organized sports or free play? - uk healthcare cecentral - ireland_633... · medial elbow pain...

$: Organized Sports or Free Play? - UK HealthCare CECentral - Ireland_633... · Medial elbow pain diagnoses in throwers • Medial epicondyle stress fracture • UCL tear • Ulnar neuritis/hypermobility$
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Musculoskeletal injuries in youth athletes:

Which is safer sports or free play?

Musculoskeletal injuries in youth athletes:

Which is safer sports or free play?

Mary Lloyd Ireland, M.D.University of KentuckyDept. of Orthopaedic Surgery and Sports MedicineLexington, Kentuckywww.marylloydireland.com

48th Family Medicine Review & Contemporary Pediatrics ConferenceNovember 6, 2016

48th Family Medicine Review & Contemporary Pediatrics ConferenceNovember 6, 2016

I have nothing to discloseI have nothing to disclose

Which is Safer?Which is Safer?

Organized Sportsor

Free Play?

Organized Sportsor

Free Play?

A Free Play

B Organized Sports

C Neither Children should Not play Sports

D Neither Based on Current Research

A Free Play

B Organized Sports



Can you identify the adult?Can you identify the adult?

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Educational Need/Practice Gap

Gap = The rate of overuse (microtraumatic) injuries in youth sports is underestimated.Health Care providers do not actively prevent overuse injuries in youth sports such as baseball and cheerleadingNeed Establish an injury registry and better document and prevent oversuse injuries in the skeletally immature patient

Need =

Expected Outcome

Show unique aspects of Macro and Micro Traumatic injuries in skeletally immature bones Understand overuse injury patterns of the elbow in pitchersProtect the Young Athlete from permanent negative effects of sport. Emphasize the positives of exercise and competition

Objectives

Review the musculoskeletal injuries that skeletally immature athletes sustain.Discuss diagnosis and implement treatment plans in youth athletes.Cite case examples to decide which is safer sports or free playSports Registries Need to be created

for Organized Youth Sports

Types of InjuriesTypes of Injuries

Microtraumatic vs. MacrotraumaticRepetitive Major Accident

Skeletally Immature Uniqueness of Injuries• Open Growth Plates• Immature Skeleton • Physiologically Lax Joints• Psychological

• Want to Please• Feel no Pain

Microtraumatic vs. MacrotraumaticRepetitive Major Accident

Skeletally Immature Uniqueness of Injuries• Open Growth Plates• Immature Skeleton • Physiologically Lax Joints• Psychological

• Want to Please• Feel no Pain

The ProblemThe Problem• 30 million children participate in organized sports(Source: Safe Kids USA)• Participation in high school athletics is increasing, with

more than 7.3 million high school students participating annually

(Source: National Federation of State High School Associations)

• High school athletics account for more than 2 million injuries annually, including

500,000 doctor visits 30,000 hospitalizations

(Source: Centers for Disease Control)

The ProblemThe Problem

• Young athletes are specializing in sports (and positions) at an earlier age, with more than 3.5 million children under the age of 14 treated annually for sports injuries.

(Source: Safe Kids USA)

• Immature bones, insufficient rest after injury, poor training and conditioning contribute to overuse injuries.

• Overuse injuries account for half of all sports injuries in middle school and high school.

(Source: Safe Kids USA)

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Survey 7-13 Years Old ChildrenSurvey 7-13 Years Old Children

• Two playing seasons• Community organized• Injury rates per 1000 athlete-exposures:

Soccer 2.1Baseball 1.7Football 1.5Softball 1.0

• Two playing seasons• Community organized• Injury rates per 1000 athlete-exposures:

Soccer 2.1Baseball 1.7Football 1.5Softball 1.0

Radelet MA, Lephart SM, Rubinstein EN, Myers JB, “Survey of the injury rate for children in community sports,” Pediatrics 2002;110:E28.Radelet MA, Lephart SM, Rubinstein EN, Myers JB, “Survey of the injury rate for children in community sports,” Pediatrics 2002;110:E28.

Contribution of Growth Plate to Length

LOWER EXTREMITY

Femoral growth 9 mm./ yearTibial growth 6 mm. / year

% of each bone

% of entire

extremity

Appearance and Closure of Secondary Ossification Centers -

LOWER EXTREMITY

Salter-Harris FracturesSalter-Harris Fractures

Kay RM and Matthys GA, "Pediatric Ankle Fractures: Evaluation and Treatment," JAAOS 9:4 (July-August 2001);

268-278.

