Download Little League Elbow

Return to Sport Following
Little League Elbow and
Shoulder
Nathan Apple, MS PT
Little League Elbow
• Medial epicondyle apophysitis
– Radiographs can assist in diagnosis
– Pain with throwing or palpation
• General term for pain due to
– Injury to the medial epicondyle and ulnar
collateral ligament
– Osteochondritis dissecans of the capitellum
Little League Elbow
• During cocking and acceleration phase of
pitching
– Valgus stress occurs at the medial elbow,
– Shearing forces in the posterior
– Compression along the lateral elbow
Little League Shoulder
• Proximal humeral epiphysitis
– Salter-Harris type 1 fracture of proximal
humeral physis
– Typical around ages 11-14, when proximal
physis of humerus is at its peak in growth
(Osbahr)
Little League Shoulder
• Diagnosis
– Progressive pain with throwing in proximal
humerus
– Tenderness to palpation over physis of
proximal humerus
– Radiographs for widening consistent with
epiphysiolysis
• Contralateral shoulder needed for comparison
(Osbahr)
Physical Therapy Evaluation
• Accurate history
– Past injuries
– Pain- aggravating and alleviating factors
– Recent growth in height
– Comorbidity
• Growth deficiencies
• Diabetes
Physical Therapy Evaluation
• Sport specific history
– Number of current sports
– Number of current teams per sport
– Sport specific demands
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What positions
What specialty
What events
Current pitch counts
– Better still, are they counting
– What pitches thrown
Physical Therapy Evaluation
• Sport specific history continued
– Hours per week (total games/practice)
• Include outside training
– Speed and conditioning
– Positions specific
– Current coaches
• How many
• Who are they
Clinical Exam
• Pain
• Joint specific range and strength
• Uninvolved extremities and core
• Check posture, strength, and range
– Scapula stabilizers
– LE and core flexibility
– Eccentric control
• Imbalances cause compensation
• Compensation results in injury
Acute PT Intervention
• Appropriate sport specific rest
• Modalities
– Cryotherapy and iontophoresis
– NMES and US?
• Pain free range of involved joint
– Pendulums, finger wall walks, wands, etc.
Acute PT Intervention
• Once full pain free range is obtained
– Begin joint specific strengthening
• Open chain as tolerated due to sport demands
– Weights and theraband
• Closed chain loading
– Seated, standing, quadruped, plank
– Assists with core and eccentrics
– Loads tissues to promote healing
Acute PT Intervention
• Don’t forget the rest of the kinetic chain
– PROM and strength as found in deficit
• Range of motion
– Pectoralis, latissimus, and lower extremities
• Scapula stabilizers strength
– Cardiovascular and endurance
• Athletes will want to return as soon as possible
• Fatigue will need to be addressed
Progression of Core Stability
• Stress good posture and eccentric control
– Physical vs. cognitive maturity
• Mat exercises
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Kneeling push up static
Planks
Full push up static
Bird dogs
Bear crawls
Unstable kneeling push up
Unstable full push up
Progression of Core Stability
• Swiss ball exercises
– Prone walk outs
– Prone walkouts with shoulder flexion
– Prone walkouts into push ups
– Prone walkouts into push ups, unstable
surface
Preparation for Return to Sport
• Are they ready for this?
• UE plyometrics
– UE shuffle
• quadruped, kneeling push up, full push up
– UE cone stack
• quadruped, kneeling push up, full push up
– UE step ups
• Up and down same side
• Up and over
Preparation for Return to Sport
• Are you sure they are ready for this?
• UE fall arrest
– Begin kneeling at wall
– Gradually increase distance of “fall” to arrest
forward fall from kneeling to floor
– DO NOT PROGRESS PAST THEIR ABILITY
Preparation for Return to Sport
• Are you really sure they are ready for this?
