Little League Elbow Why is this such a persistent problem? John Alsobrook, MD Disclosures • I have no financial interests, relationships, or potential conflicts of interest relative to this presentation Case 1 • 12 yo presents for follow-up of his hand fracture and new onset elbow pain • Patient fractured third metacarpal in right hand in October • Jammed hand on opponent in football game • Non-displaced/Non-angulated neck fracture • Immobilization in a brace for 4 weeks, with early ROM started at 3 weeks • Fracture healed, no pain • Football season was completed, so he rested and started conditioning for basketball • Mild persistent hand swelling but full pain free ROM and function Case 1 • Basketball started early in December • He returned to play without issues or pain • Started baseball conditioning just before Christmas • One pitching lesson with coach • Three weeks later, early January, he returned for another lesson with his coach • 30-minute lesson threw about 50-60 pitches • Remembers “developing soreness” in his LEFT throwing arm, medially • Pain did not stop him from continuing • Never felt a “pop” • That evening and next day developed more pain – medial elbow • Associated swelling • No associated numbness or tingling • Had not returned to baseball/throwing, but still plays basketball without pain • Ice and NSAIDs help • Presents to my office a week after the pain started with 6/10 persistent pain but at least improved Little League Elbow, Why is this such a persistent problem? A plethora of information . • Published research in both scholarly journals and sports/social media • Coaches have conferences and meetings before seasons • Websites and training programs • Relatives, friends, teammates . Very common injury • So why does little league elbow continue to plague our youth? Coaches (Dads) “Just Don’t Care” Attitude? Compliance With Injury Prevention Measures in Youth Pitchers: Survey of Coaches in Little League of Puerto Rico Kristian J. Pamias-Velázquez, MSPT,*† Mariam M. Figueroa-Negrón, MSPT,† Janiliz Tirado-Crespo, MSPT,† and Ana L. Mulero-Portela, PhD, PT† Sport Health: A Multidisciplinary Approach. May • Jun 2016. pp 274-277. • Background: Because the problem of elbow and shoulder injuries in baseball pitchers between 9 and 14 years of age has led to more recent injuries, the USA Baseball Medical & Safety Advisory Committee and the Department of Recreation and Sports in Puerto Rico developed injury prevention guidelines for pitchers. • Purpose: to determine the compliance of pitching coaches of 9- to 14-year-old Little League teams in Puerto Rico with the Administrative Order 2006-01 and the USA Baseball guidelines. • Hypotheses: 1) coaches will have a satisfactory level of compliance with the order, and 2) coach level of education and years of experience will correlate with higher level of compliance. • Results: • Most coaches (57.14%) do not have a certification as a coach from the Department of Recreation and Sports • Only 48.57% of the coaches complied with the established guidelines for pitches thrown in a game. • The number of pitches thrown in a game correlates with development of shoulder and elbow injuries • The coaches who participated in this study did not demonstrate a satisfactory level of compliance with the USA Baseball guidelines nor with Administrative Order 2006-01. • The findings of this study reflect the need to reinforce compliancewith the guidelines (pitch count restrictions) for the prevention of injuries. Why are parents so SURPRIED when the physician uses a four-lettered word as the initial form of treatment? R – E – S – T Is this Little League Elbow? Difference Is Subtle Elbow: Sport Medicine Discussion • Overview • Run Through • Anatomy • History and Evaluation • Differential Diagnosis • Little League (Throwers) Elbow • Risk Factors • Treatment/Management • Prevention Elbow Injuries Overview • Injuries to the elbow, forearm, wrist account for more than 25% of all sport-related injuries. • Acute: falls, abrupt traction injuries • Chronic: repetitive motion and overuse • Sport Specific: • Throwers: baseball, softball, javelin • Endurance: swimming • Power grippers: weightlifting, racquet sports • Weightbearing: gymnastics, cheerleading Baseball Numbers • 15 million children and adults play organized baseball annually • 5.7 million 8th grad or younger • 17% of all children play baseball • 500,000 at the high school level • 1 in 200 senior boys who play interscholastic baseball in US will actually be drafted by the MLB • Even fewer actually play in the MLB. Baseball Elbow Injury Rates • Majority non-contact injuries to the dominant arm • 6-12 yo, elbow pain incidence 1.5 per 1000 • >/= 9 years 2.7 x greater risk than <9 yo per year • 13-18 yo incidence 1.0 per 1000 • Pros