Kay RM and Matthys GA, "Pediatric Ankle Fractures: Evaluation and Treatment," JAAOS 9:4 (July-August 2001);

268-278.

Neer CS II, Horwitz BS, Fractures of the epiphyseal plate. Clin Orthop 41:24, 1965.

Peterson CA, Peterson HA, Analysis of the incidence of injuries to the epiphyseal growth plate.J. Trauma 12:275, 1972.

Cited In Ogden JA, Skeletal Injury in the Child(Philadelphia: W.B. Saunders, 1990).

Neer CS II, Horwitz BS, Fractures of the epiphyseal plate. Clin Orthop 41:24, 1965.

Peterson CA, Peterson HA, Analysis of the incidence of injuries to the epiphyseal growth plate.J. Trauma 12:275, 1972.

Cited In Ogden JA, Skeletal Injury in the Child(Philadelphia: W.B. Saunders, 1990).

Epiphyseal Fracture Rates - Lower Extremity

Ogden Peterson NeerN % N % N %

Distal femur 36 15% 18 14% 28 5%

Proximal tibia 14 6% 6 5% 17 3%

Distal tibia 83 35% 59 46% 238 41%

Distal fibula 18 8% 21 16% 302 51%

Proximal femur 11 5% 7 6%

TOTAL 236 100% 128 100% 587 100%

Cited In Ogden JA, Skeletal Injury in the Child (Philadelphia: W.B. Saunders, 1990).

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14 YO WM PunterWas Hit

14 YO WM PunterWas Hit

All 29 Patients:All 29 Patients:

18 (60%) Excellent8 (27%) Fair4 (13%) Poor

18 (60%) Excellent8 (27%) Fair4 (13%) Poor

Poor Outcome if Displaced >50%Poor Outcome if Displaced >50%

“Fractures of the distal femoral epiphyseal plate.”

“Fractures of the distal femoral epiphyseal plate.”

–Thomson JD et al. J Pediatr Orthop1995; 15(4):474-478.

–Thomson JD et al. J Pediatr Orthop1995; 15(4):474-478.

15 year old walked funny since a bicycle crash 4 years ago

MRI scan at time of initial injuryMRI scan at time of initial injury

JamesAaronMatthews.mpgJamesAaronMatthews.mpg

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13 year oldSoccer AthleteKicked a BallPlanted Felt a PopLLEDisplaced, ComminutedTibial TubercleFracture

13 year oldSoccer AthleteKicked a BallPlanted Felt a PopLLEDisplaced, ComminutedTibial TubercleFracture

14 YO Male14 YO Male

• Left ankle• Tillaux fracture

with displacement

• Left ankle• Tillaux fracture

with displacement

CT ScanCT Scan

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9 YO Female Cheerleader9 YO Female Cheerleader

• Right ankle pain• Fell from a stunt and has pain and localized bump, medial ankle• Stress reaction, medial malleolar accessory ossification center

• Right ankle pain• Fell from a stunt and has pain and localized bump, medial ankle• Stress reaction, medial malleolar accessory ossification center

Journal of Pediatric Orthopedics 7:34 - 38 © 1987 Raven Press, New York Prevention and Management of Calcaneal Apophysitis Children: An Overuse Syndrome . Ill Lyle J. Micheli, M.D., and M. Lloyd Ireland, M.D. Division of Sports Medicine, Children's Hospital Medical Center, Boston, Massachusetts

Sever’s DiseaseHeel pain growth spurt

Journal of Pediatric Orthopedics 7:34 - 38 © 1987 Raven Press, New York Prevention and Management of Calcaneal Apophysitis Children: An Overuse Syndrome . Ill Lyle J. Micheli, M.D., and M. Lloyd Ireland, M.D. Division of Sports Medicine, Children's Hospital Medical Center, Boston, Massachusetts

More commonBoys SoccerPeak Age 11

Osteochondritis dissecansOsteochondritis dissecans

“Cutting away or dissection” of bone or cartilage into a joint cavity

German surgeon F. KönigLatin: seco – “I cut”

dis – “apart”, “away”1870 Paget described “Quiet Necrosis”1887 Konig coied “Osteochondritis Dissecans”latin dissecare

means “to cut into pieces

No evidence of “drying out” or dessication.

