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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.
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Sports Med 2007; 37 (8): 717-735
I
NJURY
C
LINIC
0112-1642/07/0008-0717/$44.95/0
© 2007 Adis Data Information BV. All rights reserved.
A Review of Epidemiology of
Paediatric Elbow Injuries in Sports
Merzesh Magra,1 Dennis Caine2 and Nicola Maffulli1
1 Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine,
Stoke-on-Trent, England
2 Department of Physical Education, Exercise Science and Wellness, University of North
Dakota, Grand Forks, North Dakota, USA
Contents
Abstract ....................................................................................717
1. Elbow Anatomy ..........................................................................720
1.1 Ossification ..........................................................................720
1.2 Biomechanics and Injury Framework ...................................................720
2. Incidence of Injury .......................................................................721
2.1 Baseball ............................................................................721
2.2 Other Sports .........................................................................721
3. Injury Characteristics .....................................................................722
3.1 Injury Onset .........................................................................722
3.2 Action or Activity ....................................................................723
3.3 Situational Factors ...................................................................724
4. Injury Severity ............................................................................724
4.1 Type of Injury ........................................................................724
4.1.1 Baseball.......................................................................724
4.1.2 Other Sports ...................................................................725
4.2 Time Loss ............................................................................726
4.3 Clinical Outcome ....................................................................726
5. Injury Risk Factors.........................................................................727
5.1 Intrinsic Risk Factors in Baseball ........................................................727
5.2 Extrinsic Risk Factors in Baseball ........................................................727
5.2.1 Pitch Counts ...................................................................727
5.2.2 Pitch Types ....................................................................727
5.3 Risk Factors for Elbow Injury in Other Sports .............................................728
6. Suggestions for Injury Prevention ...........................................................728
6.1 Baseball ............................................................................728
6.2 Other Sports .........................................................................729
7. Conclusion and Suggestions for Further Research ...........................................731
The elbow is a common site of orthopaedic injury in the paediatric population.
Abstract The number of these injuries continues to rise following increased levels of
participation in paediatric recreational and competitive sport. Injuries to the
paediatric elbow can be classified as either overuse or acute. Delineating injury
patterns to the elbow in children can be challenging, given the cartilaginous
composition of the distal humerus and the multiple secondary ossification centres
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718 Magra et al.
that appear and unite with the epiphysis at defined ages. Pitching in baseball,
serving in tennis, spiking in volleyball, passing in American football and launch-
ing in javelin-throwing can all produce elbow pathology by forceful valgus stress,
with medial stretching, lateral compression and posterior impingement.
In children and adolescents, the epiphyseal plate is weaker than the surround-
ing ligaments, predisposing them to epiphyseal plate injuries. On the other hand,
post-pubescent or skeletally mature athletes are more prone to tendinous or
ligamentous injury. Injuries may cause significant impact on the athlete, parents
and healthcare system. With the exception of baseball, there are few prospective
cohort studies on the epidemiological trends of childhood elbow injuries in other
sports.
This paper aims to describe the epidemiological trends in paediatric elbow
injuries related to sports, suggests prevention strategies and discusses the scope
for further research.
A web-based search of existing articles pertaining to paediatric elbow injuries
in sports was performed.
The implications of acute and overuse injuries and the possibility of permanent
damage should be understood by parents, coaches and the athletes. Proper
understanding of the intrinsic and extrinsic risk factors that could lead to elbow
injuries is thus required. Measures to prevent elbow injuries should include proper
coaching, warm-up, officiation, legislation, medical expertise and protective gear.
There are still many opportunities for prospective studies and other research
projects among young athletes in various sports. Current studies will serve as a
baseline for future research to assess the success of specific interventions in
reducing the incidence of elbow injury in the paediatric athlete. Further epidemio-
logical studies in various sports will help expand our knowledge and prevent
potential disability and deformity in the paediatric elbow.
In the last 3 decades, participation in children’s Participating in sports has numerous health bene-
fits, including increased fitness and motor coordina-
and youth sports has been increasingly popular in tion, pleasure and relaxation and improved social
the Western world. Nearly three-quarters of house- skills. But it also involves risk of injury, with sports
holds in the US with school-age children have at being the largest contributor of injury at school.[4,5]
least one child who participates in organised Sports- and recreation-related injuries are also a
sports.[1] In the UK, approximately 75% of children common cause of paediatric injuries in surveys of
between 5 and 15 years participate in organised injury-related visits to hospital emergency depart-
sport, and approximately 11% undergo intensive ments, accounting for 19–29% of injuries in this
training.[2] Many children initiate year-round train- population in the US.[5-7] In addition to the immedi-
ing and specialisation in their sport at an early age. ate healthcare costs, these injuries may have long-
By their teens they may train 20 hours per week at term consequences for the musculoskeletal system,
regional centres in gymnastics or tennis. This is because sequelae from these injuries may persist
probably due to the ‘catch them young’ philosophy, throughout the adult years, ultimately resulting in
and to the belief that, to achieve international stand- reduced levels of activity.
ing in later sporting life, intensive training should be Elbow injuries occur frequently in children and
started before puberty.[3] adolescents who participate in recreational and com-
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Epidemiology of Paediatric Elbow Injuries 719
petitive sports, particularly in those sports requiring headings and text words used in our literature search
repetitive overhead motion. As illustrated in table I, included ‘elbow’, ‘injuries’, ‘children’, ‘adoles-
sports involving throwing, catching, hammering, cents’ and ‘sport’. The PubMed (1966 to November
pushing, pulling and hitting with a racquet, com- 2005; 212 hits), MEDLINE (1951 to November
monly result in elbow pain and injuries.[8] Injuries to 2005; 72 hits), SportDiscus® (1960 to November
the elbow in children may involve the muscles, 2005; 33 hits) and EMBASE (1974 to November
ligaments, tendons, capsule, bones, physis, articular 2005; 14 hits) electronic databases were used for the
surfaces or nerves.[9,10] There is concern that both searches, providing 82 relevant articles that were
the frequency and severity of these injuries is in- used for this paper. The search was restricted to
creasing along with the rising number of participants English-language articles. The reference lists of se-
and increased volume and intensity of training ob- lected articles were searched using the same criteria.
served in children’s and youth sports. Many of the studies retrieved were characterised
Paediatric sport-related elbow injuries are bound by methodological short-comings and study differ-
to occur; however, every effort must be made to ences that limit the interpretation and comparison of
prevent the occurrence of unnecessary injuries. It is findings across studies and sports. These included:
believed that as many as half of paediatric sports (i) diversity of study populations; (ii) short periods
injuries are preventable. To this end, epidemiologi- of data collection and small sample sizes in some
cal techniques have been increasingly applied to studies; (iii) non-random selection; (iv) variable def-
sports injury problems over the last 50 years. The inition of injury and methods of data collection; and
purpose of this article is to review the distribution (v) inadequate information on exposure of partici-
and determinants of paediatric sport-related elbow pants to risk of injury. The epidemiological litera-
injuries as reported in the literature, and to suggest ture on paediatric elbow injuries presented in this
measures for the prevention of these injuries and article should be evaluated in light of these limita-
directions for further research. Medical subject tions.
