Let me tell you Pedro’s story… • 10 years old right handed Pitcher in a local baseball team • Prospect for a baseball scholarship into high school and college • Keen on a professional career
- 3. • Noted right medial elbow pain during mid season • Did not inform parents and coaches • Decrease in pitch velocity & distance • Eventually pain so severe that his performance deteriorated
- 4. • Unable to continue playing towards the end of the season
- 5. • What should have been done to help him?
- 6. The Kinetic Chain in Overhand Pitching Shane T Seroyer, MD, et al The Kinetic Chain in Overhand Pitching Sports Health. 2010 Mar; 2(2): 135–146.
- 7. Phases of throwing • Windup • Cocking – Early – Late • Acceleration • Deceleration • Follow-through
- 8. Windup • Gains momentum in forward direction • Elbow is flexed • GHJ is slightly internally rotated. • Lasts 0.5 to 1.0 seconds
- 9. Cocking • Begins with front foot contact • Ends with shoulder in maximal external rotation
- 10. Cocking • Elbow flexes between 90–120° • Forearm pronates 90° • GHJ in abduction and reaches maximal external rotation • Lasts 0.1 to 0.15 seconds
- 11. Acceleration • Begins with Maximal EXTernal rotation • Ends with Maximal INTernal rotation (ball release)
- 12. Acceleration • Arm moves to a position of internal rotation and adduction at the shoulder and extension at the elbow • Large valgus and extension forces generated at the elbow • Lasts a few 100th of a second
- 13. Deceleration/Follow-through • Begins with Maximal Internal rotation • Ends with hindfoot contact
- 14. Deceleration/Follow-through • Follow-through is complete when pitcher achieves a balanced position and is ready to resume play
- 16. • Medial elbow is particularly prone to injury at late cocking and acceleration phases • Tremendous valgus strain • Maximum valgus stress occurs at 86°of elbow flexion in adults and 87° in adolescents, during the late cocking phase Sabick MB, Torry MR, Lawton RL, Hawkins RJ. Valgus torque in youth baseball pitchers: A biomechanical study. J Shoulder Elbow Surg. 2004
- 18. Little League Elbow Review article: Medial elbow injury in young throwing athletes Bonnie Gregory et al Muscles Ligaments Tendons J. 2013 Apr-Jun; 3(2): 91–100. 2013
- 19. Little League elbow • Repetitive overhand throwing • High valgus torque of the throwing motion • Tensile and shearing stress at the medial elbow • Apophyseal cartilage at the medial epicondyle sustains repetitive trauma at hypertrophic zone • Common in baseball pitchers 9 - 14 y/o
- 20. The medical epicondyle • May arise from >1 ossification center • Commonly the last epiphyseal center to fuse (16+ y/o) • Attachment site of the flexor muscle origins and UCL • Apophysis is the area of highest potential for injury
- 21. The medical epicondyle Ossification Fusion
- 23. Epidemiology • ~ 30 million children participate in organized sport in USA • ~ 4.8 million children aged 5-14 participate in baseball/softball • incidence of elbow pain in young baseball players: – 20–30% for 8–12 year olds – approximately 45% for 13–14 year olds – over 50% for high school, college, and professional athletes • The 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 TJ J Shoulder Elbow Surg. 2002 Mar-Apr; 11(2):151-5.
- 24. Risk Factors • Age • >80 pitches per month • > 8 months per year • Position played (Pitchers > catchers > infielders > outfielders) • involve in multiple baseball leagues • Dominant arm • Family history of osteochondrosis.
- 25. Diagnosis • Age and skeletal maturation – injury profile changes with fusion of elbow ossification centers. • Overuse vs acute injuries – Acute: sudden onset or a "pop" may indicate an avulsion – Chronic: decrease strength, active mobility, and endurance • Relationship of the pain with throwing phases – exacerbated during early acceleration/ late cocking
- 26. Diagnosis • Tenderness/swelling/hypertrophy over the medial epicondyle • Carrying angle >20: chronic pathology • ecchymosis / flexion contracture > 15° - avulsion fracture • UCL integrity : – Anterior band: valgus stress at 20° elbow flexion – Posterior band: valgus torque when the forearm is supinated and the elbow is flexed > 90° (Milking maneuvre) • Neurological exam: ulnar nerve injury.
- 27. Diagnosis Milking Maneuvre: UCL integrity
- 28. Diagnostic Imaging • Confirm diagnoses based on history and physical examination • Aid in treatment planning.
- 29. Diagnostic imaging • Plain X-Ray – medial epicondyle avulsion fractures, loose bodies, osteochondritis, bone spurs, ligament calcification, HO • Stress radiographs – Confirm elbow valgus instability with joint opening > 3 mm Imaging of sports injuries of the upper extremity in children. Emery KH Clin Sports Med. 2006 Jul; 25(3):543-68, viii
- 30. Diagnostic imaging • widening of the growth plate or irregularity of the medial epicondyle ossification center • avulsed epicondylar fragment • anterior and posterior fat pads ("sail sign"): effusion
- 31. Diagnostic imaging • Magnetic Resonance Imaging – Marrow edema in the medial epicondyle – UCL injuries: – 100% specificity, 100% sensitivity in identifying full-thickness tears – 100% 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):387–408.
