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Review Article *Corresponding author Setayesh K, Department of Orthopaedics, University of Illinois at Chicago Department of Orthopaedics, MC Upper Extremity Injuries in 844, 835 S Wolcott Ave, Room E-270, Chicago, IL, USA, Tel: 312-996-7161; Email: Submitted: 29 November 2016 Field Athletes: Targeting Injury Accepted: 02 February 2017 Published: 03 February 2017 Prevention ISSN: 2379-0571 Copyright Setayesh K*, Mayekar E, Schwartz B, Schwartz A, Watson JN, © 2017 Setayesh et al. and Hutchinson MR OPEN ACCESS Department of Orthopaedics, University of Illinois at Chicago, USA Keywords • Abstract • Upper extremity injuries Track and field is one of the most widely practiced sports amongst young athletes • Biomechanics throughout the world with athletes participating since the ancient Olympic games. • Injury prevention Despite this, there has not been much research on upper extremity injuries in the field thrower. Relevant articles published using the search terms track and field, javelin, discus, , and upper extremity injuries were identified using PubMed. Various studies report upper extremity injury rates amongst athletes from 1-10%. Cases of penetrating neurovascular injury from javelin have been reported. UCL injuries of the elbow can be reconstructed similar to players with return to play rates ~90%. Small case series of wrist and hand injuries such as distal radial physical arrest, extensor retinacular impingement, carpal tunnel syndrome and TFCC injuries are present in the literature, however the most common injuries reported were blisters and small lacerations. Track and field athletes have a propensity for overuse injuries of the upper extremity. Based on evidence provided in other sports, monitoring of the athlete’s overall conditioning including core strength, training intensity and volume of throws, and technique is crucial for injury prevention.

ABBREVIATIONS AC: Acromioclavicular; SC: Sternoclavicular; EMG: fundamentals of the kinetic chain. The forces used to throw Electromyography; UCL: Ulnar Collateral Ligament; MRI: a discus, shot put, hammer, or javelin begin with the ground Magnetic Resonance Imaging reaction forces that are transferred up the lower extremities, INTRODUCTION through the core and torso, across the scapula, shoulder and elbow, and ultimately the hand. An injury at any link along the kinetic chain will lead to abnormally increased forces and predispose the athlete to injuries further distal along the kinetic Athletic field competitions have origins dating back to the chain [2]. ancient Olympic games. Many modern track and field events have roots to the 13th century Scottish Highland Games. Indeed, past Overall, track and field athletes appear to sustain a lower events like the “stone throw” have played a role into what is now rate of upper extremity injuries as compared to other sports. known as the shot put, whereas the “blacksmith’s hammer toss” For instance, a study by Sallis et al looking at injuries amongst has become the modern hammer throw [1]. Despite the sports’ 100 athletes in various sports found a rate of 1.2 hand and wrist long history, there is a paucity of information on the injuries they injuries and 1.81 shoulder injuries amongst men per 100 track produce. The purpose of this review is to document the current and field athletes. This compares to 12.18 hand and wrist injuries knowledge regarding path mechanics and upper extremity per 100 collegiate men playing , and 7.22 shoulder injury patterns in field throwing sports. Our goal is to identify injuries per 100 male tennis players [3]. Yang et al, however, common injury patterns in the upper extremity and potential noted that male track and field athletes suffer amongst the targets for injury prevention as it pertains to specific field highest rates of overuse injuries of all college sports at 10.4% events, or a knowledge gap which may lead to future research of study participants [4]. This apparent disconnect with Sallis’ on the prevention of upper extremity injuries sustained during study can be explained by the predominance of chronic injuries throwingEtiology field & Epidemiology events. occurring in the lower extremity; however, this finding also suggests that further research is needed into how injuries along the kinetic chain may impact overuse and acute injuries of the All throwers, regardless of the event, share common upper extremity. Cite this article: Setayesh K, Mayekar E, Schwartz B, Schwartz A, Watson JN, et al. (2017) Upper Extremity Injuries in Field Athletes: Targeting Injury Preven- tion. Ann Sports Med Res 4(1): 1098. Setayesh et al. (2017) Email: Central

