Overview of Adolescent Throwing Problems


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Jordan D. Metzl, M.D.
Mickey Levinson, PT

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  • 9 year male. Acute elbow trauma. MR : Avulsion of medial epicondyle apophysis, with posterior and anterior bands of medial collateral ligament attached. Bone marrow oedema pattern in remaining portion of apophysis. Signal abnormality in captilleum may represent early OCD. Patient : Inkeles, Issac MRN : 776041 Scan date : 9/22/2003 Ref physician : Francisco Laplaza
  • Overview of Adolescent Throwing Problems

    1. 1. Little League Baseball Jordan D. Metzl, M.D. Mickey Levinson, PT
    2. 2. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. Jordan Metzl, MD Hospital for Special Surgery Disclosure: I DO have a financial relationship with any commercial interest. Types of financial relationships and the companies with whom I have relationships are as follows: Speakers Bureau - Ferring; Pharma; DePuy; Gatorade
    3. 3. Sports Are Great For Kids! <ul><li>Leadership </li></ul><ul><li>Values </li></ul><ul><li>Teamwork </li></ul><ul><li>On and Off field lessons </li></ul><ul><li>Balance </li></ul><ul><li>Injury? </li></ul>
    4. 4. Sports Injuries in the Athletic Patient <ul><li>Acute Traumatic </li></ul><ul><ul><li>Fractures </li></ul></ul><ul><ul><li>Ligament Injury </li></ul></ul><ul><ul><li>Concussion </li></ul></ul><ul><li>Overuse </li></ul><ul><ul><li>Stress Fracture </li></ul></ul><ul><ul><li>Osteochondritis Dessicans </li></ul></ul>
    5. 5. Overview: Adolescent Development <ul><li>Skeletal </li></ul><ul><li>Sexual </li></ul><ul><ul><li>SMR (Tanner) </li></ul></ul><ul><li>Psychological </li></ul><ul><li>Physiologic </li></ul><ul><ul><li>Physiologic potential </li></ul></ul><ul><ul><li>Strength </li></ul></ul>
    6. 6. Little League Baseball: Participant Demographics <ul><li>First game, NJ, 1845 </li></ul><ul><li>1871 – National Assn of Professional Baseball Players </li></ul><ul><li>16.5 million kids and teens </li></ul><ul><li>190,00 teams, 80 countries </li></ul>
    7. 7. Orbital “Blowout” Fracture
    8. 8. Eye Injuries <ul><li>1/3 from being struck by pitched ball </li></ul>
    9. 9. Eye Protection in Baseball Batting Facemask Batting Facemask Field Goggles
    10. 10. Sports Injury Prevention <ul><li>Evaluation of safety balls and faceguards for prevention of injuries in youth baseball </li></ul><ul><li>Marshall SW, Mueller FO, Kirby DP, Yang J </li></ul><ul><li>JAMA. 2003 Feb 5;289(5):568-74 </li></ul>
    11. 11. Commotio Cordis <ul><li>1879, German physician defines death of patient after being hit with stone </li></ul><ul><li>Most common cause of fatality in baseball </li></ul><ul><li>158 reported cases, 95 % male, 87% white </li></ul><ul><li>10-14 year old is peak incidence </li></ul><ul><li>Left chest injury </li></ul><ul><li>10% survival w/o AED, 50% with AED </li></ul><ul><li>? AED – Louis’s Law </li></ul>
    12. 12. Reported Cases of Commotio Cordis Frequency by Sport (1973-2002) Baseball 52 Sotball 7 Ice Hockey 7 Lacrosse 6 Karate 3 MVA/Bike 3 Others Total - 121
    13. 13. Schematic Representation of the Locations of Impact Points <ul><li>Chest walls of 12 victims of Commotio Cordis </li></ul>Baseball Hockey puck Lacrosse ball
    14. 14. Impact Object Hardness is Related to the Risk of Sudden Death in an Animal Model of Commotio Cordis <ul><li>Link MS et al </li></ul><ul><li>Journal of the American College of Cardiology . 1998;31:133A </li></ul><ul><li>56 pigs, 30 mph strikes </li></ul><ul><li>Vfib inceased with ball hardness </li></ul>Frequency of VF with hardness of object