Osteochondritis dissecans.sicco – “I make dry”sicca syndrome – dryness of mucous membranesde - “out” , “thoroughly”

“Cutting away or dissection” of bone or cartilage into a joint cavity

German surgeon F. KönigLatin: seco – “I cut”

dis – “apart”, “away”1870 Paget described “Quiet Necrosis”1887 Konig coied “Osteochondritis Dissecans”latin dissecare

means “to cut into pieces

No evidence of “drying out” or dessication.

Osteochondritis dissecans.sicco – “I make dry”sicca syndrome – dryness of mucous membranesde - “out” , “thoroughly”

“Dissecans,” not “dessicans”“Dissecans,” not “dessicans”

OCD Pathoanatomy and EtiologyOCD Pathoanatomy and Etiology

• Subchondral Bone and Adjacent Cartilage• Separate from Surrounding Bone

• Parent

• Progeny

• Repetitive microtrauma• Ischemia Trauma Ischemia

• Subchondral Bone and Adjacent Cartilage• Separate from Surrounding Bone

• Parent

• Progeny

• Repetitive microtrauma• Ischemia Trauma Ischemia


• Right knee• OCD• Repaired with Linvatec SmartNail

• Right knee• OCD• Repaired with Linvatec SmartNail

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Patellofemoral DisordersPatellofemoral Disorders

Make the Diagnosis!Make the Diagnosis!

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Enemy: Valgus & RotationEnemy: Valgus & Rotation

UCL ACL PF

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Normal Alignment Miserable MalalignmentSyndrome

Normal Alignment Miserable MalalignmentSyndrome

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Normal Alignment

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Miserable Malalignment Syndrome

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Patellar DisordersPatellar Disorders

• Make the Diagnosis• Anterior Knee Pain• Make the Diagnosis• Anterior Knee Pain

Low back pain ofSports Medicine

Headache of the Knee

Low back pain ofSports Medicine

Headache of the Knee

If Neurosurgeons operated on headaches as often as Orthopaedists did foranterior knee pain, therewould be a lot moreburr holes.

If Neurosurgeons operated on headaches as often as Orthopaedists did foranterior knee pain, therewould be a lot moreburr holes.

PatellarProtectionProgram

PatellarProtectionProgram

13 YO WM C/O Knee Pain x 18 months

Pain on ROM Hip Radiating to Knee

ROM and GaitROM and Gait

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SCFE Moves Posterior FirstCheck Lateral View

9 YO Football Linebacker9 YO Football Linebacker• Crushed during a game• Transported by EMS to ER• Called me to see patient

• Crushed during a game• Transported by EMS to ER• Called me to see patient

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ER PhysicianER Physician

• Initial diagnosis: testicular torsion• Why? Patient in a lot of pain and unable to

move, kept hip in Adducted position

• Initial diagnosis: testicular torsion• Why? Patient in a lot of pain and unable to

move, kept hip in Adducted position

Accurate DiagnosisAccurate Diagnosis

• Posterior Left hip dislocation• R/O Salter fracture proximal femur• Posterior Left hip dislocation• R/O Salter fracture proximal femur

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Initial filmsInitial films

59Post reduction

Keats TE, Radiology of Musculoskeletal Stress Injury (Chicago: Year Book Medical Publishers, 1990),

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15 YO ASIS Avulsion Fracture - Sartorius

2 months

AIIS Avulsion Fracture – Rectus Femoris

Initial XraysRightInitial XraysRight LeftLeft

Ischial Tuberosity Apophyseal Avulsion -HamstringIschial Tuberosity Apophyseal Avulsion -Hamstring

13 YO Baseball player13 YO Baseball player• Stretching in gym• Felt right groin pain after running to first• Stretching in gym• Felt right groin pain after running to first

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14 YO Soccer Athlete

Lesser TrochanterAvulsion Fracture

Iliopsoas

14 YO Soccer Athlete

Lesser TrochanterAvulsion Fracture

Iliopsoas

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Snapping Hip SyndromeSnapping Hip Syndrome

• External:• Iliotibial band on greater trochanter• Most common

• Internal – coxa soltans• Iliopsoas tendon on anterior capsule• Ballet dancer

• External:• Iliotibial band on greater trochanter• Most common

• Internal – coxa soltans• Iliopsoas tendon on anterior capsule• Ballet dancer

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Femoroacetabular impingement FAIFemoroacetabular impingement FAI

• Helpful identifying morphological variants predisposing to Intra-articular pathology:

• Pincer type (acetabular retroversion)• Cross-over sign• Posterior wall sign• Arthroscopic parameters more sensitive indicator

