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Little league elbow: valgus overload injury in the paediatric athlete
Abstract
This article describes a variety of elbow injuries often seen in young, throwing athletes. Understandings of normal skeletal development, as well as the biomechanics of throwing, provide a basis on which to evaluate, diagnose and manage "little league elbow". With emphasis on an anatomically-based differential diagnosis, the pathologic forces placed upon the young thrower's elbow, and the subsequent injury patterns, are reviewed. Medial side injuries are the most common and relate to chronic forces of valgus overload produced during the early and late cocking phases of throwing. The majority of this force is placed on the medial epicondyle and produces age-dependent injury patterns, such as apophysitis in childhood and epicondylar avulsion fractures in the more mature athlete. With repetitive valgus overload, lateral side injuries such as Panner's disease and osteochondritis dissecans of the capitellum and radial head become more apparent. These injuries relate to the compressive forces produced by the late cocking and early acceleration phases of throwing. Finally, posterior injury patterns consistent with olecranon apophysitis and posteromedial impingement, as well as flexion and capsular contracture, can be seen. The key in the treatment of "little league elbow" is prevention and this responsibility lies not only with the evaluating or team physician, but also with the coach, trainer, parents and officials. Proper throwing mechanics must be emphasised at an early age, and the determinants of elbow injury among young pitchers better understood. Early recognition and proper treatment of such injuries will then prevent later sequelae or functional disability.
... 18 Along with increased medial laxity, lateral-sided compression injuries and posterior shear-stress injuries can develop, which represent a constellation of conditions that result from a single pathophysiological mechanism: valgus extension overload. 18,19 Presentation of these injuries is largely impacted by an individual athlete's physiological stage of skeletal maturity with mechanical failures occurring at the weakest link in the chain. 14,20,21 Injury to the elbow is examined through an understanding of common medial, lateral, and posterior pathologies. ...
... Common medial pathologies such as traction apophysitis of the medial epicondyle, known as Little Leaguer's elbow, affects approximately 26%-28% of youth baseball pitchers with acute tension failure at the medial apophysis resulting in avulsion of the medial epicondyle. 14,[18][19][20] While repetitive overhead activity can lead to osteochondritis dissecans (OCD) of the capitellum on the lateral side, painful persistent olecranon physes and stress fractures have also been reported at all levels of sport, as have olecranon osteophytes and symptomatic intra-articular loose bodies in the posterior compartment. 18,19 As the burden of these injuries increase, it is important for orthopedic surgeons to understand the functional anatomy of the elbow, biomechanical forces of overhead throwing, and the surgical techniques available in order to counsel patients and make informed, evidence-based decisions. ...
... 14,[18][19][20] While repetitive overhead activity can lead to osteochondritis dissecans (OCD) of the capitellum on the lateral side, painful persistent olecranon physes and stress fractures have also been reported at all levels of sport, as have olecranon osteophytes and symptomatic intra-articular loose bodies in the posterior compartment. 18,19 As the burden of these injuries increase, it is important for orthopedic surgeons to understand the functional anatomy of the elbow, biomechanical forces of overhead throwing, and the surgical techniques available in order to counsel patients and make informed, evidence-based decisions. ...
With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7-33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete's stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.
... Among adolescent baseball players, elbow injuries are common and affect as many as 40% of young baseball athletes, as indicated in previous studies [2,13]. Among all possible causes of elbow pain, medial epicondyle (MEC) lesions are noteworthy in adolescent baseball players, as MEC lesions have been reported to cause pain [16] and loss of elbow motion [11]. MEC lesions may eventually deteriorate throwing velocities and lead to further disabilities [23]. ...
... MEC lesions among adolescent baseball players, including MEC fragmentation, MEC irregularity, MEC apophysitis, ulnar collateral ligament (UCL) injury, medial epicondylitis and medial epicondylar avulsion fracture, are caused by extreme valgus force from the throwing action, creating excessive tensile stress across the medial elbow [2,4,11,22]. Clinically, MEC lesions are known as "little league elbow" (LLE), signifying medial elbow injuries specific to skeletally immature baseball players [10,11]. ...
... MEC lesions among adolescent baseball players, including MEC fragmentation, MEC irregularity, MEC apophysitis, ulnar collateral ligament (UCL) injury, medial epicondylitis and medial epicondylar avulsion fracture, are caused by extreme valgus force from the throwing action, creating excessive tensile stress across the medial elbow [2,4,11,22]. Clinically, MEC lesions are known as "little league elbow" (LLE), signifying medial elbow injuries specific to skeletally immature baseball players [10,11]. It is generally considered that UCL injury is less common in little league players [2,11,25]; however, several studies found that UCL injury can develop in little league players [8,10,17]. ...
Purpose
Only few studies have investigated medial epicondyle (MEC) lesions, particularly in the 12–18 age group. To the best of our knowledge, no study has compared ultrasonography (US), radiography and magnetic resonance imaging (MRI) in detecting MEC lesions. The aims of this study were to examine the value of US for detecting MEC lesions and to investigate correlations among diagnostic tools.
Methods
A prospective, comparative study was performed. Young baseball players from southern Taiwan were recruited, and basic characteristics, as well as passive range of motion (pROM) of the upper extremities, were recorded. Screening US was performed to identify MEC lesions, and players with MEC lesions received follow-up plain radiography and MRI.
Results
A total of 299 young baseball players were screened using US, and 28 of 299 players with possible MEC lesions were identified with a positive predictive value (PPV) of 88% according to MRI findings. The MEC lesions were primarily comprised of unfused ossicles and bony fragmentation. Other diagnoses, including UCL strain and medial epicondylitis, were also found by MRI in players with abnormal US screening results. The pROM of shoulder external rotation (ER) of the throwing hand was significantly reduced in players with MEC lesions (p = 0.006).
Conclusions
Bony cortical discontinuity or fragmentation over the MEC warrants further research, and US provides good PPV for types of MEC lesions. Decreased shoulder ER may relate to MEC lesions and should be taken into consideration. The use of US may facilitate early detection and intervention.
Level of evidence
IV, Cross-sectional study.
... Overuse physeal injuries develop in response to excess stress placed on immature bony and soft tissue structures. [13][14][15][16][17][18]24,25,[30][31][32][33][34]36,37,40,42,44,48,58,61,62,73 Rapid physical changes combined with repetitive sport-related tasks such as running and overhead throwing are frequently associated with the development of physeal injuries in youth athletes. 13,15,20 The gradual nature of this injury progression provides clinicians with multiple opportunities for effective intervention. ...
... 2,4,6,9,21,33,63,84 "Little League elbow" is a term often used to describe a variety of physeal and cartilaginous injuries at the pediatric elbow. 12,13,15,35,38,42 By definition, Little League elbow is a repetitive traction injury to the medial epicondylar apophysis (Figure 4). 35 Diagnoses of Little League shoulder and Little League elbow are most often made after reports of persistent arm pain and loss of function in youth baseball pitchers between the ages of 11 and 15 years ( Table 2). ...