• UE box jumps
– Begin with “jumping” down first
– Land with elbows bent
– Start in quadruped, progress to kneeling then full
pushup
– Progression in each stage
• Depth of box
• Amount of elbow flexion at start
• Unstable surfaces
Keys for good outcomes
• Limiting factors
– Pain
– Fatigue
– Loss of eccentric control
• Trouble with progression
– Vary resistance
– Static vs. dynamic
– Remember body awareness and age
Sport Specific Return to Play
• Return to limited play during practice
– Respect fatigue and loss of eccentric control
– Limit specific training drills per sport
– Modify position to limit distance and number
of throws
– Know the sport, if you don’t educate yourself
• Pitch counts, types, and required rest
• Interval Throwing Programs
Pitch Counts
Maximum Pitch Counts
Age
7-8
9-10
11-12
13-16
17-18
Pitches/game
50
75
85
95
105
Source: Little League Baseball
Age Recommended for Learning
Various Pitches
Pitch
Age
Fastball
Change-up
Curveball
Knuckleball
8±2
10 ± 3
14 ± 2
15 ± 3
Forkball
Slider
Screwball
16 ± 2
16 ± 2
17 ± 2
Source: Andrews & Fleisig
Rest Periods Required
After Number of Innings Pitched
Ages 7–16
61+
41–60
21–40
1–20
Ages 17–18
76+
51–75
26–50
1–25
Rest in days
3
2
1
0
Source: Little League Baseball
Data Based Return to Sport
• Internet is abound with Interval Throwing
Programs
– Most based on gradual progression perceived
demands and one size fits all
– Baseball
• Axe, Wickham, Snyder-Mackler
• For multiple age groups
• Data based
Data Based Return to Sport
– Softball
• Axe, Windley, Snyder-Mackler
• Data based
• Only college age
– Other Sports
• Programs limited in data based progression or
simply limited at all
Interval Throwing Program
(Axe et. al.)
• Age based program- 3 versions
– Little League, ages 9-12
• 46 ft from mound to home
• 6 innings per week
– 13-14 years of age
• 60 ft 6 in mound to home
• 9 innings per week
– High School, College, and Professional
• 60 ft 6 in mound to home
• No set limits on innings, only pitch counts
Interval Throwing Program
(Axe et. al.)
• Data based
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9-12 year old from 400.5 innings
13 year old from 203.5 innings
15-18 year old from 234 innings
Div I from 440 innings
Professional 6 seasons from 80’s and 90’s
Counted number of total pitches per inning, total number of warm
up pitches per inning, and innings and number of pitches thrown
by each pitcher per game were recorded for all
• For older athletes this was further divided by starting, relief, and closing
pitches as well as pick off attempts
Interval Throwing Program
(Axe et. al.)
• Little League Program
– Starts at Phase 1
• Regardless of diagnosis
• After medical clearance
• 2-3 day rest between each Phase
– Pain is limiting factor
– 9 Phases total
• Each Phase has long and short toss component
• Distance, reps, intensity increase each Phase
Interval Throwing Program
(Axe et. al.)
• Little League Program
– Short toss
• Starts at 20 ft, increase to 46 ft by Phase 4
• 3 sets, progression of 15-25 reps/set
• Intensity
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Work to tolerance Phase 1-3 on flat ground
Begin ½ speed by Phase 4
Begin ¾ speed by Phase 5
Full speed off mound by Phase 6
• Set times between throws and for rest
– 12 sec per throw
– 6-8 minutes per set for 3 sets
Interval Throwing Program
(Axe et. al.)
• Little League Program
– Long toss
• 10 minute rest between Short and Long toss
• Distance age dependent
– Starts at 65%
– Increase 5% each Phase
– Refer to table 5 in the article
» 10 y/o throwing 45 mph
» Estimated max of 107.3 ft,
» 65% equals 69.73 ft
Interval Throwing Program
(Axe et. al.)
• Little League Program
– Long toss continued
• Begin throwing 10 ft for 3-5 throws and increase
10-15 ft every 3-5 throws until distance is reached
• 12 seconds/throw
• 25 throws total
– Ends with a simulated game (Phase 9)
– Soreness Rule
• Will determine overall time to complete
Interval Throwing Program
(Axe et. al.)
• Soreness Rule- applies to all levels
– If no soreness after a step (or phase)
• Advance one step every day
– Of scheduled practice, not calendar days
– If sore during warm-ups
• Soreness gone after warm ups repeat previous
workout
• If become soreness during this workout, stop and
rest 2 days, return one step down from last
workout
Interval Throwing Program
(Axe et. al.)