Table I. Sports commonly producing elbow injuries
Sport Common injury
American football Valgus stress when throwing a pass: hyperextension and dislocation, and olecranon bursitis with direct
trauma
Archery Extensor muscle fatigue, lateral epicondylopathy of bow arm
Baseball Valgus stress of pitching: medial traction, lateral compression, posterior abutment
Basketball Posterior compartment with follow-through on jump shot
Bowling Flexor-pronator soreness
Baseball Valgus stress of pitching: medial traction, lateral compression, posterior abutment
Canoeing, kayaking Distal bicipital tendinopathy
Golf Medial epicondylopathy on downswing with trailing arm, lateral epicondylopathy at impact with leading
arm
Gymnastics Radiocapitellar overload and posterior impingement with weight-bearing on extended elbow
Javelin Valgus extension overload of throwing: medial traction, posterior abutment, lateral compression
Racquet sports Lateral epicondylopathy with backhand
Rock climbing Brachialis or distal biceps tendinopathy
Shotput Posterior impingement with follow-through
Volleyball Valgus stress at impact of spiking
Waterskiing Valgus extension overload of posterior compartment with trick skiing
Weight training Ulnar collateral ligament sprain, ulnar nerve irritation
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720 Magra et al.
1. Elbow Anatomy
1.1 Ossification
Skeletal maturation of the elbow occurs at multi-
ple secondary ossification centres within the distal
humerus, radius and ulna. Many paediatric throwing
injuries occur at or about these centres.[11] There is a
predictable chronological order in which the ossifi-
cation of these growth centres occurs, and the ossifi-
cation centres appear in a specific sequence capitel-
lum, radial head, internal (medial) epicondyle,
trochlea, olecranon and external (lateral) epicon-
dyle.[11] Knowledge of this sequence is critical in the
evaluation of young athletes, and the mnemonic ‘C-
R-I-T-O-E’ of the order of appearance of the indi-
vidual ossification centres is helpful (figure 1).[11]
The ages at which these ossification centres appear
are highly variable, and also differ by sex, with
females usually preceding males by 6–12 months.[12]
Generally, the first ossification centre appears at the
age of 1–2 years, and each of the remaining five
ossification centres appears approximately every 2
years. The epiphysis and apophyses close slowly by
ossification as the elbow becomes more skeletally
mature, and ossification is complete by the mid-teen
years in most children.[11]
1.2 Biomechanics and Injury Framework
R
C
I
O
I
T
O
CE
R
a
b
Fig. 1. (a) Lateral and anteroposterior radiographs of a normal
elbow (boy aged 9 years). (b) Order of appearance of ossification
centres: C-R-I-T-O-E. C = capitellum; R = radial head; I = internal
(medial) epicondyle; T = trochlea; O = olecranon; E = external
(
lateral
)
e
p
icond
y
le.
The anatomy of the elbow allows flexion-exten-
sion and pronation-supination movements through ic activities, such as the handstand, and in dynamic
the ulno-humeral and proximal radio-ulnar joints, activities, such as baseball pitching.[15] This proba-
respectively. Full range of motion varies from 15°bly contributes to some of the overuse injury pat-
to 0° of extension through 150° of flexion.[11] Static terns seen in baseball pitchers and gymnasts.[15]
and dynamic stability to the elbow is provided by the
architecture of the bones and soft tissue as described The UCL complex, an important stabiliser of the
below. In full extension, the elbow has a normal elbow, consists of anterior, posterior and oblique
valgus carrying angle of 11–16°. This provides ap- bundles. Of these, the anterior bundle is functionally
proximately 50% of the overall stability of the el- the most important in providing stability against
bow, primarily against varus stress in the extended valgus stress, and is further subdivided into anterior
elbow.[11] The anterior joint capsule, ulnar collateral and posterior bands.[13,14,16] The anterior band is the
ligament (UCL) complex, and the lateral collateral primary restraint to valgus stress at lesser degrees of
ligament complex provide the remainder of the sta- flexion, and is more susceptible to injury in the
bility in the elbow.[13,14] The valgus angulation of the extended elbow.[14,16] The posterior band is func-
elbow produces asymmetrical valgus loading in stat- tionally more important than the anterior band in the
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Epidemiology of Paediatric Elbow Injuries 721
overhead-throwing athlete, given its primary million children participate in Little League baseball
stabilising role at higher degrees of elbow flex- in the US.[29] The elbow is the most frequently
ion.[12] The musculotendinous units overlying the reported location of injury in youth baseball pitch-
UCL, formed by pronator teres, flexor digitorum ers.[25] The risk of elbow injury appears to be greater
superficialis, and flexor carpi ulnaris muscles, are for some positions than others. For example, in a
primarily responsible for maintaining the dynamic recent retrospective study of 343 Little League play-
valgus stability of the elbow.[14] ers (aged 9.5–12 years), 69/120 (58%) of pitchers,
25/40 (63%) of catchers and 86/183 (47%) of field-
The lateral collateral ligament complex is com-
ers reported soreness of the throwing elbow during a
posed of the radial collateral ligament, lateral UCL
single season.[18] The frequency of injury is higher
and the accessory lateral collateral ligament.[13,16]
for those who throw with poor technique (15/29,
The lateral UCL is the primary restraint against
52%) as opposed to proper technique (1/16, 6%).[24]
rotatory subluxation of the ulnohumeral joint. Injury
at this location allows posterolateral rotatory insta-
bility to develop.[16] With the extensor muscles, the 2.2 Other Sports
radial collateral ligament is a secondary restraint, Elbow conditions in other sports are generally
imparting dynamic stability to the lateral aspect of reported as injuries, or those conditions that resulted
the elbow.[13,16]
in time loss and/or consultation with a physician or
2. Incidence of Injury other health professional. These injuries are typical-
ly reported as a proportion of all injuries, although
The frequency of elbow pain and injury varies some studies also report actual incidence rates for
greatly, depending on the sport in which the athlete injury by body location. Unfortunately, many stud-
participates, and within some sports by the position ies group elbow injuries along with other arm or
played. Injuries to the elbow, forearm and wrist upper arm injuries, thus masking the actual frequen-
account for approximately 25% of all sports-related cy of elbow injuries.
injuries.[17] The occurrence of elbow injuries in American
football is 2–6% (table III),[30-36] and in rugby it is
2.1 Baseball 2.6% (7/270).[37] The proportion of elbow injuries in
As expected, the frequency of elbow complaints girls’ club gymnastics is slightly higher: 3.7–8.5%
is higher in sports that involve throwing, such as (table IV).[38-45] Elbow injuries account for approxi-
baseball, in which 18–69% of all players report mately 9% of in-line skating injuries in American
elbow pain (table II).[18-28] Every year, more than 2 studies.[46,47] Similar results were seen in roller skat-
Table II. Frequency of elbow symptoms in baseball
Study Location Study design Sample (n) Age (years) Frequency Players reporting
measure pain (%)
Hang et al.[18] (2004) Taiwan Retrospective 343 9.5–12 Incidence 52
Lyman et al.[19] (2002) US Prospective 476 9–14 Incidence 28
Lyman et al.[20] (2001) US Prospective 298 9–12 Incidence 25.5
Ochi et al.[21] (1994) Japan Retrospective 130 15–18 Prevalence 38
Grana and Rashkin[22] (1980) US Prospective 73 14–19 Incidence 58
Hang et al.[23] (1979) Taiwan Prospective 112 11–12 Incidence 69
Albright et al.[24] (1978) US Prospective 109 11–12 Incidence 44
Gugenheim et al.[25] (1976) US Retrospective 595 9–13 Prevalence 17
Larson et al.[26] (1976) US Retrospective 120 11–12 Prevalence 20
Torg et al.[27] (1972) US Retrospective 49 9–18 Prevalence 29
Adams[28] (1965) US Retrospective 80 9–14 Prevalence 45
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722 Magra et al.