There are a handful of studies focusing on track and field rotation, elbow extension, and wrist flexion and pronation [2]. athletes in particular. According to a study of 48 high school field Along various points in the kinetic chain, the dynamic and static athletes over three years, the participants sustained 19 acute stabilizers are subject to large stresses and torques, which can injuries and 52 injuries of gradual onset, with some athletes lead to chronic and acute injuries of the stabilizing structures. sustaining repeat injuries [5]. Between 75-98% of those injuries Dysfunction of the shoulder girdle muscles, such as in scapular occurred during training sessions rather than competition [6]. In winging, can affect motion of the shoulder as well as throwing a study of 278 elite Swedish track and field athletes, Jacobsson et velocity, and can cause the micro trauma seen in rotator cuff al found that most injuries involved muscular strains of the lower disease [13, 14]. extremities, as often as 35% of the time over a one-year period. If Shoulder injuries in collegiate javelin throwers have been untreated these injuries will increase the risk of upper extremity reported in up to 29% of athletes [3]. In javelin there is not as much injuries [7]. D’Souza’s study reviewed 21 track and field throwing motion at the elbow compared to traditional throwing sports, with athletes and found a 61.9% rate of injury, with nearly a quarter of the bulk of the motion occurring at the shoulder, the torso and the thoseKinetic injuries Chain occurring in the upper extremities [8]. lumbar spine [11]. Javelin throwers demonstrate signs similar to chronic impingement, such as an inflammatory thickening of the structures above the humeral head, which decreases the The sequence of events in the standard throwing motion differ clearance of the humeral head. The affected structures include slightly from the throws required for hammer throw and discus, the rotator cuff, biceps tendon, and subacromial bursa. Posterior which involve several spins towards the front of a throwing circle capsulitis and capsular rents can also be seen in javelin throwers before transferring kinetic energy from the lower extremities to [15,16]. Posterior rotator cuff muscles such as the teres minor the discus or hammer. These differ from the throw for shot put, and infraspinatus can become strained, especially as they restrict which entails either two backward steps followed by a spin and anterior translation of the humerus during follow through. The release, or a series of spins followed by extension of the elbow, posterior capsule can become impinged between the humeral shoulder, and release of the shot put [9]. The twisting and ballistic head and glenoid during the thrust phase of the throwing motion, nature of these throwing events can place large torques and axial which can lead to chronic micro trauma and scarring, posterior loads across the glenohumeral joint and can predispose to injury shoulder pain, and pain with internal rotation. EMG activity within the shoulder as well as further distal in the kinetic chain. from javelin throwers demonstrates an increased activity in Unlike other field throwing events, there is a fair amount of posterior rotator cuff and deltoid muscles, which supports the literature on javelin throwing biomechanics. [10-12]. The javelin theory of internal impingement present in these athletes [17]. throw involves 4 phases: approach run, cross steps, delivery Scapulothoracic injuries can occur due to eccentric loading of stride and the thrust phase [10, 12]. begins with the scapula stabilizers during the follow through phase, which the javelin in the palm of the hand, horizontal to the ground over typically occur at the musculotendinous junction of the medial the throwing shoulder with the elbow flexed to approximately scapular border [18]. 90 degrees and the forearm supinated. Additional variation Neurovascular injuries can also occur from the javelin, from traditional throwing occurs as there are 3 different types of however typically not to the thrower. There are instances of javelin grips which include American, Finnish and fork style. The piercing injuries to the shoulder from a javelin throw, with the athlete will begin running with their hips square to the direction sub clavian artery beneath the clavicle at risk [19]. Damage to the in which they are throwing. With the final two strides, the contra sub clavian artery has been shown to cause significant bleeding, lateral leg should be forward while the throwing arm is extended hemothorax, and decreased blood flow to the arm. A detailed at the elbow and the javelin held at shoulder height. This elbow neurovascular exam should be performed for any penetrating extension allows for maximum acceleration and therefore injury to the shoulder or chest due to a javelin, as the brachial throwing distance. During the thrust phase (final foot strike to plexus lies anteriorly to the sub clavian artery. A summary of the release) the elbow will flex from 40 degrees to 60 degrees (high commonElbow shoulder pathologies can be found in (Table 1). level athletes) and this places angular velocities of up to 1900 degreesShoulder per second on the elbow. Similar to the shoulder, during training and competition in field sports the elbow is subjected to potential pathologic Javelin, hammer toss, discus, and shot put place axial, repetitive loads which can lead to injury. The elbow is the next translational and distraction forces across the glenohumeral, step along the kinetic chain after the shoulder and any mechanical Acromioclavicular (AC), and Sternoclavicular (SC) joints. This abnormality proximal in the kinetic chain can lead to overuse can lead to overuse injuries such as muscle strains, degenerative and injury at the elbow [2,13,14]. Like the shoulder the actual joint disease, ligament sprains, instability, and occasionally more forces across the elbow joint depend on the event. The hammer acute injuries such as dislocation. Moreover, the strength training throw tends to be a distraction force across the elbow forcing the regimen required for these events also places athletes at risk for elbow into full extension risking posterior impingement of the injury to the aforementioned joints [7]. olecranon [20]. The shot put is primarily an axial load through The stresses and torques required for javelin throwing the elbow joint as the triceps forcefully fires to achieve full are generated through the lower body and is progressively extension. These compressive loads can lead to osteochondral transferred to the arm. Initially, a stride is converted into pelvic injuries, either at the radiocapitellar or ulnohumeral joint. rotation, which leads to rotation of the torso, shoulder internal The forced extension can lead to posterior impingement of the Ann Sports Med Res 4(1): 1098 (2017) 2/6 Setayesh et al. (2017) Email: Central