... 35 Diagnoses of Little League shoulder and Little League elbow are most often made after reports of persistent arm pain and loss of function in youth baseball pitchers between the ages of 11 and 15 years ( Table 2). 21,42,63 Risk factors associated with the development of gymnast wrist include consistent UE loading and timing of growth spurts. 29 Studies suggest that participation in repetitive UE weightbearing tasks, especially during periods of rapid physical growth, is directly associated with this highly prevalent, populationspecific injury. ...
Context:
Despite rising awareness of the risks associated with sports participation, overuse injuries continue to increase in youth athlete populations. Physeal injuries are one type of overuse injury exclusive to pediatric populations that are often sustained during athletic practice or competition. Overuse physeal injuries are, in theory, preventable; however, little consensus has been reached surrounding the risk factors, prevention, and treatment strategies.
Objective:
This systematic review summarizes the best available evidence concerning overuse physeal injuries in youth and adolescent athletes. It can be used to develop prevention and treatment programs specific to this population.
Data sources:
PubMed and Academic Search Complete (EBSCOhost) were explored using the keyword physeal injuries from January 1950 through May 2015 to identify 24 studies.
Study selection:
Original research studies of athletic populations with mechanisms of injury related to sport were chosen.
Study design:
Systematic review.
Level of evidence:
Level 3.
Data extraction:
Data were extracted as available from 24 eligible studies. Study quality was rated using the Oxford Centre for Evidence-based Medicine (OCEBM) guidelines.
Results:
Risk factors for injury include periods of accelerated growth, chronological age, body size, training volume, and previous injury. Injury prevention strategies currently emphasize participation limitations and sport-specific training programs in skeletally immature athletes. The most effective treatment after an overuse physeal injury was an extended period of active rest and joint immobilization when necessary.
Conclusion:
Overuse physeal injuries are multifactorial in nature. Muscular imbalances after accelerated growth periods predispose young athletes to overuse injuries. Modifiable risk factors such as flexibility, strength, and training volume should be regularly monitored to prevent these injuries.
... This ultimately produces distraction forces across the medial elbow compartment, compression forces across the lateral elbow compartment, and a posterior shear or traction component. [56][57][58] Little Leaguer's elbow, therefore represents a constellation of injury patterns encountered in the immature elbow joint during throwing activities (Fig. 4). Medial-sided injuries include medial epicondyle avulsion injuries, apophysitis, and UCL insufficiency. ...
... Radiographs of the contralateral elbow can be extremely useful in differentiating normal anatomy from a true bony injury. 58 Medial epicondylar apophysitis is a common overuse elbow injury seen in young pitchers. 58 The etiology is secondary to valgus stress with tension on the medial epicondyle via the flexor-pronator muscle mass and UCL. ...
... 58 Medial epicondylar apophysitis is a common overuse elbow injury seen in young pitchers. 58 The etiology is secondary to valgus stress with tension on the medial epicondyle via the flexor-pronator muscle mass and UCL. It typically presents with an insidious onset of progressive medial elbow pain. ...
... Strength testing should include pronation, wrist flexion, and grip strength as this may reproduce the patient's pain or reveal weakness [38,41]. Assessment for UCL insufficiency [29,30]. Additionally, this can also happen from an elbow dislocation or direct trauma to the elbow. ...
... There is much debate in the literature on the appropriate treatment of ME avulsion fractures and whether to treat conservatively versus surgically. Treatment decision relies on amount of fracture displacement [30]. In the general population, some authors advocate for surgery for a medial epicondyle avulsion fracture with 5-15 mm of displacement [31]. ...
Purpose of Review
The goal of this paper is to summarize the evidence-based strategies for diagnosing medial elbow pathology in throwers, specifically focusing on history, physical exam, and imaging. Similarly, an evidence-based approach to managing these injuries will be covered. Cutting edge strategies for injury prevention are also discussed.
Recent Findings
Many of the medial elbow injuries in throwers occur concomitantly. The rehabilitation of these injuries requires appropriate rest, comprehensive kinetic chain optimization, monitored workload during the interval throwing program and while in competition. Injury prevention exercise strategies demonstrate promise for reducing the prevalence of arm injuries in throwing athletes.
Summary
Medial elbow pathology prevalence for throwing athletes can be reduced through load management and whole-body maintenance exercises. Future research will need to focus on effective strategies for injury prevention. Nonoperative research will need to better characterize effectiveness of evidence-based rehabilitation protocols, interval throwing programs, and return to participation times for each diagnosis.
... In individuals younger than 15-years-old, these detachments can be complete and involve the entire medial epicondylar ossification centre. In older teens, they can be partial, leading to the avulsion of one or more bony fragments from the medial epicondylar apophysis ( Klingele and Kocher 2002;Kijowski and Tuite 2010). When the individual with an avulsion fracture reaches adulthood, the healed lesion takes the form of a bony outgrowth or lacunae depending on whether or not the avulsed fragment re-united with the condyle ( Lewis 2018, 254- 255). ...
... Today, these ME injuries are common pathological findings in young baseball pitchers and are known as Little Leaguer's elbow (Klingele and Kocher 2002). They are also reported in javelin throwers (Miller 1960), but the incidence is lower, because Javelin competitions begin later -during high school in the United States (Gregory and Nyland 2013). ...
The anterior band of the medial collateral ligament (MCL) is an important stabilizer for valgus stress at the elbow. When practised intensively and repetitively, activities using overhead throwing motions can injure this ligament and its insertion. If these activities occur when the epiphyses are not yet fully fused, traction forces can result in bony detachments in the area of the MCL insertion. This study was based on commingled graves found in 16 Middle and Late Neolithic caves from Belgium. We recorded the presence of MCL lesions on 196 humeri and studied the relation between lesions, siding, and robusticity. 5.1% of the humeri displayed MCL lesions, which affected only the right robust humeri. Our results suggest a social division in throwing activities in Belgium during the Neolithic. They also suggest that throwing practice started from a young age, which invites us to re-examine the role of teenagers in prehistoric societies.
... Besides the classic osteoarthritis of the elderly, often children and adolescents are affected. In particular, repetitive stress on the elbow, e.g., as part of professional sports, seems to play an essential role [11,12], in which most common the capitellum and more rarely the trochlea are concerned [19]. ...
... In the observation period, 35 elbow arthroscopies in 32 children and adolescents were performed. From these (11)(12)(13)(14)(15)(16)(17) years. The mean follow-up period was 45.6 months. ...
Background:
Chondral or osteochondral lesions, post-traumatic contracture and loose bodies of the elbow are often associated with chronic pain, stiffness, repetitive swelling and joint blockages. Therefore, arthroscopy of the elbow is often used in the elderly for the treatment of osteochondral defects or arthrolysis. There are only a few reports and studies about arthroscopic therapy of the elbow in children and adolescents. This study assesses the clinical outcome of arthroscopic therapy in this age group.
Methods:
In a retrospective study, children and adolescents who underwent an elbow arthroscopy in the period from 2010 to 2014 were included. The children were evaluated using the validated outcome measures Mayo Elbow Performance Score (MEPS), range of motion, pain on visual analog scale (VAS), Oxford Elbow Score (OES), quick dash and postoperative satisfaction. Furthermore, all complications were analyzed.