• Cam-type (proximal femur)• SCFE; “Pistol grip” deformity (premature physeal

closure• CT reconstruction excellent for three-dimensional

architecture

• Helpful identifying morphological variants predisposing to Intra-articular pathology:

• Pincer type (acetabular retroversion)• Cross-over sign• Posterior wall sign• Arthroscopic parameters more sensitive indicator

• Cam-type (proximal femur)• SCFE; “Pistol grip” deformity (premature physeal

closure• CT reconstruction excellent for three-dimensional

architecture

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RadiographsRadiographs

• Helpful identifying morphological variants predisposing to intraarticular pathology

• Femoroacetabular impingement• Cam-type (proximal femur)

• SCFE; “Pistol grip” deformity (premature physeal closure)


• Femoroacetabular impingement• Cam-type (proximal femur)

• SCFE; “Pistol grip” deformity (premature physeal closure)

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RadiographsRadiographs


• Femoroacetabular impingement• Pincer type (acetabular retroversion)

• Cross-over sign• Posterior wall sign


• Femoroacetabular impingement• Pincer type (acetabular retroversion)

• Cross-over sign• Posterior wall sign

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Femoracetabular impingement in adolescentsFemoracetabular impingement in adolescents

• Femoroacetabular impingement (FAI)• Age group 13-18• 13 girls, 5 boys• HX: Anterior groin pain• PE: Decreased flexion and limited Internal Rotation

• 15 patients (43%) primary pincer impingement• 2 patients (6%) cam impingement• 18 (51%) both• 16 of 28 (57%) had a labral tear on MRI scan

• More common in females, dancer, pincer-type is more prevalent

• Femoroacetabular impingement (FAI)• Age group 13-18• 13 girls, 5 boys• HX: Anterior groin pain• PE: Decreased flexion and limited Internal Rotation

• 15 patients (43%) primary pincer impingement• 2 patients (6%) cam impingement• 18 (51%) both• 16 of 28 (57%) had a labral tear on MRI scan

• More common in females, dancer, pincer-type is more prevalent

Sink EL, Gralla J, Ryba A, Dayton M. Clinical presentation of femoracetabular impingement in adolescents. J Pediatr Orthop 2008;28(8):806-11.

Sink EL, Gralla J, Ryba A, Dayton M. Clinical presentation of femoracetabular impingement in adolescents. J Pediatr Orthop 2008;28(8):806-11.

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Remember rheumatologic and infectious diseases as a cause of hip painRemember rheumatologic and infectious diseases as a cause of hip pain

• Juvenile Rheumatoid Arthritis• Juvenile Psoriatic Arthritis• Septic Arthritis

• Gonorrhea• MRSA• Staphylococcus Aureus• Streptococcus

Thanks to Dr. Karl Fields for JPA cases.

• Juvenile Rheumatoid Arthritis• Juvenile Psoriatic Arthritis• Septic Arthritis

• Gonorrhea• MRSA• Staphylococcus Aureus• Streptococcus

Thanks to Dr. Karl Fields for JPA cases.

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Juvenile Psoriatic Arthritis A Presenting as Hip PainJuvenile Psoriatic Arthritis A Presenting as Hip Pain

• 14-year-old girl with JPA• Complaining of long-standing left hip

pain which has worsened over previous three months

• Strong family history of psoriasis

• 14-year-old girl with JPA• Complaining of long-standing left hip

pain which has worsened over previous three months

• Strong family history of psoriasis

Lee EY, Sundel RP, Kim S, Zurakowski D, Kleinman PK. MRI findings of juvenile psoriatic arthritis, Skeletal Radiology, 2008; 37 (11): 987-996

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Coronal STIR Coronal STIR

Figure 6a, taken from: Lee EY, Sundel RP, Kim S, Zurakowski D, Kleinman PK. MRI findings of juvenile psoriatic arthritis, Skeletal Radiology, 2008; 37 (11): 987-996

Post Gadolinium T1 Fat SatPost Gadolinium T1 Fat Sat

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Baseball catcherBaseball catcher

• C/O groin tightness• Myositis ossificans adductor• C/O groin tightness• Myositis ossificans adductor

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What’s the diagnosis?What’s the diagnosis?

Hydroculator warm pack on the back

Buetler, et al. The Natural History of Spondylolysisand Spondylolisthesis, Spine 2003

Buetler, et al. The Natural History of Spondylolysisand Spondylolisthesis, Spine 2003

• 500 First graders 1955-2000• 22 initially (4.4%)30 at adulthood (6%)• M:F 2:1• Healing ? 3, all uni• Predictors of Progression? bilat• Symptoms?