Table III. Elbow injury rates in American football as a percentage of total injuries
Study Study design Sample (n) Total number of injuries Elbow injuries (%)
Stuart et al.[30] (2002) Prospective 915 55 4
DeLee and Farney[31] (1992) Prospective 4399 2228 4
Goldberg et al.[32] (1984) Prospective 436 67 6
Culpepper and Niemann[33] (1983) Retrospective Not reported 1877 3
Olson[34] (1979) Prospective 1200 478 2
Moretz et al.[35] (1978) Prospective 903 241 3
Roser and Clawson[36] (1970) Prospective 2079 48 2
ers (11% of injuries).[48] Only 3/152 (2%) of all On the other hand, current or previous elbow pain
was reported by 22–25% of adolescent participants
snowboarding accidents resulted in elbow injuries in
in a single tennis championship.[62]
Austrian children (mean age 14.7 years).[49] Howev-
er, just over 5% (6/118) of all injuries were elbow 3. Injury Characteristics
injuries in young (mean age 13.9 years) Canadian
snowboarders.[50] In two studies of children and Compared with adults, delineating injury patterns
adolescent skiers, the proportion of elbow injuries to the elbow in children can be challenging, given
was 1.5–3%.[51,52] Approximately 3% (17/587) of all the cartilaginous composition of the distal humerus
injuries involved the elbow in an Italian study of and the multiple secondary ossification centres that
skiers aged <15 years.[51] However, combined appear and unite with the epiphysis at defined
figures for the incidence of skiing and snowboarding ages.[29,63] In paediatric athletes, injury patterns are
injuries to the elbow in a Canadian population <18 influenced by the age-related stage of elbow devel-
years was just below 1.5% (20/1390).[52] Elbow opment and the sport-specific mechanism of inju-
injuries in ice hockey account for 2–6% of the total ry.[63] Physeal injuries often occur in young throwers
injuries sustained.[53-56] In two studies of wrestling in situations that would otherwise lead to ligamen-
injuries,[57,58] elbow injuries contributed between tous injuries in adult throwers.[64] The medial side of
5% and 7% of all injuries. However, at two large the elbow is the most common site of complaints in
wrestling tournaments, a lower figure of 8/221 the paediatric population,[65] due to the mechanisms
described earlier.[12-14,16]
(3.6%) of all injuries were elbow injuries in wres-
tlers aged 6–16 years.[59] Tennis elbow comprised 3.1 Injury Onset
only 5.6% (17/304) of all injuries in young athletes
involved in competitive tennis.[60] Injuries to the paediatric elbow can be classified
Several studies of paediatric tennis injuries report as acute or overuse. In baseball, fielders and batters
the prevalence of pain episodes at the elbow. Fewer tend to sustain acute injuries caused by contact with
than 10% of boys and girls playing national level the ball, bat, another player, the ground or base.[66]
tennis in the US report lateral elbow complaints.[61] Injuries to pitchers tend to be overuse, secondary to
Table IV. Elbow injury rates in girls’ club gymnastics as a percentage of total injuries
Study Study design Sample (n) Elbow injuries (%)
Caine et al.[38] (2003) Prospective 147 4.8
Dixon and Fricker[39] (1993) Retrospective 325 8.5
Homer and Mackintosh[40] (1992) Retrospective 49 4.1
Linder and Caine[41] (1990) Prospective 90 7.3
Caine et al.[42] (1989) Prospective 192 3.7
Weiker[43] (1985) Prospective 95 5.3
Steele and White[44] (1983) Retrospective 146 4.8
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Epidemiology of Paediatric Elbow Injuries 723
cumulative microtrauma through the repetitive equal to bodyweight, can cause radial head hyper-
throwing motion.[22,67,68] Most tennis injuries are trophy and fractures, osteochondritis dissecans and
overuse, and occur at the muscle-tendon-bone unit capitellar fractures.[61,71] In the follow-through
due to repetitive micro-traumatic overload.[69] In phase, the elbow is locked in extension, leading to
American football, most elbow injuries are acute, stresses on the olecranon, triceps and olecranon
and occur following falls or a direct blow to the fossa, with avulsion or apophysitis of the olecranon
elbow. They include posterior dislocation of the apophyses.[61]
elbow, radial head fractures, and supracondylar and ‘Little League elbow’,[74] which is pain in the
intracondylar fractures.[15] Both acute and overuse elbow joint due to repetitive throwing, results from
elbow injuries are seen in gymnastics, and the pat- medial tension overload from repetitive valgus
terns seen can depend on the level of skill and stress and flexor forearm pull. Its features are not
experience of the gymnast.[45] Elite gymnasts tend to only seen in young throwers in baseball, but also in
incur more overuse injuries compared with sub-elite American football and in the tennis serve.[29,63] Val-
gymnasts.[45] gus stress is placed on the elbow as the shoulder
In in-line skating, elbow injuries tend to be acute, internally rotates from maximum external rota-
and include abrasions, contusions, sprains, fractures tion.[75] Higher varus torques and elbow extension
and dislocations.[46,70] Injuries to the elbow in skiing velocities in the pitching elbow may result in an
and snowboarding tend to be acute, and range from increased risk of valgus extension overload.[72] Var-
minor abrasions and contusions to more severe inju- us and flexion torques of 28 ± 7Nm valgus torques
ries such as fractures and dislocations.[49-52] of 18 ± 4Nm have been recorded in the arm-cocking
and acceleration phases in young baseball pitch-
3.2 Action or Activity ers.[72,73] During the arm deceleration phase, the
elbow experiences a proximal force of 400 ±
The pitching motion in baseball, serving in ten- 100N.[72] Cumulatively, these forces may lead to
nis, spiking in volleyball, passing in American foot- injuries such as medial epicondyle fragmentation
ball, passing and shooting in water polo and team and avulsion, growth alteration of the medial
handball, and launching in javelin can all produce epicondyle, osteochondritis of the capitellum, defor-
elbow pathology caused by forceful valgus stress, mation or osteochondritis of the radial head, hyper-
with medial stretching, lateral compression and pos- trophy of the ulna, olecranon apophysitis and ulnar
terior impingement.[8] nerve neuritis.[29,63,76]
The throwing action in sports such as baseball In tennis, the elbow experiences substantial rota-
and American football can be divided into six tional forces when hitting the ball (range of motion
phases: (i) wind up; (ii) stride; (iii) arm-cocking; in serve: 15–120º; velocity: 900º/sec).[69] These
(iv) arm acceleration; (v) arm deceleration; and forces are further increased by the extreme hand grip
(vi) follow-through.[71] During the acceleration positions of current playing styles.[69]
phase, young pitchers (10–15 years) experience
Young gymnasts experience repetitive micro-
maximum elbow extension and internal rotation ve-
trauma due to valgus compressive forces at the
locities of 2230º ± 300º/sec and 6900º ± 1050º/sec,
elbow during manoeuvres such as tumbling, hand-
respectively.[72] Arm-cocking and acceleration
stand and one-arm balance.[77] This may lead to
cause the elbow to rapidly extend, thus creating a
osteochondritis dissecans of the capitellum and trac-
valgus force, placing the medial structures in tension
tion injuries to the medial epicondyle.[78,79] Another
and compressing the lateral structures.[61,73] Medial
distinctive feature in gymnastics is the sudden ex-
tension can cause fatigue fractures of the medial
tension of the elbow through the action of the tri-
epicondyle, muscle strains of the flexor muscles and
ceps.[80] This results in traction and shearing forces
collateral ligament injuries.[15,61] High compressive
on the olecranon acting at two sites: the insertion of
forces in the lateral part of the elbow, approximately
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724 Magra et al.