Results:
In total, 27 patients were included. The mean (range) age was 14 (11-17) years, with a follow-up of 45 months. Fourteen (52%) were female and thirteen children (48%) were male. Twenty children had an arthroscopy due to osteochondritis dissecans and seven children for post-traumatic pain and stiffness. The mean (standard deviation) MEPS improved from 65 (15) to 96 (8; p = .005). The OES and quick dash were 93 and 5.4. The mean extension improved from - 15° (± 13.8) to 3° (± 10.2; p < .001). The mean flexion improved from 131° (± 13.4) to 137° (± 9.5; p = .003). Average pain on VAS was postoperative .2 (± .5), and 81.5% of all children had excellent or good results. There were no complications such as damage of nerves or blood vessels observed.
Conclusion:
Elbow arthroscopy is an appropriate and safe treatment option in children and adolescents with good and excellent postoperative results.
... 1,13 In overhead throwing athletes, the elbow is subjected to valgus overload with significant compression and shear forces applied to the radiocapitellar joint between 30 and 90 of flexion, and with repetitive overhead throwing these may cause capitellar OCD. 7,9,10 It is generally believed that anteroposterior (AP) radiographs with the elbow in 45 of flexion is the best position to detect capitellar OCD in baseball players. 15,16 However, several gymnasts with early-stage capitellar OCD lesions had lesions that were not detected with 45 AP radiography but rather with radiographs performed in full extension ( Figure 1). ...
... On the other hand, repetitive microtrauma to the capitellum of the elbow is thought to be one of the primary causes of OCD. 1 In baseball players, the pathogenesis of capitellar OCD may be high compression and shear forces on the radiocapitellar joint that occur during the late cocking and early acceleration phases of throwing, when the elbow is flexed from 30 to 90 ( Figure 5A). 7,9,10 In a CT osteoabsorptiometry study in baseball players, Momma et al 11 reported the stress distribution to the anterior part of the capitellum, which supports the hypothesis that high compression and shear have an important role in the development of elbow OCD in baseball players. However, gymnasts load the radiocapitellar joint with their elbows fully extended, and that force seems to cause capitellar OCD ( Figure 5B). ...
Background:
Osteochondritis dissecans (OCD) lesions are often observed in the humeral capitellum both in young baseball players and gymnasts. It is generally believed that capitellar OCD in baseball players can be seen on an anteroposterior (AP) radiograph with the elbow in 45° of flexion. However, the mechanism of injury seems to be different in baseball players and gymnasts. Repetitive valgus overload with the elbow in flexion is believed to be the cause of capitellar OCD lesions in baseball players, whereas weightbearing with the elbow in extension may be the cause of OCD in gymnasts.
Purpose:
To determine the difference in capitellar OCD location between baseball players and gymnasts and to propose the optimal AP radiographic angle of the elbow for visualization of early-stage OCD lesions in adolescent gymnasts.
Study design:
Cross-sectional study; Level of evidence, 3.
Methods:
Subjects consisted of 95 baseball players (95 elbows) and 21 gymnasts (24 elbows) with a mean age of 13.7 years (range, 11-18 years). To localize the lesion, inclination of the affected area in the humeral capitellum against the humeral axis was investigated using sagittal computed tomography images of the elbow. The inclination angle was defined as the angle between the long axis of the humerus and the line perpendicular to a line that connected the anterior and posterior margin of the lesion. The inclination angle in each group was compared and statistically analyzed.
Results:
The mean inclination angle was 57.6° ± 10.7° in baseball players and 28.0° ± 10.7° in gymnasts. Capitellar OCD lesions were located more anterior in baseball players when compared with gymnasts (P < .01).
Conclusion:
Due to differences in applied stress, capitellar OCD lesions in baseball players were located more anteriorly compared with those seen in gymnasts. Therefore, although AP radiographs with the elbow in 45° of flexion are optimal for detecting OCD lesions in baseball players, radiographs with less elbow flexion or full extension are more useful in gymnasts, especially in early-stage OCD.
... The pediatric elbow can be vulnerable to overuse because it has six ossification centers which appear and close at different ages of skeletal maturity as well as multiple muscle and ligamentous attachments. The repetitive motion of throwing, for example, can transfer high volumes of valgustype forces through these immature growth centers or apophyses resulting in microtraumatic or even macrotraumatic insults (47,48). The centers that withstand the most impact from these valgus stresses include the medial epicondyle, ulnar collateral ligament, and the flexor-pronator mass with its associated apophysis (75). ...
... The medial epicondyle first originates at about 5 to 6 yr of age and fuses by about 14 to 16 yr in males and is the attachment site for the common tendon of the wrist flexors. In fact, the medial epicondyle is usually the last apophysis in the elbow to fuse (32,47,48). Anatomically, the medial collateral ligament (MCL) of the elbow is a three-part structure made up of anterior, posterior, and oblique bundles. ...
In pediatric patients, musculoskeletal overuse injuries are common clinical complaints. Recently, the number of youth who are engaged in formal competition has increased. A National Council of Youth Sports survey found that 60 million children aged 6 to 18 yr participate in some form of organized athletics. Surveillance reporting systems, such as the National High School Sports-Related Injury Surveillance System and the High School Reporting Information Online (high school RIO), an Internet-based sports injury surveillance tool, have suggested an increase in the rates of overuse injuries. This article will focus on potential risk factors for overuse injuries, including those that are intrinsic and extrinsic in youth athletes. We also make note of some of the more common overuse injuries seen in the outpatient clinical setting, their diagnoses, and treatment based on current evidence-based literature.
... This observation suggested that a morphologic change in the radial head could disturb of elbow exion Although the etiology of capitellar OCD has remained unclear, previous studies show that repetitive and/or high valgus forces on the radiocapitellar joint are the crucial factor. 2,9,15,19 Speci c sports activities, such as throwing, increase compression and shear force on radiocapitellar articulation. 10,15,19 Such repetitive microtrauma affects the humeral capitellum and the radial head, which causes capitellar OCD and concomitant changes in the radial head. ...
Radial head enlargement is a secondary change when capitellar osteochondritis dissecans (OCD) lesions progress. This study was performed to clarify geometric differences between the radial head of the OCD side and the contralateral side in patients with capitellar OCD, and to investigate the correlation between radial head enlargement and elbow range of motion. Eighteen patients with capitellar OCD were underwent computed tomography (CT) images of bilateral elbow joints. Five patients underwent conservative treatment (Nonoperative group) and 13 patients underwent operative treatment (Operative group). Three-dimensional (3D) CT models of the proximal radius were created and exported into polygon and point-cloud models. The radial head geometry of the OCD side was compared with that of the mirror-imaged model of the contralateral side by using a 3D–3D registration technique. The surface-to-surface least distance was calculated. Mean least distance was 1.08 mm (SD 0.55 mm.) The radial head in the Operative group was significantly larger than that in the Nonoperative group ( p = 0.02). Elbow flexion correlated negatively with radial head enlargement ( P = 0.02 and r = 0.552). Our results clarified that the radial head enlargement increases with disease progression and correlated negatively with elbow flexion in capitellar OCD.