• SF-36 of this population NO different than norms

• 500 First graders 1955-2000• 22 initially (4.4%)30 at adulthood (6%)• M:F 2:1• Healing ? 3, all uni• Predictors of Progression? bilat• Symptoms?

• SF-36 of this population NO different than norms

Pars InterarticularisPars Interarticularis

Spondylolysis

Spondylolysis= Presence of a fracture

Spondylolisthesis= Translation

Treatment of Symptomatic AthleteTreatment of Symptomatic Athlete

< 50% Slip• Rest and Analgesia• Anti-Lordotic Bracing

• No hyperextension without brace

• Brace worn while training/competing

• Duration-6 wk full/6 wk part

• Hamstring Stretching• Williams Flexion Exercises

< 50% Slip• Rest and Analgesia• Anti-Lordotic Bracing

• No hyperextension without brace

• Brace worn while training/competing

• Duration-6 wk full/6 wk part

• Hamstring Stretching• Williams Flexion Exercises

> 50 % Slip• Surgical Stabilization

• Ant v Post v Both• Reduce?• Decompress?• Instrument?

> 50 % Slip• Surgical Stabilization

• Ant v Post v Both• Reduce?• Decompress?• Instrument?

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IntroductionIntroduction

• Children participating in sports each year:30 million

• 3.5 million children < age 12 treated for sports injuries

• 50% of injuries are overuse

• Children participating in sports each year:30 million

• 3.5 million children < age 12 treated for sports injuries

• 50% of injuries are overuse

Epidemic injury patterns in youth sports – elbow injuries in pitchersEpidemic injury patterns in youth sports – elbow injuries in pitchers

Little League pitchers do NOT become Big League pitchersLittle League pitchers do NOT become Big League pitchers

Physeal and ROM ChangesPhyseal and ROM Changes• 79 youth baseball players

• Age 8 – 15 years• Increased physeal width on dominant side• Increased ER dominant side

• 79 youth baseball players• Age 8 – 15 years

• Increased physeal width on dominant side• Increased ER dominant side

Mair SD, Uhl TL, Robbe RG, Brindle KA, “Physeal changes and range-of-motion differences in the dominant shoulders of skeletally immature baseball players,” J Shoulder Elbow Surg 2004 Sep-Oct;13(5):487-91.

Mair SD, Uhl TL, Robbe RG, Brindle KA, “Physeal changes and range-of-motion differences in the dominant shoulders of skeletally immature baseball players,” J Shoulder Elbow Surg 2004 Sep-Oct;13(5):487-91.

Little Leaguer’s Shoulder

Little Leaguer’s Shoulder

Youth Elbow: Baseball PitcherYouth Elbow: Baseball Pitcher

• Little Leaguer’s Elbow• Described by Adams, 1964

• Medial humeral epicondyle stress fracture• My definition of Little Leaguer’s Elbow

• 1980s: osteochondritis dissecans• Incidence reduced in US? from pitch count restrictions? • Increased incidence in Japan

• 2000: ulnar collateral ligament tears• Epidemic

• Little Leaguer’s Elbow• Described by Adams, 1964

• Medial humeral epicondyle stress fracture• My definition of Little Leaguer’s Elbow

• 1980s: osteochondritis dissecans• Incidence reduced in US? from pitch count restrictions? • Increased incidence in Japan

• 2000: ulnar collateral ligament tears• Epidemic

Need Injury Registry for childhood sports injuries Need Injury Registry for childhood sports injuries

Throwing Development Phase 1Throwing Development Phase 1

Video courtesy of Mark R. Hutchinson, M.D.Video courtesy of Mark R. Hutchinson, M.D.

Throwing Development Phase 2Throwing Development Phase 2

Video courtesy of Mark R. Hutchinson, M.D.Video courtesy of Mark R. Hutchinson, M.D.

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CY YOUNG

“. . . when my arm hurt, I just pitched more often, and it always got better.”

Denton True Young1867-1955

from Andrews JA, et. al., Injuries in Baseball, Lippincott-Raven, 1998.