Table 1:

Body Part Injury breakdownInjury based on field event andSport body part. before release [10,11]. This puts a significant valgus force on the Osteolysis medial side of the elbow, and repetitive use can lead to failure

of the ulnar collateral ligament (UCL) and valgus extension Javelin, Hammer AC Joint toss, Discus, Shot put overload. The first reported UCL injury was reported in javelin Chronic glenohumeral throwers in 1946 [27]. Dines et al reviewed 10 javelin throwing Instabilityinternal impingement [15,17,20] athletes who underwent UCL reconstruction using the docking

Glenohumeral technique [11]. They obtained excellent outcomes based on SLAP tears the Conway scale in 9 out of 10 athletes, and found the average rents Javelin Posterior capsulitis, capsular Joint [13,15,16,23,31] return to previous level of competition was 15 months. Athletes with UCL injury can expect a similar timeframe for recovery Posterior rotator cuff strains after surgical reconstruction. In addition to UCL tears, javelin Glenohumeral Scapulothoracic injuries throwers occasionally have symptoms of ulnar neuritis related to Hammer toss, Chronic rotator cuff attenuation of the UCL [11]. There have been several reports of Discus, Shot put HumerusJoint Fracturetendinopathy [5,7,13,15,17,20,31] olecranon stress fractures occurring in javelin throwers [27, 28]. UCL tear Lavallee et al reported a case of an elbow dislocation in a javelin Shot put [12,30] Ulnar neuritis thrower but failed to provide any further details regarding the case [29]. There is limited data on long-term outcomes in career Medial epicondylitis javelin throwers. Schmitt et al evaluated 21 elite level (including Elbow Javelin [9,14,15] Medial elbow instability a gold medalist and former world record holders) athletes via Posterior impingement clinical, radiographic and magnetic resonance imaging (MRI) Olecrenon stress fracture studies with an average of 19 year follow-up [18]. Sixteen of Elbow Posterior impingement Hammer toss [4,7,32] these patients had medial epicondylitis and one had gross medial

