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Overuse Elbow Injuries in the Young Athlete Aaron Provance, MD No financial disclosures 2 Objectives • Background • Review common overuse elbow injuries of the young athlete • PT • Prevention • New CHSAA Bylaws 3 Epidemic • Dr. Andrews has recently called overuse injuries of the elbow in youth pitchers an epidemic • 5% of youth pitchers suffer a serious elbow or shoulder injury requiring surgery or retirement from sport within 10 years of play • Increasing number of Tommy John (UCL reconstruction) surgeries are performed every year • Much research on this topic identifying risk factors for these injuries 4 Pathophysiology • Chronic repetitious injury from throwing mechanism • Continued play and throwing despite significant pain in the elbow • Pitch counts may not be tracked by the team • Poor pitching mechanics can contribute to the mechanism of injury 5 Risk Factors • Number of pitches • Pre-existing pain • Year round play without rest • Side arm throwing • Multiple teams / Travel teams 6 Overuse Injury/ Growth Concerns • Microtrauma from submaximal loads • Inflammatory response • Most growth plate injures heal without complications 7 Common Causes of Elbow Pain in Young Athletes • • • • • Panner’s Disease Osteochondritis Dessicans Ulnar Collateral Ligament Injury Medial Epicondyle Apophysitis Medial Epicondylitis 8 Panner’s Disease • Fragmentation, irregular ossification of capitellum • Caused by avascular necrosis from chronic repetitive trauma • Self limiting process; regeneration and recalcification • Ages 6-10 years • Hx of lateral elbow pain aggravated with activity • Focal tenderness over capitellum, may have effusion, limited extension typical (20-30° lag) 9 Osteochondritis Dessicans • Fragmentation of bone and overlying cartilage of capitellum or radial head • Chronic lateral compression stress associated with throwing sports • Ages 10-16 years • Lateral elbow pain worst with activity, swelling, mechanical symptoms, loss of ROM 10 Ulnar Collateral Ligament Injury • Excessive valgus forces on medial compartment of elbow • Late cocking/early acceleration phase of throwing • Acute rupture or chronic inflammation leading to microscopic tears • Medial elbow pain worse with throwing https://www.arthrex.com 11 Medial Epicondyle Apophysitis • Traction apophysitis of medial epicondyle • Repetitive overuse, valgus overload • Tenderness over medial epicondyle, pain with resisted flexion and pronation • Typical age: 10-15 yrs • Medial elbow pain worse with throwing activity 12 Medial Epicondylitis • Overuse injury of flexor/pronator muscles originating at medial epicondyle • Older adolescent with fused medial epicondyle apophysis • Medial elbow pain, worse with activity 13 Proper PT • Addressing rotator cuff weakness, scapular stabilizer weakness, core strength and scapular dyskinesia • Proper pitching biomechanics • Pitching, throwing and practice drills are vital for a young pitcher to develop the coordination, strength, flexibility, endurance, mentality and skills necessary for success 14 Prevention – Pitch Counts Age • 17-18 105 pitches per day • 13-16 95 pitches per day • 11-12 85 pitches per day • 9-10 75 pitches per day • 7-8 50 pitches per day 15 Prevention • Young pitchers should not be allowed to throw as hard as they can until they demonstrate mature throwing mechanics 16 Prevention 17 Governing State HS Associations • Most of the State High School Associations’ bylaws do not reflect the current research in the medical journals • Need significant changes in rules, perceptions and most importantly the CULTURE of youth baseball! 18 CHSAA Baseball • CHSAA (Colorado High School Activities Association) previous throwing bylaws: – “A pitcher may appear in no more than 12 innings in any three consecutive calendar days.” – “A pitcher may not appear in more than 70 innings, exclusive of district, regional or state playoffs games during the season.” – Violation results in playing being ineligible = team forfeits the game 19 New Bylaws • Based on current medical literature/recommendations • Focus on pitch counts • Pitches thrown in innings vary significantly 20 New Bylaws • New pitching limits for varsity and junior varsity – GO TO CHSAANOW • If a pitcher reaches or exceeds the pitch limit, this will result in one day of mandated rest • Any school not entering the information within the mandated timeframe will be placed on restriction from the playoffs 21 New Bylaws • Pitchers should not be throwing through pain, fatigue or decreased accuracy • Players are discouraged not to play pitcher and catcher positions in the same game • Production of an educational video including risk factors, proper pitching techniques and when to be evaluated by a medical professional https://www.youtube.com/watch?v=yNwaZfWM5bo 22 Conclusion • Proper treatment, education on overuse injuries, and prevention is the key to decreasing the incidence • Pitch counts and proper mechanics • Spread the word about STOPsportsinjuries.org 23 24