Appearance and fusion of secondary ossification centers of the elbow in females and malesAppearance and fusion of secondary ossification centers of the elbow in females and males

Lateral Forces = CompressionMedial Forces = TensionLateral Forces = CompressionMedial Forces = Tension

© 2007 Kentucky Sports Medicine

Medial elbow pain diagnoses in throwersMedial elbow pain diagnoses in throwers

• Medial epicondyle stress fracture• UCL tear• Ulnar neuritis/hypermobility• Flexor-pronator strain much less common• Subluxating medial triceps• Valgus extension overload

• (elbow impingement)

• Sublime tubercle fracture proximal ulna

• Medial epicondyle stress fracture• UCL tear• Ulnar neuritis/hypermobility• Flexor-pronator strain much less common• Subluxating medial triceps• Valgus extension overload

• (elbow impingement)

• Sublime tubercle fracture proximal ulna


• Medial Right elbow pain• Football quarterback and baseball pitcher• Referred in with diagnosis of “Little

Leaguer’s elbow”

• Medial Right elbow pain• Football quarterback and baseball pitcher• Referred in with diagnosis of “Little

Leaguer’s elbow”

Initial view: Right elbow

Pain whenthrowing football orbaseball for2 months

Initial view: Right elbow

Pain whenthrowing football orbaseball for2 months

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12 YO boy12 YO boy

• Little Leaguer injured while pitching 5 months prior

• Felt pop in medial elbow• Did not seek medical attention• Sat out rest of season, got better• Played football -- no problems

• Little Leaguer injured while pitching 5 months prior

• Felt pop in medial elbow• Did not seek medical attention• Sat out rest of season, got better• Played football -- no problems

Case courtesy of Dr. Adam SmithCase courtesy of Dr. Adam Smith

Rapid growth phase, medial elbow pain when started pitching againRapid growth phase, medial elbow pain when started pitching again

Elbow initial x-raysElbow initial x-rays

Medial epicondyle displaced fractureUCL tear complete vs. partial

Left elbow initial x-raysLeft elbow initial x-rays

Right elbow initial x-raysRight elbow initial x-raysFollow up:Follow up:

4-weeks:4-weeks:

2 weeks:2 weeks:6-weeks:6-weeks:

4 months:4 months:

7 months:7 months:

19 months:19 months:

19-month follow up19-month follow up

• 8th Grade• 14 y, 6 mos• 6’3”• 217 lbs.

• 8th Grade• 14 y, 6 mos• 6’3”• 217 lbs.

14 YO Pitcher, medial elbow pain for a year, open medial humeral epiphysis torn UCL

14 YO Pitcher, medial elbow pain for a year, open medial humeral epiphysis torn UCL

Stress ViewsStress Views

UCL reconstruction performed, baseball career ended

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BB Bullet Appearance to medial epicondyle fractureBB Bullet Appearance to medial epicondyle fracture

• May heal if you don’t allow pitching too early

• May take long time to heal, but UCL is intact

• May heal if you don’t allow pitching too early

• May take long time to heal, but UCL is intact

BB GunBB Gun

• Don’t allow to fire too soon

• Don’t allow to fire too soon

UCL ReconstructionUCL Reconstruction• 27 Patients, with avg. 35 month followup• Risk factors (6)• Patient results:

• Avg. 3 risk factors• Fastball velocity 83 mph• 67% threw breaking pitchs < age 14

• 50% increase in UCL reconstructions in high school players

• J.R. Andrews UCL reconstructions• 1988-1994: 8% high school (7 / 85) • 1995-2003: 13% high school (77 / 609)

• 27 Patients, with avg. 35 month followup• Risk factors (6)• Patient results:

• Avg. 3 risk factors• Fastball velocity 83 mph• 67% threw breaking pitchs < age 14

• 50% increase in UCL reconstructions in high school players

• J.R. Andrews UCL reconstructions• 1988-1994: 8% high school (7 / 85) • 1995-2003: 13% high school (77 / 609)

Petty DH, Andrews JR, Fleisig GS, Cain EL, “Ulnar Collateral Ligament Reconstruction in High School Baseball Players: Clinical Results and Injury Risk Factors,” Am J Sports Med 32(5), 2004;1158-1164.

Petty DH, Andrews JR, Fleisig GS, Cain EL, “Ulnar Collateral Ligament Reconstruction in High School Baseball Players: Clinical Results and Injury Risk Factors,” Am J Sports Med 32(5), 2004;1158-1164.