... Adölesanlarda epifiz kıkırdağı, yetişkinlerdeki eklem kıkırdağına göre tekrarlayan strese daha az dirençlidir. Bu yüzden adölesanların epifiz kıkırdağı, büyüme plakası boyunca enine bir kırılmaya daha yatkın olabilir 49 . Cimnastikçiler avülsiyon kırıkları yaşadıktan sonra, genellikle yoğun bir tedavi ile 6-8 hafta içinde spora geri dönerler 50 . ...
Cimnastik, dünya çapında yüksek katılım oranına sahip olimpik bir spor branşıdır. Uluslararası Cimnastik Federasyonu, artistik, ritmik, trampolin, aerobik ve akrobatik cimnastik olmak üzere 6 disiplin tanımlamıştır. Cimnastiğin en popüler alt disiplini olan artistik cimnastik branşında diğer spor branşlarıyla kıyaslandığında daha fazla yaralanma gözlenmektedir. Erken yaşlardan itibaren başlanılan yoğun antrenmanlar, sporcularda ayak ve ayak bileği bölgesinde çeşitli kas-iskelet sistemi patolojilerine neden olabilmekte, yaralanmayı takiben uzun süreli performans kayıpları görülebilmekte ve sporcuların kariyeri olumsuz etkilenebilmektedir. Artistik cimnastikçilerde ayak ve ayak bileğinde yaralanmaya yol açabilecek risk faktörlerinin tespiti ve bunların önlenmesine yönelik antrenman programının planlanması ve müdahale stratejilerinin geliştirilmesi gerekmektedir. Bu çalışmanın amacı, artistik cimnastikçilerde ayak ve ayak bileği yaralanmalarını ve bunlara neden olabilecek risk faktörlerini incelemektir. Bu çalışma için PubMed ve Web of Science veri tabanları kullanılarak 2000-2022 yılları arasında “artistik cimnastik”, “cimnastikçilerde yaralanma”, “medial tibial stres sendromu”, “ayak-ayak bileği yaralanması”, “aşil tendon yaralanması” anahtar kelimeleri ile tüm İngilizce ve Türkçe çalışmalar tarandı, toplam 92 bilimsel çalışma incelendi.
... 11,21,26,30 Several risk factors, including skeletal immaturity, high pitch count, pitch type, pitch velocity, throwing mechanics, loss of shoulder motion, and elbow torque, have been shown to increase a pitcher's risk of injuries. 3,8,11,19,23,40 Based on these findings, several primary prevention strategies have been considered. Limiting the pitch count is regarded as the most effective way to prevent throwing injuries. ...
Background
Reducing the number of pitches thrown is regarded as the most effective way to prevent throwing injuries in youth baseball pitchers. However, few studies have compared the effectiveness of limiting the pitch count versus the limiting the number of innings pitched in terms of elbow injuries.
Hypothesis
We hypothesized that, compared with inning limits, pitch count limits would lead to greater decreases in elbow pain, range of motion deficits, positive moving valgus stress test results, and the risk of capitellar osteochondritis dissecans (OCD).
Study Design
Cohort study; Level of evidence, 3.
Methods
This study retrospectively reviewed baseball pitchers aged 8 to 12 years in 2017 and 2018. Inning and pitch count limits in games were set to a daily maximum of 7 innings in 2017 and 70 pitches in 2018. Elbow pain, range of motion, and moving valgus stress test results were evaluated. The presence of capitellar OCD was assessed on ultrasonographic and radiographic images.
Results
A total of 352 pitchers in 2017 and 367 pitchers in 2018 participated. The mean pitch count per game was lower in the pitch count limit (CL) group (52.5 ± 16.0) than in the inning limit (IL) group (98.2 ± 19.5) ( P < .001). Compared with the IL group, the CL group had significantly lower rates of elbow pain (40.9% vs 31.9%, respectively; P = .01) and reduced flexion (19.0% vs 10.6%, respectively; P = .001). Multivariate analysis revealed a significant association between elbow pain and age in both the IL and the CL groups ( P < .0001 and P = .02, respectively) and between OCD and elbow pain in the CL group ( P = .04).
Conclusion
A pitch count limit of ≤70 pitches per day for baseball pitchers ≤12 years could be more protective against elbow pain and reduced flexion than a limit of ≤7 innings per day, but it may not be effective for reducing the risk of capitellar OCD.
... The medial epicondylar apophysis can also become painful, particularly in older children and young adolescents involved with pitching [8]. Radiographs show sclerosis and fragmentation (Fig. 2). ...
Osteochondrosis is an abnormality of the epiphyses or epiphyseal equivalents (round bones and apophyses) during later stages of endochondral ossification. This process of abnormal endochondral ossification can occur at various locations throughout the body. The pathogenesis of osteochondrosis is under active investigation. In humans, the process of abnormal endochondral ossification has been attributed to a combination of vascular insult and trauma. Although the proposed etiology of osteochondrosis varies based on body part affected, the overall process is defined by necrosis, revascularization and repair. As such, common radiologic findings include those of osseous destruction and associated inflammation. The purpose of this review is to discuss the current understanding of osteochondroses as a disease entity and explore imaging features of osteochondroses throughout the body.
... The exact etiology of capitellar OCD is unclear, although existing literature suggests that repetitive and/or high valgus forces applied to the radiocapitellar joint are a primary etiologic factor. 2,11,15,17 Repetitive microtrauma exposes the radiocapitellar articulation to increased compression and shear forces, which can equal up to 2.4 times a patient's body weight during certain sporting activities. 12,15 OCD has frequently been reported in male baseball players and female gymnasts, as demonstrated in the current study. ...
Background
Osteochondritis dissecans (OCD) of the elbow has almost exclusively been described in the humeral capitellum, with only a small number of reports describing secondary osteochondral changes in the radial head.
Hypothesis
The authors hypothesized that concomitant radial head lesions (RHLs) would be seen with capitellar OCD and that patients with RHLs would present with more advanced capitellar OCD lesions and would respond better to procedures restoring articular congruity.
Study Design
Cohort study; Level of evidence, 2.
Methods
A total of 86 elbows from 82 patients (39 female patients; mean ± SD age, 13.8 ± 2.2 years; age range, 9.8-23.6 years) were treated for capitellar OCD and enrolled in a prospective registry. Clinical and radiographic data were compared between those with and without RHLs, with a median follow-up of 10.8 months (interquartile range, 6.2-17.1 months). Magnetic resonance imaging was used to characterize and measure RHLs and OCD lesions. Postoperative clinical results were compared between patients who underwent drilling and those who had osteochondral autograft transplantation surgery (OATS).
Results
RHLs were present in 26 (30%) elbows—17 in the dominant arm. Edema was seen in 22 elbows; 17 had involvement of the anterior third of the radial epiphysis. Cysts were present in 4 elbows: 2 in the anterior third and 2 in the middle third. Blunting of the normal concave contour of the radial epiphysis was present in 10 elbows in the anterior third. Demographic and presenting clinical features were similar between those with and without RHLs. RHLs were more commonly seen in Nelson grade 4 OCD lesions (P = .04) as compared with elbows without RHLs. Elbows with RHLs that underwent OATS (n = 9) trended toward greater improvement in forearm range of motion (P = .058) and fewer persistent mechanical symptoms (P = .06) postoperatively as compared with elbows having RHLs that underwent drilling. There were no postoperative differences in elbows without RHLs that underwent OATS versus drilling.