the triceps tendon into the olecranon, and the olecra- tion, and none occurred in players in a defensive
non physis.[81] position.[56]
In sports such as in-line and roller skating, elbow 4. Injury Severity
injuries occur as a result of falls on the outstretched
arm, or directly on the tip of the olecranon.[46-48,82]
These falls may result from losing balance, colli- 4.1 Type of Injury
sions or attempts made to avoid collisions with other
skaters, people or obstacles. The majority of elbow Depending on the forces sustained and the mech-
injuries in young snowboarders are caused by falls, anism of injury, acute injuries to the elbow may vary
and seldom by collisions with other users of the between minor abrasions and contusions to substan-
slope.[49] tial fractures and dislocations. Elbow injuries can be
Young arm wrestlers may sustain a fracture-sepa- generally classified into sprains, dislocations/ sub-
ration of the medial epicondyle secondary to a vio- luxations, primary fractures and miscellaneous inju-
lent contraction of the elbow flexors in the presence ries. Injuries may occur at the epiphyseal plate, the
of mechanical imbalance.[83] This usually occurs joint surface, and the apophyseal insertions of the
when the opponent suddenly tries to force the end of muscle tendon units. In children with immature
the match and the arm wrestler counters the move, skeletons and during the adolescent growth spurt,
thus causing a sudden passive stretch of the flexors, the epiphyseal plate is weaker than the surrounding
which are already maximally contracted. This places ligaments, predisposing children and adolescents to
undue load on the epiphyseal plate, and leads to the epiphyseal plate injuries.[89] On the other hand,
injury. In wrestling (e.g. Greco-roman), most (86%) prepubescent or skeletally mature athletes are more
of the injuries to the elbow are caused by hyper- prone to tendinous or ligamentous injury.[89]
extension of the elbow joint.[57]
4.1.1 Baseball
Elbow injuries result from cumulative micro-
3.3 Situational Factors trauma from the repetitive, dynamic overhand
In most sports, more time is spent in practice than throwing motion used in pitching.[22,67] Rapid
in competition. As a result, the frequency of injuries growth of bones about the elbow during adoles-
is higher in practice than competition. For example, cence, coupled with the fact that their growth carti-
the percentage of all injuries in women’s gymnastics lage is less resistant to repetitive microtrauma than
varies from 79% to 96.6% in practice versus adult cartilage, predisposes to ‘Little League el-
3.4–21% in competition.[38,41,42,84-86] However, when bow’,[90] which is seen in skeletally immature pitch-
the number of injuries is computed with reference to ers who throw for long periods of time, and is most
the exposure data, there is a higher rate of elbow common in throwers aged 8–16 years.[91] This entity
injuries in competition than practice.[38,81] This may includes a number of injuries: (i) osteochondritis
be explained by the fact that gymnasts are better dissecans of the capitellum, trochlea and radial
protected during training than in competition, with head; (ii) medial epicondyle fragmentation and
the use of foam pits, spotting and softer mats.[87] avulsion; (iii) growth alteration of the medial
In an Australian study, in-line skaters tended to epicondyle; (iv) epiphyseolysis of the medial
choose different skating environments depending on epicondyle and olecranon; (v) hypertrophy of the
their age. Younger skaters (9 years) predominate in ulna; (vi) olecranon apophysitis; and (vii) flexor-
rinks (49%), whereas adolescents (15–19 years) pronator tendinopathy.[63,92,93] These injuries are
tend to use parks (55.6%).[88] unique, in that the pitchers’ elbow is still develop-
In a prospective study of a junior ice hockey team ing, and severe injuries at this stage can have long-
during a single season, all the elbow injuries oc- term consequences. The epiphyseal growth plate
curred in children who played in the forward posi- may fail from repeated microtrauma.[94] Injury to the
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Epidemiology of Paediatric Elbow Injuries 725
physis can cause long-term disability, deformity and fractures heal well, rarely progressing to non-
shortening.[61] union.[61,69] Tension and shear forces can also lead to
In the Houston Study of 595 Little League base- physeal irritation, widening or avulsion of the olec-
ball players, 100 (17%) had elbow symptoms, 74 ranon.[61]
(12%) demonstrated measurable flexion contrac- Repetitive loading of the elbow in physically
tures, 219 (37%) had an increased carrying angle, immature athletes can predispose them to develop
and only 6 (1%) had severe elbow symptoms that osteochondritis dissecans of the capitellum in gym-
prevented them from pitching.[25] Similar results nasts[78,81,96] and water polo players.[61,97-99] Also,
were seen in the Eugene study of 120 Little League traction apophysitis can occur at the insertion of the
players, in which 25 (20%) players had elbow symp- triceps tendon into the olecranon epiphysis in gym-
toms, and 12 (10%) demonstrated flexion contrac- nastics, wrestling, hockey and diving.[94]
tures.[26] However, there was no significant increase In some high-contact sports such as children’s ice
in elbow symptoms, flexion contractures, carrying hockey, the elbow is usually spared from more
angle or radiographic changes with increasing pitch- serious injuries such as fractures and dislocations,
ing experience.[25,26] More recently, in a study of 120
and instead is prone to abrasions and contusions.[54]
Little League pitchers, flexion contractures and val-
This could possibly be because of the mandatory
gus deformities were reported in 10 (8%) and 7 (6%)
protective gear used in ice hockey. The Austrian
pitchers, respectively.[18] It may be possible that rule
changes limiting pitching might have influenced the experience of young snowboarders demonstrated
findings in later studies[18] compared with earlier that all elbow injuries sustained in this age group
ones.[25,26] were contusions or sprains.[49] Interestingly, a 4-year
In Little League baseball players, the injury pat- retrospective study of young Italian skiers demon-
terns vary according to skeletal and chronological strated 587 injuries in total, of which only 17 were
age.[29] Valgus overload to the elbow generally leads confined to the elbow.[51] Of these, fractures, dislo-
to medial apophysitis in younger players, but the cations and epiphyseal injuries constituted more
same stress on the adolescent elbow results in com- than 75% (13/17) of all elbow injuries.[51]
plete or partial avulsion fracture of the medial In children, fractures around the elbow from
epicondyle.[29] Avulsion of the medial epicondyle is sports and leisure activities form a significant pro-
the most common fracture in adolescent and portion of all injuries sustained. Landin[100] and
preadolescent overhead-throwing athletes.[25] A ret- Houshian et al.[101] found that 21% and 49.6%, re-
rospective study of a single season in 195 Little spectively, of all elbow fractures in children
League baseball players showed that only 95 (49%) originated from sports- and equipment-related lei-
of boys (aged 9.5–12 years) with proven radiograph- sure activities. Overuse injuries of the olecranon
ic medial epicondyle separation reported elbow growth plate (figure 2) have been reported in gym-
pain.[18] These data raise concerns that many of these nasts,[80] and in a wrestler.[102] Olecranon tip frac-
injuries may go unrecognised. tures are also seen in baseball pitchers, and could
result from impingement of the already hypertrophic
4.1.2 Other Sports olecranon in its fossa, or chronic intermittent over-
Both lateral (tennis elbow) and medial epicon- load on the olecranon by the extensor mechanism.[75]
dylopathy are seen in young tennis players.[95] Al- Elbow fractures accounted for 4/106 (3.8%) of all
though the incidence of tennis elbow is lower than in fractures seen in young (mean age 11.7 years) in-
adults, it is still greater than the incidence of medial line skaters.[103] Acute injuries, in the form of dislo-
epicondylopathy.[69] Compared with adults, medial
cations and fractures at the elbow, are more common
collateral ligament tears are rare in children.[61] In-
in certain sports such as gymnastics.[81] Dislocations
stead, small avulsion fractures may occur because of
can be associated with fractures of the medial
the anatomy of the adolescent elbow; these avulsion
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726 Magra et al.