Elbow Osteochondral injuries Shot put [7] elbow instability. Ten patients (48%) had a deficit in extension of greater than 5 degrees and four patients (19%) were unable Radius Distal physis growth arrest Javelin[8] to flex the elbow greater than 120 degrees. They found the loss DeQuervain’s tenosynovitis Wrist Hammer Toss [14] of extension to correlate with the duration of high performance TFCC injuries (p<0.03) and training with weights of more than 3 kg (p=0.08). Carpal tunnel syndrome impingement No patients were found to have a deficit in pronation or Wrist Extensor retinacular Shot Put [1,33] Carpus supination. All dominant elbows showed increased radiographic degenerative changes when compared to the non-dominant side Fingers Scaphoid nonunion Javelin[34] Abbreviations: and joint space narrowing was more frequently seen in patients Dislocation Hammer toss [27] who trained with weights greater than 3 kg (p=0.07). A summary AC: Acromioclavicular; SLAP: Superior Labrum from Wristof the common and Hand elbow pathologies can be found in (Table 1). Anterior to Posterior; UCL: Ulnar Collateral Ligament; TFCC: Triangular Fibro cartilage Complex The terminus of the kinetic chain in all throwing athletes olecranon or overuse tendinopathy of the triceps [8]. The javelin, is the hand and wrist. Forces generated via the kinetic chain while slightly non-traditional in throwing motion, places the culminate at the wrist and hand to transfer energy to the object elbow at risk of valgus extension overload similar to traditional being thrown. Since the weight of the shot put, javelin, discus, and throwing sports. Inherent to valgus extension overload of the hammer vary, the actual energy delivered to the object will vary. elbow there is an associated risk of traction injury to the medial Indeed, the gripping mechanism and biomechanics of delivery ulnar collateral ligament, as well as axial injury of the capitellum also play a key role in how the energy is transferred across the and radial head, and posterior impingement with full extension wrist and hand. For example, the javelin is held with multiple [21]. There is limited evidence based literature which correlates grips, but all have a circular grip in common with the primary elbow biomechanics of field events with clinical injury. Most load across the wrist being radial to ulnar. The shot put is held clinicians extrapolate the available literature on other throwing deep in the hand leading to wrist and finger extension during sports to the care of shot put, discus, and hammer throw athletes. cocking and acceleration phases. The hammer and discus will There have been two case reports of humerus fractures occurring create distraction loads across the wrist but the fingers maintain in shot put athletes; one treated conservatively in a cast and a flexed position until release. Field events in general appear to the other underwent an open reduction internal fixation, with have a very low rate of hand and wrist injury as compared to the each going onto union [22,23]. There are few biomechanical shoulder and elbow [30]. One survey reviewed 147 track and studies that evaluate the throwing motions involved in shot field athletes finding no hand and wrist injuries at all [8]. What is put and discus, but there is no discussion on the cause of these not clear is whether this demonstrates an actual reduced injury specific injuries or ways to prevent them [24,25]. McLennan et risk or, more likely, a paucity of literature or reporting on hand al. performed a survey of participants in Scottish heavy athletics, and wrist injuries in field athletes. and found a 13% injury rate in the Scottish heavy athletic sport of stone throw, a predecessor of shot put [26]. Although most upper Walaszek reported a remote history of one asymptomatic extremity javelin injuries occur in the shoulder, there are several scaphoid nonunion in a competitive adult javelin thrower in case series demonstrating elbow injuries. In elite athletes, 70% Europe [31]. The patient was previously treated non operatively of javelin release speed is developed in the last tenth of a second with immobilization for 2 months. He returned to his level of Ann Sports Med Res 4(1): 1098 (2017) 3/6 Setayesh et al. (2017) Email: Central