Conclusion
RHLs were seen in one-third of elbows with capitellar OCD. Lesions predominantly occurred in the anterior RH in patients with more advanced capitellar lesions. Short-term clinical follow-up suggested greater improvement in range of motion and resolution of mechanical symptoms for patients with RHLs who were treated with OATS than with drilling.
... Competitive athletic activity has been associated with a number of orthopaedic conditions in adolescent patients such as ''little leaguer's elbow'' and Osgood-Schlatter disease [22][23][24]. Although some authors have postulated that participation in elite-level sports may lead to an increased incidence of lumbar degenerative disc disease [4,8], to date, level of athletic activity has not been associated with symptomatic pathology in the adolescent (10), tennis (7), lacrosse (2), golf (1) population. ...
Purpose
To determine if adolescent athletics increases the risk of structural abnormalities in the lumbar spine.
Methods
A retrospective review of patients (ages 10–18) between 2004 and 2012 was performed. Pediatric patients with symptomatic low back pain, a lumbar spine MRI, and reported weekly athletic activity were included. Patients were stratified to an “athlete” and “non-athlete” group. Lumbar magnetic resonance and plain radiographic imaging was randomized, blinded, and evaluated by two authors for a Pfirrmann grade, herniated disc, and/or pars fracture.
Results
A total of 114 patients met the inclusion criteria and were stratified into 66 athletes and 48 non-athletes. Athletes were more likely to have abnormal findings compared to non-athletes (67 vs. 40 %, respectively, p = 0.01). Specifically, the prevalence of a spondylolysis with or without a slip was higher in athletes vs. non-athletes (32 vs. 2 %, respectively, p = 0.0003); however, there was no difference in the average Pfirrmann grade (1.19 vs. 1.14, p = 0.41), percentage of patients with at least one degenerative disc (39 vs. 31 %, p = 0.41), or disc herniation (27 vs. 33 %, p = 0.43). Body mass index, smoking history, and pelvic incidence (51.5° vs. 48.7°, respectively, p = 0.41) were similar between the groups.
Conclusion
Adolescents with low back pain have a higher-than-expected prevalence of structural pathology regardless of athletic activity. Independent of pelvic incidence, adolescent athletes with low back pain had a higher prevalence of spondylolysis compared to adolescent non-athletes with back pain, but there was no difference in associated disc degenerative changes or herniation.
... OCD is currently recognized as an acquired lesion of the subchondral bone and is characterized by degrees of osseous resorption, collapse, and sequestrum formation with possible involvement of the articular cartilage through delamination unrelated to an acute osteochondral fracture of the normal cartilage [2][3][4][5][6][7][8][9][10][11][12][13]. ...
Osteochondritis dissecans (OCD) is a musculoskeletal condition that occurs primarily during the maturation of the skeleton. It is a cause of elbow pain and disability in the adolescent athlete, and it is an uncommon disorder in the general population [1]. OCD typically affects adolescent athletes engaged in repetitive overhead or upper extremity weight-bearing activities (e.g., baseball, tennis, volleyball, and gymnastics).
... Continuing to train through discomfort and pain can lead to accumulation of forces. Other diagnoses to consider include the following: valgus overload syndrome, medial epicondyle growth plate avulsion, Panner's disease, osteochondritis of the capitellum and radial head, olecranon apophysitis, ulnar stress fracture, posterior interosseous nerve entrapment, and ulnar nerve neuritis (6,8). This can lead to long-term adverse effects like growth deformities, movement restrictions, and prolonged activity-associated pain. ...
Background
Rates of shoulder and elbow pathology are well documented among competitive baseball players in the United States; however, little is known about the prevalence of these pathologies in the Dominican Republic (DR).
Purpose
To report the epidemiology of shoulder and elbow pathology among participants at a Major League Baseball scouting event in Santo Domingo, DR.
Study Design
Retrospective descriptive study.
Level of Evidence
3.
Methods
All pitchers and position players who attended the 2021 scouting event were reviewed. Those with complete medical history, physical examination, imaging series, and radiology reports were included. All participants underwent shoulder and elbow radiography, while pitchers also underwent magnetic resonance imaging (MRI). All pathologic findings on imaging studies were recorded and compared among position players and pitchers.
Results
Seventy-five participants (average age, 17.9 years) were reviewed (42 position players, 33 pitchers); 72% and 32% had ≥1 abnormal finding on elbow and shoulder radiographs, respectively. Position players had significantly higher numbers of elbow radiographic findings compared with pitchers (81% vs 57.6%, P = 0.03) but similar numbers on shoulder radiograph (28.6% vs 33.3%, P = 0.66). Position players had high numbers of acromioclavicular separation (14.3%) and little leaguer’s shoulder (14.3%) on shoulder radiograph, with olecranon osteophytes (23.8%) and medial epicondyle nonunions (11.9%) prevalent on elbow radiograph. Pitchers had high numbers of rotator cuff pathology (93.9%), labral tears (75.8%), and Bennett lesions (51.5%). On elbow imaging, pitchers had high numbers of ulnar collateral ligament (UCL) abnormalities (81.8%), olecranon osteophytes (69.7%), osteochondral lesions (18.2%), and medial epicondyle nonunions (12.1%). Two pitchers had complete UCL disruption (6.1%), while 8 had partial tears (24.2%).
Conclusion
Dominican baseball prospects had high numbers of asymptomatic shoulder and elbow pathology on imaging studies. Knowledge of the prevalence of these pathologies can guide injury prevention programs in Dominican youth baseball.
Elbow injuries related to the throwing motion in baseball during the growth period present difficulties for early detection and may cause serious future disabilities. This study aimed to comprehensively determine the characteristics and clinical assessment of elbow pain in youth baseball players. Two hundred and sixteen young baseball players underwent elbow medical examination. Basic information and physical examination, clinical assessment, and ultrasonography results were examined. Univariate analyses were statistically performed between the pain-free (98 participants) and elbow pain (118 participants) groups. The mean age was 11.6 years, and ultrasonographic abnormalities were found on the medial side of the elbow in 37.5%. In total, 118 (54.6%) participants experienced elbow pain, with 64.4% of them complaining of elbow pain on the medial side. Players with multiple positions (≥2 positions) had a significantly higher prevalence of elbow pain. Height, weight, length of baseball experience, and positive rates of horizontal flexion and moving valgus stress tests were higher in the elbow pain group than in the pain-free group. The risk factors and clinical assessment for elbow pain are useful for the prevention and early detection of throwing elbow injuries in youth baseball players.
Injury to the flexor pronator mass is a common condition that is especially prevalent in overhead throwing athletes. The increasing incidence of these injuries has promoted considerable efforts in research to better understand the pathology, risk factors, and potential mechanisms to prevent injury in these athletes. While there are numerous intrinsic and extrinsic factors associated with injury, a common theme involves chronic overuse and microtrauma with inadequate resting intervals between performances. The purpose of this review is to discuss medial elbow injuries in young athletes with a particular focus on the flexor pronator mass.
Purpose
This study compared medial elbow torque in youth baseball pitchers with and without a history of medial elbow injuries to determine the relationship between medial elbow torque during pitching and having a history of medial elbow injuries.