4.2 Time Loss
There is little information available on time loss
associated with elbow injuries in paediatric sports.
After sustaining an elbow injury in gymnastics, the
average time lost was 4.1 months, with 5/30 (16.6%)
of those patients with injuries not returning to active
competition at all.[81] In ‘Little League elbow’, the
average time to return to competitive pitching is 3
months.[11] In New Zealand, most schoolboy rugby
players with elbow injuries returned to play in under
a week (71%), or between 1 and 3 weeks (29%).[37]
4.3 Clinical Outcome
Francis et al.[104] reported that 15% of a sample of
398 male college students who pitched in youth
baseball felt their ability to throw while at college
was hampered by pain, tenderness or limitation in
movement as a result of their youth baseball pitch-
ing. However, radiographic evaluation indicated no
difference between those who reported pain and
those who did not. Sports-related symptoms in
youth baseball pitchers may therefore continue into
adulthood. In the Houston Study of Little League
baseball players, only 6/595 (1%) of the pitchers had
severe elbow symptoms that prevented them from
pitching.[25]
Severe fractures around the elbow joint in chil-
dren must not be taken lightly, as many of these
injuries will have sequelae in later life. A 12-year
longitudinal study of acute traumatic sports injuries
in children showed that 42.9% of elbow fractures
(Abbreviated Injury Scale score of 2) demonstrated
permanent subjective and objective sequelae in later
life.[105]
Two case series studies reported ‘career-ending’
injuries affecting the elbow in young gym-
nasts.[96,106] In one study,[96] of seven female gym-
nasts, osteochondritis dissecans of the capitellum,
a
b
Fig. 2. (a) Anteroposterior and (b) lateral view of an olecranon
fracture secondar
y
to overuse. positive radiographs, and failure of conservative
management precluded return to competitive gym-
epicondyle or radial neck, or an injury to the median nastics. In that study, only one athlete continued her
or ulnar nerve.[94] gymnastic training, and one of them retired due to an
unrelated injury. The rest retired from gymnastics,
and could not perform any physical activity requir-
ing significant upper extremity contribution.
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Epidemiology of Paediatric Elbow Injuries 727
Maffulli et al.[106] reported the middle term (mean the physis is at increased risk of injury during the
3.6 years) outcome of articular surface lesions of 12 active phases of growth.[106] Pitchers aged 11–12
gymnasts (6 male, 6 female). There was a high years throwing change-up deliveries have signifi-
frequency of osteochondritic lesions, intra-articular cantly decreased odds of elbow pain compared with
loose bodies, and early signs of joint aging. All 9- to 10-year-olds.[20] Decreased height would result
patients showed marked loss of elbow extension, in shorter moment arms in the kinetic chain to
and ten patients had residual mild pain in the elbow transfer the forces generated, which will result in
at full extension. On the other hand, in a case series greater forces being exerted on the elbow.[106] Simi-
reporting traction apophysitis of the olecranon to the larly, increased weight would result in greater val-
elbows of ten young gymnasts (12 elbows, followed gus torque and potential energy being transferred to
up for an average of 6.2 years), all but three were the elbow along the kinetic chain during the forward
able to return to the same level of competitive gym- stride.[73,107]
nastics.[80] The three retirements occurred because
of other injuries. The mechanism of sustaining these 5.2 Extrinsic Risk Factors in Baseball
injuries in young gymnasts has been highlighted
earlier (section 3.2),[77-80] and it is possible that the 5.2.1 Pitch Counts
favourable results seen in traction apophysitis[80] The number of pitches in a baseball game or
compared with articular surface lesions[106] could be season has been associated with an increased risk of
because in traction apophysitis the joint line is not elbow injury.[20] However, no correlation was found
involved. between average number of pitches per inning and
elbow pain.[25] The former study is probably more
5. Injury Risk Factors accurate because elbow pain was evaluated after
each game pitched rather than through a cross-sec-
Few studies have tested risk factors associated tional survey or at the end of a season. There is a 6%
with injury in children’s and youth sports, and even increase in the odds of elbow pain per 10 pitches
fewer have tested risk factors for particular injury thrown in a game.[20] At >75 pitches, the odds of
types. Intrinsic risk factors believed to be related to elbow pain increase to >50%.[20] Cumulative pitches
elbow injury in children’s and youth sports include (600) thrown during a season are also an important
bone plasticity, ligamentous laxity, susceptibility of risk factor for elbow pain.[20] Pitchers playing recre-
physeal plate injury and immature musculature.[65]
ational baseball outside their league games and prac-
Growth leads to a longitudinal increase in the bone, tice sessions have a significantly increased likeli-
but the soft tissues around the bone, which have no hood of elbow pain.[20] An associated risk factor is
growth centres of their own, elongate secondarily in the misguided training regimen encountered in
response to bone growth.[89] This often results in sport-intensive summer camps, in which a child who
increased strength with decreased flexibility, caus- normally plays baseball an hour or so each weekend
ing muscle-tendon imbalances around the elbow. In suddenly trains 6 hours per day, every day of the
this situation, continued intensive, repetitive motion week.[89]
may lead to overuse injuries and nerve entrapment
syndromes.[89] 5.2.2 Pitch Types
Certain types of motions while pitching (e.g.
5.1 Intrinsic Risk Factors in Baseball curveball, slider) are more stressful on the elbow
Increased age, increased weight and lower height joint than others (e.g. change-up, sidearm pitch-
are believed to be significant independent risk fac- ing).[19,91,108,109] The ‘slider’ has an overall 86% in-
tors for elbow pain in pre-adolescent baseball pitch- creased risk of elbow pain, with a 12% reduction in
ers (range 9–12 years, mean 10.8 years).[20] Age and the risk among pitchers who throw the ‘change-up’
the timing of growth spurt are risk factors because delivery.[19] Albright et al.[24] found an increased risk
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728 Magra et al.
of elbow injury with a horizontal arm during deliv- amination would also address medical and psycho-
ery (particularly with a whipping or snapping mo- logical issues important to general health, and may
tion) in Little League baseball pitchers (age 14 be the athlete’s only contact with a healthcare pro-
years). However, Grana and Rashkin[22] found no vider.[114,115]
relationship between elbow injury and sidearm de-
livery or speed of delivery in older pitchers (14–19 6.1 Baseball
years). Apart from a few prospective cohort studies,[19,20]
the suggestions enumerated below for elbow injury
5.3 Risk Factors for Elbow Injury in
prevention in baseball have not been formally test-
Other Sports
ed, and most of the information has only been ob-
There is a paucity of information on extrinsic risk tained from cross-sectional studies or individual ob-
factors for injury in other sports. The use of thinner servations.