Risk FactorsRisk Factors

• Overuse• Fatigue• High Pitch Velocity• Showcase Participation• Age Groups – Age Matched Case Control Study

• 95 pitchers surgery / 45 adolescent no surgery• Multivariant Analysis, Injury Risk Pitching:

• >8 months/year 5-fold• >80 pitches/game 4-fold• >85 mph 2.6X• Arm fatigue 36X

• Overuse• Fatigue• High Pitch Velocity• Showcase Participation• Age Groups – Age Matched Case Control Study

• 95 pitchers surgery / 45 adolescent no surgery• Multivariant Analysis, Injury Risk Pitching:

• >8 months/year 5-fold• >80 pitches/game 4-fold• >85 mph 2.6X• Arm fatigue 36X

Olsen II SJ, Fleisig GS, Dun S, Loftice J, Andrews JR, “Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers,” Am J Sports Med 34(6); 2006,905-912.

Olsen II SJ, Fleisig GS, Dun S, Loftice J, Andrews JR, “Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers,” Am J Sports Med 34(6); 2006,905-912.

Dr. Andrews:“. . . the speed gun is the worst invention in the history of Little League baseball.”

Conclusion:13 YO “Big Pitcher” SyndromeConclusion:13 YO “Big Pitcher” Syndrome

• Skeletally and mentally immature

• Fast growth phase

• Poor pitching mechanics

• Hip weakness= UE overuse injury

• Skeletally and mentally immature

• Fast growth phase

• Poor pitching mechanics

• Hip weakness= UE overuse injury

Protect our young athletesProtect our young athletes• Reduce rate of Rotator Cuff and UCL tears in young

pitchers• Reduce rate of Rotator Cuff and UCL tears in young

pitchers

14 YO WM LH-Dominant14 YO WM LH-Dominant• Avid baseball pitcher• Pain in left elbow, 2 months• Could not straighten out elbow.

• Avid baseball pitcher• Pain in left elbow, 2 months• Could not straighten out elbow.

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14 YO WM14 YO WM• RHD baseball player, wrestler, and football player• Right elbow pain posterior over the olecranon• RHD baseball player, wrestler, and football player• Right elbow pain posterior over the olecranon

6 months following initial symptoms, recurrent posterior elbow pain6 months following initial symptoms, recurrent posterior elbow pain

3 months post op3 months post op Age Group at High RiskAge Group at High Risk

• 15 YO Females ACL Tears• 14 YO Male Pitchers UCL Tears• Growth Phases

• 15 YO Females ACL Tears• 14 YO Male Pitchers UCL Tears• Growth PhasesHigh Risk Sports for Overuse

Males Baseball

Females Cheerleading, Swimming,Cross-Country

High Risk Sports for OveruseMales Baseball

Females Cheerleading, Swimming,Cross-Country

Distal radial growth arrestDistal radial growth arrest

Little Leaguer’s ShoulderLittle Leaguer’s Shoulder

STOP Elbow Injuries in Youth Baseball:Youth Sports Injury Prevention

STOP Elbow Injuries in Youth Baseball:Youth Sports Injury Prevention

Sports Trauma and

Overuse Prevention

Sports Trauma and

Overuse Prevention

www.stopsportsinjuries.org/

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Should the “STOP” program really be the “GO and PARTICIPATE in activities”program?

Should the “STOP” program really be the “GO and PARTICIPATE in activities”program?

We all should encourage our youth to be physically active, fit, and healthy . . . We all should encourage our youth to be physically active, fit, and healthy . . .

Proper Technique is KeyProper Technique is Key• Provide proper instruction on throwing

mechanics• Discourage the teaching of curve balls until

high school (puberty)• Ban the radar gun in youth sports• Mandate a 3 month “rest-period” each year

for throwing athletes

Additional Prevention StrategiesAdditional Prevention Strategies

Work with local athletic governing bodies to mandate pitch counts and limit number of matches or tournaments played.

More Prevention StrategiesMore Prevention Strategies

• Encourage participation for fun and limit emphasis on winning

• Discourage early specialization• Treat symptoms of problems/injury EARLY

Unique AspectsUnique Aspects

• Young athletes: • Feel no pain• Goal is to please parents, peers, coaches• Must be protected

• Young athletes: • Feel no pain• Goal is to please parents, peers, coaches• Must be protected

• NCCSIR 2 Direct Catastrophic Injuries/Year (0.6 per 100.000 cheerleaders

• CPSC estimated 1258 head injuries• 1814 neck injuries in cheerleaders of all

ages • 6 skull fxs• 76 cervical fractures

• NCCSIR 2 Direct Catastrophic Injuries/Year (0.6 per 100.000 cheerleaders

• CPSC estimated 1258 head injuries• 1814 neck injuries in cheerleaders of all

ages • 6 skull fxs• 76 cervical fractures

Barry P. Boden: Direct Catastrophic Injury in Sports. JAAOS 13(7):445–454, Nov 2005