• Soreness Rule continued
– If sore more than one hour after workout or
the next day
• Take one day off, repeat most recent workout
– If sore during warm up and soreness
continues through first 15 throws
• Stop, take 2 days off, upon return drop down one
step.
Interval Throwing Program
(Axe et. al.)
• 3 Phases older athlete programs
– Return to Throw
– Return to Pitch
– Intensified Pitching
• Ends with a simulated game
• Medical clearance required to begin
Interval Throwing Program
(Axe et. al.)
• 13-14 year-old program
– Phase 1- Return to Throwing
• 3 steps (1-3)
– Phase 2- Return to Pitching
• 3 steps (4-6)
• Fastballs from ground
– Phase 3- Intensified Pitching
• 10 steps (7-16)
• Pitch from the mound
• Off-speed begin step 13
Interval Throwing Program
(Axe et. al.)
• Beginning step for the older athletes is
determined by type of injury
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Location anywhere other than the throwing arm
Throwing arm, not involving the joint
Throwing arm, mild injury to joint
Throwing arm, severe injury to joint
• Must refer to tables to know at what step to
begin the program
TABLE 7. Pitching program instructions for 13- or 14-year-old
players (Axe)
A. Baseline/Preseason
To establish a base for training and conditioning, begin with step 3 and advance one step
daily to step 14 following soreness rules.
B. Non-throwing arm injury
After medical clearance, begin step 3 and advance one step daily to step 16 following
soreness rules.
C. Throwing arm- Bruise or bone involvement
After medical clearance, begin with step 1 and advance program as soreness rules allow
throwing no more than every other day.
D. Throwing arm- Tendon/Ligament injury (Mild)
After medical clearance, begin with step 1 and advance program to step 3 throwing every
other day as soreness rules allow. Throw every third day on steps 4–8 as soreness rules
allow. Return to throwing every other day as soreness rules allow for steps 9–16.
E. Throwing arm- Tendon/Ligament injury (Moderate, severe, or post op)
After medical clearance, begin throwing at step 1. For steps 1–3, advance no more than 1
step every 3 days with 2 days of active rest (warm-up and long tosses) following each
workout. Steps 4–8 advance no more than 1 step every 3 days with 2 days active rest (see
step 11) following each workout. Advance steps 9–16 daily as soreness rules allow.
Appendix C.
13/14-Year-Old Baseball Pitchers
Interval Throwing Program (Axe)
Phase I—Return to Throwing
All throws are at 50% effort
Distances listed in feet
Phase II—Return to Pitching
Fastballs are from level ground
following crow hop- 60 feet
Step 1 Warm-up toss to 60
15 Throws at 30*
15 Throws at 30*
15 Throws at 30*
20 Long tosses to 60
Step 4
* Rest 6 minutes after these sets
Warm-up toss to 105
20 Fastballs (50%)*
16 Fastballs (50%)*
16 Fastballs (50%)*
25 Long tosses to 105
Appendix C.
13/14-Year-Old Baseball Pitchers
Interval Throwing Program (Axe)
Phase III—Intensified Pitching
Pitches are from mound with
normal stride
Step 7
Warm-up toss to 120
20 Fastballs (50%)*
20 Fastballs (75%)*
20 Fastballs (75%)*
20 Fastballs (50%)*
25 Long tosses to 160
* Rest 6 minutes after these sets
Simulated game
Step 16
1) 10 Minutes Warm-up of 50–80
Pitches With Gradually Increasing
Velocity
2) 5 Innings
3) 22–27 Pitches Per Inning,
Including 15–20 Fastballs
4) 6 Minutes Rest Between Innings
Interval Throwing Program
(Axe et. al.)
• High School, College, and Professional
– Phase 1- Return to Throwing
• 7 steps (1-7)
– Phase 2- Return to Pitching
• 5 steps (8-12)
• Fastballs from ground
– Phase 3- Intensified Pitching
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10 steps (13-21)
Pitch from the mound
Relief and closing pitchers (after step 15 go to 21)
Off-speed start step 15
TABLE 8. High school, college, professional pitching program
instructions (Axe)
A. Baseline/Preseason
To establish a base for training and conditioning, begin with step 4 and advance one step
daily following soreness rules.