mats in gymnastics has been associated with an Proper throwing mechanics and equipment are
increased risk of elbow injury.[81] Also, absence of important. This must be emphasised by coaches at
spotters and mal-positioned or inexperienced spot- an early age to minimise the risk of injury to the
ters increase the risk of sustaining an elbow inju- elbow in Little League baseball players.[19,20,29,72]
ry.[81] Inexperience[47,110,111] and not wearing protec- Symptoms already present can be eliminated if the
tive elbow pads[47] increased the risk of an elbow style of pitching is changed.[24] Logically, the best
injury in in-line skaters (rollerblading). The likeli- time to correct a pitcher’s improper biomechanics
hood of sustaining an elbow injury is 9.5 times would be at the very start of his or her career, i.e. in
higher when not wearing elbow guards.[47] Other the Little Leagues, thereby reducing the incidence of
risk factors in this sport include speed, obstacles and future elbow injuries.[109] Videotape analysis by a
hard surfaces.[46] Poor design and fitting of elbow physical therapist or other expert well versed in
pads, rather than the severity of body or stick con- throwing mechanics is often the most effective way
tact, has been attributed to increasing the risk of to identify errors in pitching that increase the risk for
elbow injuries in ice hockey players.[53] In tennis, recurrent injury.[11] Using a ball with a smaller diam-
increased risk of elbow injuries has been attributed eter might allow the young pitcher to learn proper
to a small grip and racquet size, tight string tension, grips before progressing to learning grips on a big-
and the one-handed backhand technique.[112] ger ball.[72] Pitching when fatigued should be avoid-
ed, and an accurate pitch count should be kept
6. Suggestions for Injury Prevention during the game, making sure that the agreed limit is
not exceeded. Also, using lighter baseballs may
Prior to examining potential prevention strategies allow young pitchers to generate arm velocities sim-
to minimise elbow injuries in sport, a good under- ilar to the adult pitcher.[72]
standing of the incidence rates, at-risk population,
sport participation, and risk factors for injury is Little League Baseball Inc. limits pitchers to a
necessary. In general, interventions for injury pre- maximum of six innings of pitching per week, and
vention should include education and behaviour requires mandatory rest periods between pitching
modification, and environmental and legislative appearances.[116] Young pitchers (9–12 years)
changes. The six potential mechanisms by which should not be allowed to throw more than 75 pitches
this could be achieved are: (i) pre-season physical in a single game, and 600 pitches in a single season,
examination; (ii) medical coverage at sporting to limit the risk of elbow pain.[20] The recommended
events; (iii) proper coaching; (iv) adequate hydra- pitch counts per game by age are: 8–10 years, 50;
tion; (v) proper officiating; and (vi) proper equip- 11–14 years, 75; 15–16 years, 90; 17–18 years,
ment and surface playing conditions.[113] Besides 105.[11] These recommendations should be adhered
detecting medical conditions, pre-participation ex- to as strictly as possible, as 8- to10-year-old pitchers
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Epidemiology of Paediatric Elbow Injuries 729
have thrown well over 100 pitches per game.[91] tion and early ball release could be adopted by
players hesitant to alter their pitching styles.[19]
However, 476 pitchers aged 9–14 years threw 100 or
Throwing at high velocity (>80 mph [>128 km/
more pitches in a game in only 6% of their appear-
h]) should be discouraged in the skeletally immature
ances.[19] High pitch counts may not only increase athlete.[11] However, if the kinetic sequence and the
the risk of immediate injuries, but also increase the transfer of forces are coordinated, balanced and
likelihood of the player developing overuse injuries smooth throwing may be possible at the same speed
in the future if they continue to play baseball beyond with limited detrimental forces across the elbow.[109]
their youth.[19] Pitch limits rather than inning limits Young players must undergo strength training
could help in improving the safety in youth baseball programmes tailored according to age and ability of
players.[19] Physicians must convince young pitch- the player before beginning a formal throwing pro-
ers, their parents, and coaches that excessive pitch- gramme.[121] Pre-season training of pitchers should
ing is a major cause of ‘Little League elbow’,[91] and consist of a gradual increase in the number, distance
that this condition is an important health problem, and intensity of throws.[91] The young athlete should
which could have an impact on their ability to con- not be allowed to progress more than 10% per week
tinue to play the game. Restricting the allowed num- in the amount and frequency of training.[108] Proper
ber of pitches may not be enough, as all too often a warm-up and stretching programmes should be
team is dependent on a single pitcher, and that maintained in the off-season or, at a minimum, be
individual is used in every possible situation as started 6 weeks before the pitchers start pitching in
governed by the rules.[117] This could be prevented competition.[91] Pitchers should not compete more
by an amendment of the rules by limiting the num- than 9 months per year, and should avoid overhead
ber of batters a pitcher can face to 15 per game and activities during the 3 months of rest.[11] At least a
120 per season.[19] 2-day rest is recommended following a series of
competitive pitches.[122-124] Recurrent elbow dis-
Experienced coaches should alter a pitcher’s
comfort must not be ignored in young pitchers, and
style away from the sidearm delivery and prohibit the ‘no pain, no gain’ philosophy should be discour-
‘curve balls’ and ‘sliders,’ which cause an increased aged. Pitchers who report arm fatigue should be
incidence of elbow pain.[19,118,119] Pitchers should be removed from further pitching in that game to pre-
encouraged to learn the ‘change-up’ style of pitch- vent elbow injury.[20] Also, once a pitcher is re-
ing, which improves pitching performance and de- moved, that pitcher should not return to competitive
creases the risk of elbow pain.[19,20] The ‘change-up’ pitching in the same game, or practice any post-
provides a safe alternative, and can be just as effec- game competitive pitches.[11] The pitcher should
tive as other breaking pitches, because the off-speed fully recover strength, range of motion and pain-free
upsets the batter’s timing.[19] To minimise the throwing before returning to competition.[91]
chance of sustaining injury, pitchers should first It must be acknowledged that there are huge
learn the fastball (age 8 ± 2 years), then the change- practical limitations in implementing all the recom-
up (age 10 ± 3 years), followed by the curveball (14 mendations made to reduce injury in youth baseball
± 2 years), and finally the slider (16 ± 2 years).[120] players, as these recommendations often run contra-
Pitching styles requiring exaggerated external rota- ry to conventional wisdom, and are not necessarily
tion at the shoulder should be avoided, as they tend warranted given the paucity of high-quality research
to stress the elbow more severely.[73] Unfortunately, in this area.
these styles provide a greater arc over which the ball
can be accelerated before release, and pitchers may 6.2 Other Sports
therefore be hesitant to adopt a pitching style that
protects the elbow at the cost of pitch velocity.[73] To Recommendations from cross-sectional and co-
counteract this, a backward lean in the balance posi- hort studies to reduce elbow injuries during gymnas-
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730 Magra et al.