Catastrophic Cheerleading InjuriesCatastrophic Cheerleading Injuries

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Cheerleading is associated with the highest # of Direct Catastrophic Injuries for all sports in which females participate

Cheerleading is associated with the highest # of Direct Catastrophic Injuries for all sports in which females participate

National Center for Catastrophic Sports Injury Research: Twentieth Annual Report, Fall 1982 Spring 2002. Chapil Hill, NC: National Center for Sports Injury Research, 2002, pp1-25

From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.


Female Student-AthletesFatalities and Catastrophic and Serious Injuries in

US 1982-1997


US 1982-1997Direct Fatalities and Catastrophic InjuriesHIGH SCHOOLDirect Fatalities and Catastrophic InjuriesHIGH SCHOOL

Cheerleading 18Gymnastics 9

Track 3Swimming 2Basketball 2


Track 3Swimming 2Basketball 2

Softball 2Field hockey 2

Volleyball 1

TOTAL 39

Softball 2Field hockey 2

Volleyball 1

TOTAL 39



Indirect FatalitiesHIGH SCHOOLIndirect FatalitiesHIGH SCHOOL

Basketball 8Swimming 5

Track 4Cheerleading 3

Soccer 1Cross Country 1

Volleyball 1

Basketball 8Swimming 5

Track 4Cheerleading 3

Soccer 1Cross Country 1

Volleyball 1

TOTAL 23TOTAL 23


US 1982-1997


US 1982-1997



Direct Fatalities and Catastrophic InjuriesCOLLEGEDirect Fatalities and Catastrophic InjuriesCOLLEGE Cheerleading 16

Gymnastics 2Field hockey 1

Downhill skiing 1Lacrosse 1

TOTAL 21


Field hockey 1Downhill skiing 1

Lacrosse 1TOTAL 21


US 1982-1997


US 1982-1997

Prevention StrategiesCoaches Should:Prevention StrategiesCoaches Should:

• Supervise all practices• Be safety certified• Have an emergency plan

• Supervise all practices• Be safety certified• Have an emergency plan



Cheerleaders Should:Cheerleaders Should:• Have a preparticipation physical exam• Be trained in gymnastics, spotting, conditioning• Participate in stunts they have mastered

• Have a preparticipation physical exam• Be trained in gymnastics, spotting, conditioning• Participate in stunts they have mastered

Prevention StrategiesCheerleaders Should:Prevention StrategiesCheerleaders Should:

• Have a preparticipation physical exam• Be trained in gymnastics, spotting,

conditioning• Participate in stunts they have mastered

• Have a preparticipation physical exam• Be trained in gymnastics, spotting,

conditioning• Participate in stunts they have mastered



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Youth Sports Injuries(from Fayette Co. Public Schools “Focus on Fitness” series

– Dr. Ireland and host Dick Simpson)

Youth Sports Injuries(from Fayette Co. Public Schools “Focus on Fitness” series

– Dr. Ireland and host Dick Simpson)

ConclusionsConclusions

• Children arenot little adults.

• They heal and act differently.

• Protect our young Athletes

• Encourage Participation in sports

• Children arenot little adults.

• They heal and act differently.

• Protect our young Athletes

• Encourage Participation in sports

Learn how to land at a good age

Encourage physical activity

Make sports fun and exciting

Sports allowed me to succeed in a male-dominated career and stay active

Learn how to land at a good age

Encourage physical activity

Make sports fun and exciting

Sports allowed me to succeed in a male-dominated career and stay active

MLI, on swing set, real band-aids

I Am Invincible!

I Am Invincible!

Who am I mostWorried about?Who am I mostWorried about?

A Free Play

B Organized Sports



My answer:Need youth injury registries ModerationLet them have fun

A Free Play

B Organized Sports



My answer:Need youth injury registries ModerationLet them have fun

Which is Safer? Organized Sports or Free Play?Which is Safer? Organized Sports or Free Play?

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Mary Lloyd Ireland, M.D.University of KentuckyDept. of Orthopaedic Surgery and Sports MedicineLexington, Kentuckywww.marylloydireland.com

organized sports or free play? - uk healthcare cecentral - ireland_633... · medial elbow pain...

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