previous play, winning a national championship for Javelin and biomechanics [21]. Once the problem has been identified, then throwing. His grip strength was 98% of the contra lateral side. De a prevention program can be instituted which targets the injury Smet et al described a case of distal radial physis growth arrest risk. Ultimately, one must review the impact of each intervention in a 14 year old female who had trained in javelin throwing for 2 by re-assessing outcomes and alterations in injury patterns based years [32]. The arrest resulted in 5mm ulnar positive variance, on the intervention. Regarding throwing athletes in field sports, decreased inclination of the radius, and a radical shift of the some foundational epidemiology is available but significant data carpus, all which can alter the load distribution across the wrist collection through prospectively designed research would be joint and lead to chronic injuries. This patient was asymptomatic necessary to assure an effective impact of intervention. What we and no operative treatment was needed. More commonly do know is that the intervention will need to be sports specific fingertip lacerations and blisters can occur due to abrasion and will likely focus on the kinetic chain mechanics. Modeling between the athlete’s hand and the grip cord at release [33]. after other sports such as baseball would suggest that pre- These injuries can typically be prevented by limiting the number participation evaluation of kinetic chain function will be a key of practice throws, as they are exacerbated by fatigue. component, although the throwing styles in field events differ compared to baseball. This may be especially true for track and Amongst hammer throw athletes, Lavallee et al., suggested field, as many of these athletes participate in multiple events several potential injury patterns leading to DeQuervain’s (i.e. decathletes). Many of the non-throwing events in the track tenosynovitis and triangular fibro cartilage complex (TFCC) and field arena predispose athletes to lower extremity injury. injuries [29]. These athletes are also susceptible to finger While the specifics of the lower extremity injuries in track and dislocations and sprains [34]. In addition, they are susceptible field athletes is beyond the scope of this article, preventing lower to blisters, an injury which can be prevented by wearing gloves extremity injuries is critical in maintaining a healthy kinetic chain or taping the fingers. Care must be taken to not inadvertently from top to bottom. Assessment of core function via single leg disqualify the athlete through the use of tape, and therefore squats and scapular function via pre-participation side-to-side it is advisable to have it inspected prior to competition [33]. Unfortunately, there is very little literature describing these comparison would be a good start. injuries in further detail. Injury patterns in younger or less elite field athletes may Shot put athletes are susceptible to carpal tunnel syndrome be associated with poor mechanics. It is clear in other sports due to repetitive gripping, a claim supported by Banks et al, that altered throwing mechanics along the kinetic chain will [35]. Additionally, shot put athletes are particularly susceptible increase the load at subsequent segments increasing the risk of to wrist and hand sprains due to the weight of the shot and the injury. Trunk-Scapular kinesis and proper form is imperative wrist extension required to throw [36]. Early in the season most to prevention of valgus overload and MCL injuries at the elbow. athletes hold the shot deep in their hand, making them more prone Throwing sports where the MCL is at risk should focus on both to wrist sprains. As the season progresses and balance improves, flexor-pronator strengthening and throwing mechanics. As most hold and propel the shot from their fingertips, placing always, young field athletes should be evaluated by quality them at risk of volar plate injury, collateral ligament sprain or coaches to assure proper techniques. Finally, as in most sports, tear, and intrinsic hand muscle strains. Van Heest et al., reported the most common injuries in field athletes can be correlated to one case of extensor retinaculum impingement in a shot putter repetitive overuse. It is recommended to avoid throwing weights due to repeated wrist extension in their series of eight wrists in javelin training more than 3 kg, and to incorporate preventive [37]. The athlete noted pain while holding the shot put with the practices into training, such as throwing with lighter weights or wrist in extension. On exam, he had tenderness to palpation over elastic bands to increase power in the thrust phase. Monitoring the distal retinaculum, aggravated by extension. A trial of anti- training intensity and the number of throws, especially in inflammatory medications and rest or a corticosteroid injection skeletally immature athletes is essential. Younger athletes with was recommended for extensor retinaculum impingement. In an open proximal humerusphysis can demonstrate remodeling this case, however, the athlete still had pain in competition after to allow increased external rotation in the shoulder. This can lead conservative measures were undertaken, and was therefore to internal rotation deficits and posterior capsular impingement. As such, programs emphasizing posterior capsular stretching level.treated with distal retinaculum excision. The athlete returned to competition, winning a conference championship at the collegiate are important for prevention of glenohumeral injuries. Bilateral arcs of motion of the glenohumeral joint should be monitored to screen for rotation deficits and strengthening of the scapular As with other field throwing events, the most common injury stabilizers is important for any throwing program as well. amongst discus throwers is blistering or lacerations of the fingers. Most are superficial, but care must be taken to make sure The best method of prevention of wrist injuries amongst shot no flexor tendon, digital artery or nerve is injured. Discus athletes putters consists of wrist strengthening programs, taping, and are prone to wrist sprains and de Quervain’s tenosynovitis, strict attention to proper technique including the avoidance of particularly if wrist snap at time of release is overemphasized. wrist hyperextension. Likewise, finger injuries are best prevented A summary of the common hand and wrist pathologies can be by good technique and avoiding premature progression to foundTargeting in (Table Injury 1). Prevention & Discussion fingertip push-off or other advanced maneuvers [36]. Blisters and lacerations can be avoided with glove or tape use, but should be carefully inspected to prevent risk of disqualification from Based on the van Mechelen model of injury prevention, one competition. Similarly, discus throwers are also subject to blisters must first identify the problem through a study of epidemiology and finger lacerations. Such lacerations can be best prevented Ann Sports Med Res 4(1): 1098 (2017) 4/6 Setayesh et al. (2017) Email: Central

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Cite this article Setayesh K, Mayekar E, Schwartz B, Schwartz A, Watson JN, et al. (2017) Upper Extremity Injuries in Field Athletes: Targeting Injury Prevention. Ann Sports Med Res 4(1): 1098.

Ann Sports Med Res 4(1): 1098 (2017) 6/6