Methods
We recruited 171 youth baseball pitchers aged 9–12 years old. The exclusion criteria included current pain with pitching, history of surgery on the tested extremity, or osteochondritis dissecans of the humeral capitellum. The participants were grouped into three groups: injury <1Y, injury >1Y, and control, based on ultrasonographic abnormalities of the elbow and the presence of elbow pain. Pitchers pitched three fastballs while wearing a sensor sleeve that recorded the medial elbow torque, arm speed, and shoulder rotation. Ball velocity was measured using a radar gun.
Results
The final analysis included 164 pitchers. Thirty were assigned to the injury <1Y group, 34 to the injury >1Y group, and 100 to the control group. The medial elbow torque was significantly greater in the injury <1Y group compared to the control group (18.6 ± 3.6 Nm vs. 16.2 ± 4.8 Nm, P = .023). A multiple regression analysis revealed that ball velocity (B = 0.282, P < .001) and body weight (B = -0.224, P < .001) were significantly associated with medial elbow torque, but not with the history of medial elbow injuries.
Conclusions
Increased medial elbow torque was associated with greater ball velocity regardless of the history of medial elbow injuries. Youth baseball pitchers with a history of medial elbow injuries within one year had greater medial elbow torque during pitching; however, having a history of medial elbow injuries was not an independent factor in increasing medial elbow torque. Limiting the ball velocity can reduce medial elbow torque and may prevent elbow injuries in youth baseball pitchers.
Apophysen sind sekundär verknöchernde Knochenvorsprünge, an denen Sehnen ansetzen. Ihr anatomischer Aufbau entspricht weitgehend dem von Epiphysen und deren Wachstumsfugen, sie tragen jedoch nicht zum Längenwachstum bei. Apophysen gehören zu den bei Kindern und Jugendlichen am häufigsten verletzten Strukturen. Apophysenausrisse werden unter Sehnenrissen subsumiert (ICD S76.-), Apophysenerkrankungen unter juvenilen Osteochondrosen (M92.-).
Pediatric orthopaedics is a vast area of topics that encompass everything from congenital deformities, bone-related growth abnormalities, and common injuries. Because some disorders and injuries are more common at different ages, a differential diagnoses list can be adjusted accordingly which aids in early detection and treatment. In most cases, initiation of an early treatment and monitoring plan is key to the long-term function of the affected extremity as an adult.
Familiarity with throwing mechanics during elbow range of motion allows accurate diagnosis of sports-related elbow injuries, which occur in predictable patterns. In addition, repetitive stress-related injuries are often clinically apparent; however, imaging plays an important role in determining severity as well as associated injuries that may affect clinical management. A detailed understanding of elbow imaging regarding anatomy and mechanism of injury results in prompt and precise treatment.
This article reviews injuries encountered in active pediatric patients and discusses common presentations, diagnostic criteria, treatment modalities, and prevention. An emphasis is placed on overuse injuries, including a review of physeal and apophyseal injuries encountered in skeletally immature, active patients as well as back disorders often encountered in adolescents. This article is not meant to be comprehensive, but it offers directions for management of these patients in the outpatient primary care setting.
Adolescent overhead throwing athletes repeatedly place supra-physiologic strain on the immature humeral medial epicondyle. This overload can lead to medial epicondyle apophysitis—often referred to as “Little Leaguer’s Elbow.” Medial epicondyle apophysitis denotes an inflammation of the physis due to repeated distal tugging from the contracting forearm common flexor-pronator mass and ulnar collateral ligament (UCL). Valgus stress during the pitching motion peaks in the late cocking and early acceleration phase of throwing and can lead to the widening of the physis, bone marrow edema, and in more severe cases, fragmentation of the apophysis. These pathologies cause medial elbow pain in young throwers, which becomes aggravated while throwing and generally dissipates with rest. Medial epicondyle apophysitis lies within the same spectrum of youth throwing-related injuries as medial epicondyle avulsion fractures, capitellar osteochondritis dissecans, and posteromedial impingement, among others. These injuries can cause deterioration of performance and loss-of-play in a throwing athlete. Though long-term data are lacking, experts widely agree that with appropriate first-line non-operative treatment in the form of an extended period of rest, symptoms will resolve, and play can resume.
Context:
Baseball pitching is a coordinated movement involving the spine. A previous study indicated that increased thoracic kyphosis angle in a standing position was a risk factor for medial elbow injuries in youth baseball players. However, spinal alignments in single-leg standing and their relationships with medial elbow injuries, scapular alignment, or hip joint range of motion are unclear.
Objective:
To examine the difference in spinal alignment between standing and single-leg standing positions in youth baseball players and analyze their relationship with elbow injuries, scapular alignment, or hip joint range of motion.
Design:
Cross-sectional study.
Setting:
University laboratory.
Participants:
There were 51 youth baseball players with medial epicondylar fragmentation (medial elbow injury group) and 102 healthy youth baseball players (control group).
Main outcome measures:
Thoracic kyphosis, lumbar lordosis, and trunk inclination angles during standing and single-leg standing, forward scapular posture, and hip joint range of motion.
Results:
In the single-leg standing position, the thoracic kyphosis and backward trunk inclination angles were significantly higher in the medial elbow injury group than in the control group (P = .016 and P = .046, respectively). In the standing position, no significant difference was observed between both groups. The thoracic kyphosis angle in single-leg standing was positively correlated with the bilateral forward scapular posture in the medial elbow injury (P = .008 and P < .001 on the throwing and nonthrowing sides, respectively) and control (P = .010 and P = .032 on the throwing and nonthrowing sides, respectively) groups.
Conclusions:
High thoracic kyphosis and backward trunk inclination angles are characteristics during single-leg standing in youth baseball players with medial elbow injuries. Spinal alignment measurement in single-leg standing may be useful for identifying youth baseball players who are at risk for sustaining medial elbow injury.
The elbow, compared to the lower extremity and shoulder, is much less involved in sports injuries in general; however in specific sports it is nevertheless quite common (e.g., gymnastics). Acute injuries are relatively rare and most injuries are the result of overuse. From a biomechanical standpoint two major mechanisms are responsible for this. The first is the athlete who is involved in sports that require a large number of the same repetitive movements like in baseball, specifically in pitchers. The second mechanism is seen in athletes who basically use their arm as a weight-bearing limb like in gymnastics or weightlifting. All known imaging modalities are useful in elbow imaging each with their own merit. Plain films is almost always the first imaging modality used. The clinical situation and the findings on plain films direct the next step of imaging (if necessary). For the evaluation of the soft tissues ultrasound will usually suffice but if more information is needed, especially for the evaluation of the joint, MRI and CT both play important roles. It has to be emphasized that both have their own merits and that they often are complementary to each other.
Because of the unique demands of a pitch, baseball players have the greatest percentage of injuries resulting in surgery among high school athletes, with a majority of these injuries affecting the shoulder and elbow due to overuse from throwing. These injuries are believed to occur because of repeated microtrauma to soft tissues caused by the repetitive mechanical strain of throwing. Researchers and practitioners have suggested that baseball pitchers' workloads are a significant risk factor for injury in adolescent players, resulting in lost time and slowing of performance development. The purpose of our review was to investigate the current research relative to monitoring workload in baseball throwers and discuss techniques for managing and regulating cumulative stress on the arm, with a focus on preventing injury and optimizing performance in adolescent baseball pitchers.