- 32. Diagnostic imaging • Marrow edema in the medial epicondyle and adjacent bone
- 33. Diagnostic Imaging • Partial thickness tear: Increased T2- weighted signal within the anterior bundle of UCL ligament • Edema-like signal changes in the proximal pronator muscle strain • Edema in the sublime tubercle
- 34. Diagnostic Imaging • Osteochondritis Dissecans – Junior high school > high school and collegiate players • MCL injuries – High school and collegiate > junior high school players – Pitchers 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 KS Clin J Sport Med. 2009 Jul; 19(4):271-6.
- 35. Diagnostic Imaging • Dynamic ultrasonography – UCL injury – operator-dependent • CT arthrography – 86% sensitive and 91% specific for UCL injury
- 36. Treatment • REST: 4-6 weeks • restriction from throwing • Wrist and Elbow strengthening exercises • Gradual return to throwing if asymptomatic • Avoid aggravating pitches, restrict pitch counts • Change position that involves less throwing, such as first base • Conservative treatment: – full recovery rates in 40–50% 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 DW J Shoulder Elbow Surg. 2010 Oct; 19(7):951-7
- 38. Fixation of medial epicondyle • Significantly displaced medial epicondyle avulsion fractures • Younger children: K-wires • Near Skeletal maturation: Screw fixation • Operative treatment affords a significantly higher union rate over the non-operative management • There was no difference in pain at final follow-up Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review Atul K Kamath, et al J Child Orthop. 2009 Oct; 3(5): 345–357
- 39. Fixation of medial epicondyle
- 40. Fixation of medial epicondyle • Great care is needed to ensure a smooth surface over which the ulnar nerve will lie
- 41. UCL reconstruction • favored over primary surgical repair (only yield 50% return to previous level) • Tommy John Surgery – first baseball player to undergo the surgery, MLB pitcher Tommy John • UCL disruption and insufficiency • Restore medial stability of the elbow
- 42. UCL reconstruction Common site of donar tendon graft: • Palmaris Longus • Hamstring • Toe extensor • Allograft
- 43. UCL Reconstruction Review article: Elbow medial collateral ligament injuries Ra’Kerry K. Rahman, et al Curr Rev Musculoskelet Med (2008) 1:197–204
- 44. UCL reconstruction Jobe’s Technique • Detachment of the flexor-pronator mass • Transposition of the ulnar nerve • Bone tunnels directed posterior on the humeral epicondyle • Graft in a figure of 8 ✕Technically demanding ✕High complication rate, ulnar nerve palsy in 21%
- 45. UCL reconstruction Docking Technique • Graft is passed through the proximal ulnar bone tunnel and medial epicondyle • Graft is tensioned with the elbow flexed with an applied varus stress • The proximal limb of the graft is sutured to the medial intermuscular septum outside the drill hole on the superior surface of the epicondyle
- 46. UCL reconstruction • The native ligament repaired over the graft with simple sutures • Graft fashioned to an exact length to fit inside the humeral tunnel • The free ends of the graft are controlled with sutures that are passed through the two exiting tunnels and tied over a bony bridge.
- 47. Rehabilitation • Immediate 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 exercises • At 4–6 weeks: strengthening exercises, avoiding valgus stress • At 4 months: begin throwing program with gradual increase in pitch count • 18 months may be needed to regain pre-op level with accurate ball control
- 48. Platelet-rich plasma injection • Peripheral blood from the patient is centrifuged • Autologous activated platelets retained in fibrin matrices – Source of molecular signals to control cell growth + differentiation – synthesis of functional proteins. • PRP injected to the injured ligament to stimulate healing • Widely in treatment in different sports injuries – ACL repair and tendon surgery – No report of usage in Little League elbow – lack of good evidence
- 49. Prevention • Warm up properly by stretching, running, and gradual throwing • Develop skills that are age appropriate • Don’t pitch with elbow or shoulder pain • Don’t pitch on consecutive days • Adhere to pitch count guidelines • Rotate playing different positions • Don’t play year-round
- 50. Prevention Pitches in a game (Ages < 14) Pitches in a game (Ages 15-18) Required rest days after game 66+ 76+ 4 days 51-65 61-75 3 days 36-50 46-60 2 days 21-35 31-45 1 day 1-20 1-30 none Source : Little League Baseball Required Rest days after a game
- 51. Prevention Pitch limit 9-10 y/o 11-12 y/o 13-14 y/o Per game 50 75 75 Per week 75 100 125 Per season 1000 1000 1000 Per year 2000 3000 3000 Pitch Count Recommendations by Age The American Sports Medicine Institute 2006 http://www.asmi.org/asmiweb/usabaseball.htm#Counts
- 52. Thank you!