    15. 15. Anabolic Steroid Use in Youth Sports <ul><li>Buckley et al, 1988, 6.6% user-rate in HS seniors </li></ul><ul><li>Johnson et al, 1988, 11% user-rate, HS juniors </li></ul><ul><li>Faigenbaum et al, 1998, 2.7% user-rate, middle school </li></ul>
    16. 16. Anabolic Steroids: Kids vs. Adults
    17. 17. Shoulder Pain in the Young Thrower <ul><li>13 year old pitcher </li></ul><ul><li>4 weeks of worsening shoulder pain </li></ul><ul><li>Initially only with throwing hard </li></ul><ul><li>Now pain with throwing softly </li></ul>
    18. 18. Developmental Phases of Throwing Facing target – Push Facing target, Cocking, Toss Age 2
    19. 19. Developmental Phases of Throwing Facing target, Ipsilateral step Perpendicular to target, Contralateral step Age 4
    20. 20. Developmental Phases of Throwing Wind-up, Cocking, Contralateral step Body momentum, Follow-thru Age 6-9
    21. 21. Phases of Throwing Wind-up Cocking Acceleration Deceleration Follow- thru E.McFarland ACSM-kinematics
    22. 22. A mature mechanic by age 10? Age 10 Division 1 collegiate athlete
    23. 23. Little League Shoulder: Case 1
    24. 24. Little League Shoulder: Case 2
    25. 25. Little League Shoulder: Case 3
    26. 26. Proximal Humeral Physis <ul><li>Appears at 1 year of age </li></ul><ul><li>Fuses between 15-19 years of age </li></ul><ul><li>Accounts for 80% of humeral growth </li></ul><ul><li>Adaptive remodeling increases external rotation, decreases internal rotation </li></ul>
    27. 27. Treatment: LLS <ul><li>No throwing until pain free </li></ul><ul><li>Xray for initial evaluation, possibly if concern for growth arrest </li></ul><ul><li>Asses risk factors </li></ul><ul><li>Modify throwing mechanic ? </li></ul>
    28. 28. Pitch Counts Guidelines for maximum effort pitches 10 pitches per years of age per 7 day period.
    29. 29. Guidelines for Appropriate Pitch Types
    30. 30. Biomechanics <ul><li>Stance </li></ul><ul><li>Windup </li></ul><ul><li>Cocking/acceleration </li></ul><ul><li>Landing </li></ul><ul><li>Follow through </li></ul>
    31. 31. Prevention Program for Throwers <ul><li>Warm-up 5-10 minutes </li></ul><ul><li>Strength </li></ul><ul><ul><li>forearm </li></ul></ul><ul><ul><li>upper arm </li></ul></ul><ul><ul><li>shoulder </li></ul></ul><ul><ul><li>core </li></ul></ul><ul><ul><li>hips </li></ul></ul>
    32. 32. Elbow Pain in a Pitcher <ul><li>12 year old pitcher </li></ul><ul><li>5 weeks of worsening medial elbow pain </li></ul><ul><li>Pain initially with throwing </li></ul><ul><li>Now pain with most activities </li></ul><ul><li>Acute onset of pain after throw </li></ul>
    33. 33. Pediatric Elbow <ul><li>Multiple ossification centers (6) </li></ul><ul><li>Common site of injury </li></ul><ul><li>Traction injuries are common on the medial (ulnar) side </li></ul><ul><li>Medial humeral apophysis </li></ul>
    34. 34. Little League Elbow
    35. 38. Treatment - LLE <ul><li>History </li></ul><ul><li>Diagnosis </li></ul><ul><li>Rest </li></ul><ul><li>Mechanics </li></ul><ul><li>Return to activity ? </li></ul>
    36. 39. Ligamentous Anatomy (UCL) <ul><li>Adolescent UCL injury </li></ul><ul><li>? Frequency </li></ul>
    37. 41. Radiocapitellum Overload <ul><li>RC joint sees most force with throwing </li></ul><ul><li>Can produce “overload” force </li></ul><ul><li>Compressive force on lateral side </li></ul>
    38. 42. Osteochondritis Dessicans <ul><li>Compressive side of throwing elbow </li></ul><ul><li>9-15 year old throwers </li></ul><ul><li>Diagnosis </li></ul><ul><li>Treatment </li></ul>
    39. 43. Conclusions <ul><li>Baseball is a great sport for kids </li></ul><ul><li>Throwing can cause injury in young athletes </li></ul><ul><li>Recognition and early intervention are the keys to successful outcomes </li></ul>