Objective:
We conducted ultrasonography (US) examination for asymptomatic elbow injuries in judo athletes to confirm availability of US screening for elbow.
Materials and methods:
One hundred and thirty-two black belts in judo (85 males and 47 females; mean age, 20.0 ± 1.6 years) participated in this screening. Forty-eight participants had a history of elbow injury (elbow-injury group), and 84 did not (no-elbow-injury group). All participants completed a survey in the form of a questionnaire. Subsequently, US scanning of both elbows was performed.
Results:
The maximal thickness of the medial collateral ligament of both elbows was significantly larger in the elbow-injury group than in the no-elbow-injury group. The width of the joint space was significantly larger in the right radiohumeral joint in the elbow-injury group than in the no-elbow-injury group. Combination injuries involving ligament and bone and those involving both the medial and lateral collateral ligaments were most commonly seen in both elbows in the elbow-injury group; however, these combined lesions of both elbows were also found in the no-elbow-injury group.
Conclusions:
Because US screening can reveal abnormalities of the asymptomatic elbow, US is recommended as a complementary imaging modality that is useful for evaluation of elbow injuries in athletes.
Background:
Although the pronator teres muscle, a major dynamic stabilizer of elbow valgus stress during throwing, frequently presents stiffness, its relationship with elbow injuries in youth baseball players is unknown. This study investigated the relationship between the elasticity of the pronator teres muscle and elbow injuries in youth baseball players.
Methods:
The strain ratio (SR) of 15 individuals with osteochondritis dissecans of the humeral capitellum (OCD group), 67 individuals with medial epicondylar fragmentation (medial injury group), and 115 healthy individuals (control group) was measured as the index of the elasticity of the pronator teres muscle using ultrasound strain elastography. In addition, the forearm and glenohumeral joint rotation range of motion was measured.
Results:
The SR of the throwing arm was significantly higher in the OCD and medial injury groups than in the control group (both P <.001). In the OCD group, the SR was significantly higher in the throwing arm than in the nonthrowing arm (P <.001), whereas in the medial injury group, there was no significant difference between both arms. The glenohumeral joint external rotation range of motion of the throwing arm was moderately negatively correlated with the SR (r = -0.478, P <.001).
Conclusions:
Stiffness of the pronator teres muscle was exhibited only in the throwing arm of individuals with OCD and in both arms in individuals with medial elbow injury. These findings may contribute to an accurate evaluation and prevention of elbow injuries in youth baseball players.
This is a 5-year-old boy who fell off a trampoline and injured his left elbow. Radiographs, including stress views, were negative for fracture or effusion (not shown).
Children in the western countries are increasingly involved in sporting activity, both team and solo sports. Participation is increasingly focused on a single sport or even a specific role in a specific sport. Children are thus increasingly at risk of sports related injury. Repetitive focused activity predisposes some children to stress and repetitive trauma type injuries.
Background:
There are excellent data supporting recommendations to prevent elbow injuries (osteochondritis dissecans [OCD] and ulnar collateral ligament [UCL] injuries), such as pitch count and pitch type in baseball, but anatomic risk factors have not been thoroughly examined. This study aimed to evaluate radiographic measurements in adolescents with elbow OCD lesions or UCL injuries and controls.
Methods:
We retrospectively identified adolescent patients between 2011 and 2016 with isolated capitellum OCD, UCL tear, or normal elbows based on magnetic resonance imaging. Nineteen patients (mean age, 13.5 years) had isolated OCD defects of the capitellum, 8 patients (mean age, 16.9 years) had isolated UCL complete tear, and the remaining 16 patients (mean age, 14.6 years) were normal controls. Radiographic measurements from corresponding anterior-posterior elbow radiographs were taken, including carrying angle, distal humeral articular surface angle, and radial neck-shaft angle. On the lateral radiograph, anterior angulation of the articular surface of distal humerus was measured.
Results:
Significant differences were observed in carrying angle between controls (15.7°) and OCD patients (11.6°; P = .03) as well as between controls and UCL patients (10.3°, P = .02), with the OCD and UCL patients tending to be in more varus. Significant differences were also found between controls (88.5°) and OCD patients (93.6°; P = .01) and between controls and UCL patients (93.3°; P = .03) in distal humeral articular surface angle, with OCD and UCL patients with increased valgus at the distal humerus articular surface. There were no significant differences between groups in radial neck-shaft angle or anterior angulation of articular surface of distal humerus.
Conclusions:
Patients with OCD and UCL injuries have anatomic differences compared with normal controls that can be measured radiographically.
With the recent increase in youth sports participation and single-sport youth athletes over the past 30 years, there has been an increase in the number of acute and overuse sports injuries in this population. This review focuses on overuse and traumatic injuries of the shoulder and elbow in young athletes. In particular we discuss little league shoulder, glenohumeral internal rotation deficit, glenohumeral instability, superior labrum anterior posterior lesions, Little League elbow, Panner disease, osteochondritis dissecans of the capitellum, posteromedial elbow impingement, and posterolateral rotatory instability of the elbow. There is a significant emphasis on the evaluation and management of upper extremity injury in the overhead thrower.
Injuries to the shoulder and elbow in the pediatric and adolescent throwing athlete are common. Both knowledge of throwing mechanics and understanding of normal bone development in the immature skeleton are key to the diagnosis, treatment, and potential prevention of these common injuries. Pathologic changes from chronic repetitive trauma to the developing shoulder and elbow manifest as distinctly different injuries that can be predicted by the skeletal maturation of the patient. Sites of vulnerability and resulting patterns of injury change as the child evolves from the skeletally immature little league player to the skeletally mature high school/college athlete.
Pediatric overuse injuries are becoming more prevalent in today's society with more children competitively playing year-round sports at a younger age. The importance of prompt diagnosis and treatment is paramount to the treatment for these injuries, second only to rest and activity modification. This article will focus on overuse injuries of the upper extremity, specifically: little league elbow, elbow osteochondritis dissecans, and gymnast wrist. It will also discuss the pathophysiology, diagnosis, imaging, and treatment of each of these entities.
Supracondylar fractures are the most common in children. A visible posterior fat pad is the best clue to their presence. Significant displacement is associated with neurovascular complications. Lateral mass fractures are not common but are easily overlooked with devastating consequences. Medial avulsion injuries can be subtle if displaced into the joint. The mnemonic CRITOL tells us that if we see an apparent trochlear before a medial epicondyle ossification centre it is probably a displaced medial epicondyle. OCD of the capitellum is an important misuse injury in children. Careful scrutiny of the plain radiograph is needed to detect the injury.
Baseball is an extremely popular sport in the United States and baseball and softball injuries account for more emergency room visits in the United States each year than those related to any other sport. In general, upper extremity injuries are more common than those involving the lower extremities. Upper extremity injuries are more common in pitchers while fielders tend to suffer from injuries of the lower extremities, especially the knee. Baseball injuries typically result from one of three mechanisms: overuse, direct trauma and indirect trauma. This chapter will focus on baseball injuries related to the first two categories, with an emphasis on the overuse injuries that so commonly affect the shoulder and elbow of the throwing athlete.