tics are outlined in table V.[38,41-43,45,77,86,125-129] Sug- Line Skating Association recommendation that skat-
gestions include, adequate funding allocated to re- ers always wear full protective gear.[133] The follow-
cruit appropriately trained professionals such as ing have been suggested to increase the frequency of
coaches, therapists and spotters,[43,86,126,128,129] all of children wearing elbow pads: (i) parents encourag-
whom should meet a minimum level of qualifica- ing and educating children about the benefits of
tion.[43] Relevant coaching must be provided by wearing protective pads, even though it is hot or
these individuals,[125] with spotting made obligatory peers are not wearing them; (ii) developing
during high-risk events.[41] They should regard pain programmes that increase the awareness of children;
as a warning sign of possible growth plate injury,[42] (iii) compulsory use of protective gear in play-
and must seek medical advice as soon as the child grounds, competitions and skate tours; (iv) retailers
complains of elbow pain.[126-128] In summary, these offering financial incentives or reduced prices when
preventive strategies in gymnasts require interaction protective gear is bought together with skates; and
between gymnasts, coaches, medical staff and legis- (v) manufacturers making the gear more comforta-
lature. Most of these suggestions are derived from ble and attractive.[132] ‘Gear Up’, ‘Asphalt Bites’
descriptive data and still await confirmation from and ‘Play it Safe’ campaigns promote use of person-
more controlled epidemiological studies to evaluate al protective equipment and other safety measures
their effectiveness in preventing injuries. that must be incorporated by in-line skaters to re-
duce the risk of injury.[130] Novice skaters should
In in-line skating, elbow injuries could be re-
avoid roadways with traffic, uneven surfaces, hills
duced by 82% by wearing elbow pads.[47] Despite
and obstacles.[46] Skating trails should have good
the availability of relatively inexpensive elbow
drainage, be kept free of sand, dirt, twigs and leaves,
pads, few in-line skaters wear them. In two Canadi-
and should flatten for at least 30 feet [9m] before
an studies, only 4.6%[130] and 9%[131] of skaters aged
intersections.[46] ‘Skitching’, the practice of holding
15 years wore elbow pads, and in a study of 9- to
on to a moving vehicle while on skates, should be
13-year-olds from The Netherlands, only 14% wore
elbow pads.[132] This is despite the International In- strongly prohibited.[46]
Table V. Recommendations to reduce elbow injuries during gymnastics
Preventive measure Type of evidence
cross-sectional cohort
Require coaches to meet a minimum level of qualification Weiker[43] (1985)
Teach and practice correct landing techniques to prevent fractures and Mackie and Taunton[125] (1994)
dislocations of the upper extremity
Recognise the existence or potential for growth plate injury and the importance Caine et al.[126] (1992) Kolt and Kirby[127,128] (1995,
of referring the gymnast for medical evaluation as soon as symptoms occur 1999)
Pain should be regarded as a warning, and not something to get used to; ‘no Caine et al.[42] (1989)
pain – no gain’ is inappropriate
Spotting should be used more extensively during practice and obligatory during Lindner and Caine[41] (1990)
high risk events
Availability of well trained spotters Bak et al.[129] (1994)
Weiker[43] (1985)
Increase thickness of mats during practice and competition Priest and Weise[77]
(1981)
Administer pre-participation physical examination prior to entry into competition, Kolt and Kirby[127,128] (1995,
before any change in the competition level, and before returning to practice 1999)
following injury Caine et al.[42] (1989)
Gymnastic clubs should have enough funds to hire an athletic trainer, or Caine et al.[126] (1992) Kolt and Kirby[128] (1999)
physical therapist, at least on a part-time basis Garrick and Requa[86] (1980)
Re-evaluation of competition rules and performance environment given the high Caine et al.[38] (2003)
incidence of injury linked with competition
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Epidemiology of Paediatric Elbow Injuries 731
In tennis, racquets with a larger head and grip prospective cohort studies on the epidemiological
size, and a laxer string tension may help reduce the trends of elbow injury in other sports, and most
incidence of elbow injuries in children playing the studies tend to be retrospective or series of case
sport.[112] Also, the two-handed backhand may offer reports with a short literature review. Studies on the
protection to the elbow compared with the single- aetiology of elbow injuries in the paediatric popula-
handed backhand.[112] tion will require a dynamic model that accounts for
the multifactorial nature of these injuries, taking into
Ice hockey is played with a fair amount of protec-
account the sequence of events leading to an injury.
tive gear, which could partially explain the low
There is a need for analytical studies that test risk
incidence and severity of elbow injuries sustained
factors and evaluate preventive measures.
by children in this sport.[54] Having said that, profes-
sional adult ice hockey players are well known for Two of the most important factors influencing
their violent behaviour, which is often mimicked by the likelihood of permanent sequelae are the charac-
children. Rigorous rule enforcement and strict pen- teristics and the severity of the lesion. Usually,
alties should be applied by referees to help reduce return to athletic activity is not inhibited, except in
the incidence of injury.[54] In addition, improve- acute traumatic injuries such as elbow fractures, and
ments in the design and fitting of elbow pads may also in some cases of osteochondritis of the capitel-
play an important role in reducing elbow injuries in lum, where there may be a long-term disability and
junior ice hockey players. [53] inability to return to effective sports participation.
Good longitudinal follow-up studies are needed to
7. Conclusion and Suggestions for document the incidence and severity of such inju-
Further Research ries, which can result in permanent sequelae to the
elbow. The study design must incorporate a target
The number of injuries to the elbow in paediatric population, a strict definition of injury, and an ap-
and adolescent athletes has risen following the ex- propriately qualified team of people making the
panded participation and higher level of competition diagnosis.
in youth sports. These injuries are unique and specif- Conditioning and training errors coupled with
ic to the biomechanical demands placed on the el- rapidly changing physical characteristics are some
bow in a given sport. Sports that involve throwing or of the factors to be addressed to curb the rising
other means of strain on the elbow result in a signifi- injury rate in the paediatric athlete. Early recogni-
cant amount of force on the elbow, not often en- tion of injury leads to better outcomes, and will aid
countered during daily living. In sports such as in the prevention of persistent functional disabilities.
baseball, radiographic changes in the elbow may be For early recognition, a high index of suspicion and
present in the absence of clinical symptoms, thus a thorough physical examination, including radio-
opening up new avenues for research analysing the graphs of the affected and contralateral side, are
precise aetiology of the bony changes. required.
Injuries may have a significant impact on the
Young athletes are highly motivated and, despite
athlete, parents and healthcare system. Current stud-
being in pain, usually continue to participate in
ies show considerable variability in research design
sports for reasons such as love of the game, fear of
and measurements used to assess exposure and inju-
losing their position, not wanting to be teased and
ry. Injury definition and methods of injury data
wishing to impress their peers, parents and coaches.
collection are extremely variable. Methods of data
To prevent serious injury, awareness of the possible
collection vary from self-report to therapist or physi-
dangers and a sensible approach to the amount of
cian report. All these factors could account for the
throwing performed, with appropriate medical and
variations in the reported rates of injury. Most of the
radiographic evaluation, are needed. The attitudes of
literature available is on athletes involved in over-
‘no pain, no gain’, ‘play through the pain’, ‘throw
head throwing activities, e.g. baseball. There are few
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732 Magra et al.
6. Simon TD, Bublitz MS, Manbidge SJ. External causes of pedi-
the pain out’ and ‘more is better’ should not be atric injury-related emergency department visits in the United
encouraged. Muscle soreness is normal, and a sign States. Acad Emerg Med 2004; 11: 1042-8
7. Burt CW, Overpeck MD. Emergency visits for sports-related
of the beneficial training stresses imposed on the injuries. Ann Emerg Med 2001; 37: 301-8
muscles around the elbow in throwing sports such as 8. Whiteside JA, Andrews JR. Common elbow problems in the
baseball; but joint pain is not normal, and should be recreational athlete. J Musculoskel Med 1989; 6: 17-34
9. DaSilva MF, Williams JS, Fadale PD, et al. Pediatric throwing
regarded as a warning for overuse injury. injuries about the elbow. Am J Orthop 1998; 27: 90-6
Sport-specific dynamic exercise programmes 10. Kandemir U, Fu FH, McMohan PJ. Elbow injuries. Curr Opin
Rheumatol 2002; 14: 160-7
may be effective in managing and preventing elbow 11. Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport
injury in sport, and should cater for the age, gender Med 2005; 15: 37-40
and skill level of the athlete. Training programmes 12. Chen FS, Diaz VA, Loebenberg M, et al. Shoulder and elbow
injuries in the skeletally immature athlete. J Am Acad Orthop
may not be able to cater to the needs of all athletes, Surg 2005; 13: 172-85
and programmes may need to be individually tai- 13. Morrey BF, An KN. Functional anatomy of the ligaments of the
lored in some athletes. The dangers of overuse inju- elbow. Clin Orthop Relat Res 1985; 201: 84-90
14. Callaway GH, Field LD, Deng XH, et al. Biomechanical evalua-
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be discussed with the parents, whose only focus is Joint Surg Am 1997; 79: 1223-31
often the success of their children in their chosen 15. Hotchkiss RN. Common disorders of the elbow in athletes and
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projects and prospective studies in young athletes 17. Amadio PC. Epidemiology of hand and wrist injuries in sports.