B. Non-throwing arm injury
After medical clearance, begin step 4 and advance one step daily following soreness rules.
C. Throwing arm- Bruise or bone involvement
After medical clearance, begin with step 1 and advance program as soreness rules allow
throwing every other day.
D. Throwing arm- Tendon/Ligament injury (Mild)
After medical clearance, begin with step 1 and advance program to step 7 throwing every
other day as soreness rules allow. Throw every third day on steps 8–12 as soreness rules
allow. Return to throwing every other day as soreness rules allow for steps 13–21.
E. Throwing arm- Tendon/Ligament injury (Moderate, severe, or post op)
After medical clearance, begin throwing at step 1. For steps 1–7, advance no more than 1
step every 3 days with 2 days of active rest (warm-up and long tosses) following each
workout. Steps 8–12 advance no more than 1 step every 3 days with 2 days active rest
(see step 14) following each workout. Steps 13–16 advance no more than 1 step every
other day with 1 day active rest (see step 14) between steps.
Advance steps 7–21 daily as soreness rules allow.
Appendix D.
High School College And Professional Baseball Pitchers
Interval Throwing Program (Axe)
Phase I—Return to Throwing
Throws at 50% Effort
Distances listed in feet
Phase II—Return to Pitching
Throws at Effort Level Given
Step 1
Step 8
Warm-up toss to 60
15 Throws at 30*
15 Throws at 30*
15 Throws at 30*
20 Long tosses to 60
* Rest 9 minutes after these sets.
Warm-up toss to 120
15 Throws at 60’ 6” (75%)*
20 Throws at 60’ 6’’ (75%)*
20 Throws at 60’ 6” (75%)*
15 Throws at 60’ 6 “(75%)*
25 long tosses to 160
Appendix D.
High School College And Professional Baseball Pitchers
Interval Throwing Program (Axe)
Phase III Intensified Pitching
Simulated game
Step 13 Warm-up toss to 120
25 Fastballs (75%)*
20 Fastballs (100%)*
10 Fastballs (75%)
15 Fastballs (100%)*
25 Fastballs (75%)*
25 long tosses to 160
Step 21
1) 10 Minutes warm-up of 50–80
pitches with gradually increasing
velocity.
2) 5–8 Innings for starters, 3–5
innings for relievers, 2–3 innings
for closers.
3) 15–20 Pitches per inning,
including 10–15 fastballs.
4) 9 Minutes rest between innings.
* Rest 9 minutes after these sets.
Interval Throwing Program
(Axe et. al.)
• Progression of older athletes
– Time between throwing days determined by type of
injury
• Varies from every other day, to every three days with active
rest on off days
• Based on 4 types discussed earlier, must reference chart to
determine (Tables 7 & 8)
– Soreness rule
• Process could be lengthy
Prevention
• Home program to maintain
– Include PROM and core strength
• Avoid overtraining
– Cross train
– One sport at a time
• Education to all involved
– Coaches, parents, players
– Good equipment and proper technique
References
Articles
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Axe M, Wickham R, Snyder-Mackler L. Data-Based Interval Throwing Programs for Little League,
High School, College, and Professional Baseball Pitchers. Sports Medicine and Arthroscopy
Review. 2001;9: 24-34.
Axe M, Windley T, Snyder-Mackler L. Data-Based Interval Throwing Programs for Collegiate
Softball Players. Journal of Athletic Training. 2002;37: 194-203.
Marsh, Darrin. Little League Elbow: Risk Factors and Prevention Strategies. Strength and
Conditioning Journal. 2010;22: 22-37.
Osbahr D, Kim H, Dugas J. Current Opinions in Pediatrics. New York, NY: Lippincott Williams &
Wilkins. 2010, 35-40.
Websites
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http://www.childrensmercy.org/sportsmedicine/
http://www.stopsportsinjuries.org/
http://stopsportsinjuries.reingoldweb.com/files/pdf/AOSSM_Baseball.pdf
http://stopsportsinjuries.reingoldweb.com/files/pdf/AOSSM_Softball.pdf