Handball players are prone to traumatic injuries because of the highly aggressive nature of the sport, which is based on speed, strength, and explosiveness and involves frequent direct body contact, falls, blocks, jumping, throwing, and counter running. In this chapter, we will review the epidemiology of injuries in handball players and illustrate various types of injuries of the upper and lower extremities, including osseous and soft tissue injuries such as muscles, ligaments, and tendons. Multimodality imaging plays an important role in the diagnosis of these injuries. Moreover, cross-sectional imaging such as CT and MRI helps to determine the choice of treatment.
Sports related injuries are common in children and adolescents, with a reported incidence of around one in ten children each year. Boys incur more and severer sports injuries than girls, and chance for injury is greater with contact or jumping sports. Sports injuries seen in children under 10-years of age are non-specific, including contusions, mild sprains, and extremity fractures, usually Salter fractures of the physes (growth plate) or plastic fractures. In the very young athlete, sports injury of the ligaments or muscle is rare as are spine or head injuries. With growth and adolescence, the intensity of sports involvement increases. Pre-pubertal children still have open physes that are prone to injury, both acute or due to stress from a repetitive activity. In addition to injury of the physes of the long bones, injuries to the physes of apophyses are common. Ligamentous injury is uncommon before physeal closure, but can occur. After the physes fuse, ligamentous injury is seen with patterns similar to adults. This review will include a description of sports related injuries seen in children and adolescents. We will concentrate on injuries that are specific for the growing skeleton, with a brief mention of those seen after fusion of the physes.
Objective: To review the existing data available on the epidemiology of elbow injuries in sport. Data sources and study selection: A comprehensive, web-based search of existing articles pertaining to elbow injuries in sports was performed. Main results: Age, sex, and level of experience in sport influence the incidence of common elbow conditions in tennis players, golfers, snowboarders, baseball players and football players. The cartilaginous composition of the distal humerus and multiple secondary ossification centres in children leads to different injury patterns as compared to adults. Most of the injuries sustained are chronic overuse injuries, and a higher incidence of injuries has been reported with increasing years of play. The amount of time lost from playing sport after sustaining elbow injuries depends on the type and severity of the elbow injury sustained. Return to athletic activity is not usually inhibited after sustaining an elbow injury. The study of epidemiological trends in elbow injury has paved the way for various injury prevention strategies which focus on instructional programmes, flexibility, strengthening, endurance, conditioning of the musculature, warm-up, stretching, and avoidance of fatigue. Conclusions: There are few prospective studies on epidemiological trends of elbow injury in sports other than baseball. Extensive sport specific dynamic exercise programmes, are effective in managing and preventing elbow injury in sport. Such programmes should cater for the age, gender, and skill level of the athlete. There is still a vast scope to conduct research and prospective studies in athletes with elbow injuries.
Avascular necrosis of the humeral capitellum (Panner’s disease), a relatively rare disorder in the juvenile. We diagnosed three patients using radiographs and magnetic resonance imaging, who were previously misdiagnosed with osteochondritis dissecans of the humeral capitellum. All patients were successfully treated by restriction of sports activities using the upper extremities. It is often difficult to distinguish Panner’s disease from osteochondritis dissecans of the humeral capitellum. Panner’s disease has been reported to occur in boys between 7 and 10 years old, which is younger than susceptible age of osteochondritis dissecans. In MRI, low intensity area in the ossification center of the humeral capitellum in T1-weighted image is useful findings for diagnosis. For the treatment, the conservative treatment has been recommended in the early stage of Panner’s disease, while surgical intervention is required in some cases of osteochondritis dissecans. © 2015, Kobe University School of Medicine. All rights reserved.
1. In a study of 595 Little League pitchers, approximately 17% had a history of elbow symptoms: only 1% had elbow symptoms which had ever excluded them from pitching. There was no correlation between the presence of symptoms and years of pitching experience. 2. Some limitation of active extension of the elbow was seen in 12% of the pitchers; however, there was no correlation between elbow flexion contractures and years of pitching experience, symptoms, or roentgenographic pathology. No normal child had an elbow flexion contracture greater than 15 degrees. 3. A slight valgus carrying angle is considered a normal anatomic variant in the dominant arm. There was no correlation between valgus carrying angle and years of pitching experience or symptoms or roentgenographic pathology. 4. No roentgenographic evidence of avascular necrosis of the capitellum, radial head, or both was seen in this population. 5. Roentgenographic findings such as bony hypertrophy, enlargement of the medial epicondyle, and secondary ossification centers are normal anatomic variants not related to symptoms. Undisplaced stress fractures of the medial epicondyle respond well to conservative treatment, with no functional residual.
After dislocation of the elbow with avulsion of the medial epicondyle, the management of the latter is controversial. Of 28 children followed up after initial closed reduction of the elbow, 19 had a satisfactory closed reduction of the epicondyle and were treated in plaster. At follow-up, 11 children had a normal elbow and eight had lost an average of 15 degrees of flexion. Nine children had had open reduction and internal fixation of the fragment, one for an open injury, three for displacement of the epicondyle and six for intra-articular entrapment of the fragment. Five of these children had ulnar nerve contusion or compression, four requiring anterior transposition of the nerve. At review, only three had normal elbows and six had lost an average of 37 degrees of flexion. We agree with other authors that surgery is indicated only for children in whom the epicondyle is trapped in the joint or is significantly displaced after closed reduction.
The skeletally immature athlete sustains upper extremity injuries unique to the epiphyseal plate, articular cartilage, musculotendinous units, and specific to the sport itself. Specific shoulder and elbow conditions can be predicted based on the biomechanics of the sport and age of the patient. In the young athlete, recognition of these unique injury patterns with early activity modification and treatment can prevent permanent deformity and functional disability.
Proper throwing mechanics may enable an athlete to achieve maximum performance with minimum chance of injury. While quantifiable differences do exist in proper mechanics for various sports, certain similarities are found in all overhand throws. One essential property is the utilisation of a kinetic chain to generate and transfer energy from the larger body parts to the smaller, more injury-prone upper extremity. This kinetic chain in throwing includes the following sequence of motions: stride, pelvis rotation, upper torso rotation, elbow extension, shoulder internal rotation and wrist flexion. As each joint rotates forward, the subsequent joint completes its rotation back into a cocked position, allowing the connecting segments and musculature to be stretched and eccentrically loaded. Most notable is the external rotation of the shoulder, which reaches a maximum value of approximately 180 degrees. This biomechanical measurement is a combination of true glenohumeral rotation, trunk hyperextension and scapulothoracic motion. Near the time of maximum shoulder external rotation (ERmax), shoulder and elbow musculature eccentrically contract to produce shoulder internal rotation torque and elbow varus torque. Both the shoulder and the elbow are susceptible to injury at this position. At ball release, significant energy and momentum have been transferred to the ball and throwing arm. After ball release, a kinetic chain is used to decelerate the rapidly moving arm with the entire body. Shoulder and elbow muscles produce large compressive forces to resist joint distraction. Both joints are susceptible to injury during arm deceleration.
Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.