with elbow injuries from sports. Further epidemio- Hand Clin 1990; 6: 379-81
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Article
The aim of the present study is to provide a review of the available scientific knowledge in terms of tennis injuries for the last 15 years with the aim of establishing the current state of knowledge about the matter and to allow a better approach of the lines of research.The main findings of this systematic review were firstly the great variation in the reported injury incidence between the different descriptive epidemiological studies analyzed. On the other hand, although a great scientific evidence proves that most of the injuries take place in the lower limbs, only the 24% of the studies analyzed in the present systematic review had the lower limbs and the trunk as research objects. Taking into account the intervention studies analyzed, just 7 articles were published between 1995 and the present time, besides having limitations due to the fact that they not include confidence intervals when reporting the effectiveness of the intervention under exam. Lastly, from 2007 to the present time the number of published studies in the field of tennis injuries has been progressively decreasing, so it becomes necessary a greater investigation in order to solve this fact and to develop tennis injury prevention programs which prove to be really effective.
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The purpose of this study was to determine the biome-chanical and anthropometric factors contributing to elbow valgus torque during pitching. Video data of 14 youth pitchers throwing fastballs were used to calculate shoulder and elbow kinematics and kinetics. Peak elbow valgus torque averaged 18 Nm and occurred just before maximal shoulder external rotation. The magnitude of valgus torque was most closely correlated with the thrower's weight. When subject weight and height were controlled for, maximum shoulder abduction torque and maximum shoulder internal rotation torque were most strongly associated with elbow val-gus torque, accounting for 85% of its variance (P < .007). When only kinematic variables were considered, maximum shoulder external rotation accounted for 33% of the variance in valgus torque. Given that the biomechanical variables correlated with peak val-gus torque are not easily modifiable, limiting the number of innings pitched is likely the best way to reduce elbow injury in youth pitchers.
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Fractures constitute 10% to 25% of all pediatric injuries and are more common in boys than in girls, and after age 13 or 14 years are twice as common. The results from an epidemiologic study in Malmo indicate that a child's risk of sustaining a fracture is 42% in boys and 27% in girls from birth to age 16 years. Fractures of the distal end of the radius are the most common injury, followed by fractures of the phalanges of the hand. From 1950 to 1979 there was a twofold increase in the risk of fracture, due to an increase in light-energy trauma, mainly sporting activities. Since the end of the 1970s there has been no further increase in the fracture risk. The data also indicate that preventive measures have been effective in decreasing severe accidents.
Article
Stress fractures have been reported in the upper limb of sportspeople involved in upper limb dominated events. Olecranon stress fractures have been cited in baseball pitchers, javelin throwers, and gymnasts. The unusual case of a stress fracture of the olecranon in a young weight lifter is reported here. The minimally displaced stress fracture was treated with tension band and two Kirschner wires. The fracture healed in four months and the patient returned to light sports activity after six months.
Article
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 consisitent 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.
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Background: This study focuses on the analysis of snowboarding versus skiing injuries, especially fracture, dislocation, or both, of the elbow, based on 7 years of medical records and roentgenograms of patients injured at a ski-snowboard area, Mt. Zao National Park, and demonstrates the precise characteristics of snowboard injury in the elbow region. Methods: A retrospective study of 1,445 injured snowboarders and 10,152 injured skiers was undertaken to assess both snowboarding and skiing injuries. Sixty-four cases of snowboarding injuries and 152 cases of skiing injuries were available for precise analysis of fracture, dislocation, or both, in the elbow region. Results: Fractures, dislocations, or both, in the elbow were more frequently observed for snowboarders (30 of 64 cases, 46.9%) when compared with that for skiers (26 of 152 cases, 17.1%) (p < 0.001). The rate of dislocation with or without fracture of the elbow was also significantly higher for snowboarders (17 of 64 cases, 26.6%) than for skiers (8 of 152 cases, 5.3%, p < 0.001). Seventeen cases of elbow dislocation in snowboarding were all of the posterior type, which accompanied two coronoid process fractures and two radial neck fractures. Fractures of the coronoid process (five cases), radial head (one case), radial neck (five cases), olecranon (one case), proximal ulnar shaft (one case), and extension-type fracture of distal humerus (four cases) were the fracture types observed in the analysis. Conclusion: Posterior dislocation; fractures of coronoid process, radial neck, and radial head; and extension-type fracture of the distal humerus characterize the particular and frequent injury mechanism responsible for snowboarding trauma in the elbow region. Thus, snowboarding injury of the elbow is recognized as a severe injury and is characterized by a frequent risk of posterior dislocation, fracture, or both. The severity of elbow injuries in snowboarding mainly seems to be due to direct mechanical force on the elbow, receiving the full impact of falling down, combined with an outstretched hand and elbow extension, or with an outstretched hand and longitudinal thrust force, to the proximal radius and ulna and distal humerus.
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There is relatively little information about injuries to club gymnasts. Therefore, the author conducted a statistical prospective study of the epidemiology of this group, following 873 club-level gymnasts for a nine-month season to establish injury incidence and related trends. Although the number of subjects was too small for statistical validity, many trends were identified. It seems that club gymnastics does not have an excessively high injury rate and that further data should make it possible to decrease the number of injuries.
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A prospective one-year epidemiological study was carried out to determine the injury incidence and the injury mechanisms in different groups of gymnasts and to identify possible risk factors. A total of 115 gymnasts with a median age of 16 (8-25) were followed through a whole season of median 48 weeks (ranges 40–51). The overall injury incidence was 85 per 100 gymnasts per season, ranging from 27 in subelite males to 157 in subelite females. This high incidence is partly explained by the use of a sensitive injury definition, the high exposure time, and the large proportion of highly competitive gymnasts in the population. Considering the exposure time, however, the incidence is lower than in most other sports, 1.6 per 1000 h of gymnastic activity. Subelite female gymnasts were more commonly injured than other artistic gymnasts, in particular in relation to balance beam exercises and inadequate spotting. Injuries were predominantly localized to the lower extremities (64%) for the whole population of gymnasts. A siwcantly large proportion of the male artistic gymnasts, nevertheless, sustained upper extremity injuries corresponding to their apparatus performance. Most injuries were of mild or moderate severity, the recovery time was, however, considerable (median 30 days, ranges 1–365), and the injuries sustained during competition had a median recovery period of 180 days (7-270). Twenty-two per cent of the injuries resulted in a recovery period of more than 6 months. Re-evaluation of the criteria of the score system for dismount as well as an increased use of spotters during practice and high-risk events are possible measures to prevent serious injuries.
Article
We present a study of the pattern of elbow fractures in children under 15 years of age, during a 5-year period, with special reference to supracondylar humerus fractures. The incidence was 308/100 000 per year; 58% of the children had a fracture in the supracondylar area of the humerus. There were 355 elbow fractures, and there were 164 boys (46%) and 191 girls (54%). The mean age for the entire group was 7.9 years (for boys, 7.2 years; for girls, 8.5 years). Of 209 supracondylar fractures (including 5 combination fractures), 134 were type I, 40 were type II, and 35 were type III (as classified by Gartland). Associated temporary nerve injuries involving the median, radial, and ulnar nerves were seen in 15 patients with type III supracondylar fractures. Associated brachial artery injuries were seen in 6 patients, 5 of whom had type III fractures.