incidence 1.7 per 1000 • Wilhelm: increased serious elbow injuries in pros who specialized in baseball before high school. • Coach and to a less extent parents are the reasons for specialization before high school • Correlations of these numbers prompt the question: “What are the reliable and valid risk factors?” Risk Factors → Prevention Elbow Anatomy Elbow: Articulation Anatomy • Three interrelated joints • Radiocapitellar joint • articulation of the capitellum of humerus and radial head • Ulnohumeral joint • articulation of the humerus with coronoid process, trochlear notch, olecranon of ulna • Radioulnar joint • radial head and radial notch of the ulna: annular ligament • Landmarks • Medial epicondyle: origin of wrist and finger flexors and pronators • Lateral epicondyle: origin of the wrist and finger extensors • Olecranon process: insertion of the elbow extensors (triceps) Elbow: Ligament Anatomy • Ulnar Collateral Ligament • Origin: Medial Epicondyle → Insertion: Sublime Tubercle • Function: Medial Stability • Annular Ligament • Origin: Ulnar Notch → Insertion: Ulnar Notch • Function: Maintains Contact between proximal radius and ulna • Radial Collateral Ligament • Origin: Lateral Epicondyle →Annular Ligament • Function: Maintains radio-capitellar alignment • Lateral Ulnar Collateral Ligament • Origin: Lateral Epicondyle (distal to Radial Collateral) → Supinator tubercle of Ulna • Function: Maintains Lateral Elbow Stability Elbow – Musculature Anatomy • Flexion and Extension at the ulnohumeral joint • Flexion: biceps brachii and brachialis muscles • Extension: Triceps and anconeus • ROM arc (children and adolescents): • -15 to 0 degrees in full extension • 150 degrees full flexion • ADLs requires 30 degrees extension and 130 degrees flexion • Supination and Pronation • Radius rotating over the stationary ulna at the radiohumeral and proximal radioulnar articulations • Pronation: pronator quadratus and pronator teres (pronate the wrist) • Supination: supinator and the biceps brachii • ROM arc • 90 degrees supination and pronation • ADLs requires 50 degrees Elbow: Neuroanatomy • Median: medial to biceps tendon/brachial artery, antecubital fossa • Innervates wrist flexor/pronator, finger flexors, thenar muscles • Ulnar: posterior and medial, cubital tunnel of humerus • Innervates the intrinsic muscles of hand and flexor carpi ulnaris • Radial: anterior to the lateral epicondyle • Innervates wrist extensors and supinators • Musculocutaneous: lateral to antecubital fossa • Innervates the elbow flexors Elbow: Skeletal Development and Ossification • Classified according to appearance and fusion of secondary ossification centers • Bone age milestones • Childhood ends with appearance of all secondary ossification centers • Adolescence ends with fusion of all secondary ossificiation centers • Young adulthood ends with completion of all bone growth • Girls are 1-2 years ahead of boys both appearance and fusion • CRITOE (Appearance) • Capitellum(5,7 mos), Radial Head(4,5), Inner (Medial) Epicondyle(5,7), Trochlea(8,9), Olecranon(9,10), External (Lateral) Epicondyle (11,12) • TECORI (Fusion) • Trochlea (10,12), External (11,13), Capitellum(12,14), Olecranon (13,15), Radial Head (14,16), Inner (15,17) Little League Elbow Relevance Elbow History and Evaluation Elbow Pain History • History: Acute vs. Chronic • Acute/Discrete Event • Pain/Injury local to elbow vs. radiation from shoulder/neck • Mechanism (fall, throwing, impact, etc)? • Subacute or Chronic • Insidious onset and longer duration of symptoms • Repetitive activity or start of a new activity • Frequency, intensity, duration, progression, mechanics of activity History → Diagnosis • Age • Throwing History (Acute, Subacute, or Chronic) • Pain develops insidiously “over time” or “going on for a while” • No pain “until I felt a sharp pain or pop while throwing” • Mild pain for a while and “then it became sharp during or after my tournament this past weekend” • Young athletes often try to minimize their symptoms so they can continue playing the sport. • Aching, sharp pain, and swelling on the inside of the elbow. • Symptoms may occur only with pitching, but • May progress to the point when any throwing causes pain. • But they can’t hide the Pain → Change in Functional Performance • Pain with ADLs causing loss of ROM and/or loss of strength (usually an acute history) • Pain with throwing causing loss of velocity, loss of control (ball sailing), endurance fatigue (pain more chronic) Elbow Evaluation • Swelling +/- and Tenderness to medial epicondyle. • Full Range of Motion, but pain may restrict it. • Full ROM varies from −15° to 0° of extension, through 150° of flexion around the ulnohumeral joint. • Supination and pronation occur by rotation of the radius over the