o Pathologic changes can be observed in majority of overhead athletes including those that are asymptomatic

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1 Thrwing Overhead Sprts See als Medial epicndylar apphysitis (Little League Elbw) See als Shulder Impingement Syndrme in Athletes See als Rtatr Cuff Tear in Athletes See als Shulder Rehabilitatin See als H&P f Shulder in Athletes Backgrund 1. General Infrmatin Sprts at risk f shulder injury frm verhead usage Baseball Racquet Sprts (Tennis and ther racquet sprts) Vlleyball Swimming Gymnastics Track & Field (Javelin Thrw) Synnyms f Little League Shulder 1 Prximal humeral apphysitis, epiphysilysis, stechndrsis, stress fracture and rtatinal stress fracture Pathphysilgy 1. Pathlgy f disease 2 Pathlgic changes can be bserved in majrity f verhead athletes including thse that are asymptmatic N exact cellular r pathlgic mechanism is knwn, but examinatin f bimechanics, anatmic patterns, and utcmes t txs have shaped current understanding Adaptive changes fund in verhead athletes: GIRD (Glenhumueral Internal Rtatin Deficit) An increase in external rtatin and a decr in internal rtatin when cmpared t nn-thrwing shulder Average shift is 10º and maintain a cmpensatry change s their ttal arc f mtin is unchanged but ften times the deficit in internal rtatin is greater than the gain in external rtatin Facilitated by sseus and capsular adaptatins Little League Shulder 1 The exact mechanism f injury t the prximal humeral epiphysis is uncertain It has been prpsed that cnstant tractin and rtatinal trque frces applied t the prximal humeral epiphysis cause micrfractures t the physis Pathlgy is widening and ptential fracturing f the prximal humeral physis in a grwing child Rtatr Cuff Disrders Als See: Rtatr Cuff Tear in Athletes Overuse Injury, Repetitive nature f verhead sprts Impingement Thrwing Overhead Sprts Page 1 f

2 Als See: Shulder Impingement Syndrme in Athletes Cracacrmial arch irritates tendns and bursa as they mve beneath the bny arch SLAP (Superir Labrum Anterir and Psterir) Lesins The biceps tendn insertin superir t the labrum is detached frm the antr and pst. prtins f the glenhumeral labrum frm a tear in the labral rim 2. Incidence/prevalence 3. Risk factrs MRI f asymptmatic elite verhead athletes revealed: 79% glenid labrum abnrmalities 2 40% partial r full thickness rtatr cuff tears 2 Pediatrics (8-15 y) 55% f asymptmatic and 62% f symptmatic pts revealed physeal widening f prximal humerus 2 GIRD Greatest change in range f mtin f shulder ccurs in y 2 60% f prfessinal baseball players with clinically significant GIRD develped shulder injuries during that seasn 3 Specific fr Little League Shulder The average age f nset f little league shulder is 14 4 M/c seen in male baseball pitchers age 11 t 16 1 Pitchers wh thrw curveballs and sliders are at incr risk f little league shulder 4 Pr mechanics Overuse 4. Mrbidity/mrtality Little League Shulder N knwn cmplicatin Self-limiting cnditin Diagnstics 1. Histry Assess fr trauma (acute vs chrnic) Neurvascular symptms Level f activity, length f seasn, number f cntests/practices, and f special cncern: pitch cunts in pitchers and what types f pitches thrwn Medicatins/therapies used Little League Shulder Present w/ cmplaints f lateral shulder pain while ding activity Typically nt an acute event Often an insidius curse w/ pain fr mnths Cmmnly prmpted t seek care fr: Increase pain Decrease in velcity, accuracy, r ther perfrmance declines SLAP lesins Pts ften cmplain f Thrwing Overhead Sprts Page 2 f

3 Clicking Deep shulder pain Dead Arm Instability 2. Physical examinatin Full examinatin f the shulder is warranted: See als Hx & PE f Shulder in Athletes Inspectin fr Swelling Asymmetry in bny architecture Muscle build Palpatin Palpatin Up t 70% with little league shulder have pain ver the prximal and lateral prtins f the humerus 4 AC and SC jints and biceps tendn shuld be evaluated fr tenderness as well ROM Particular attentin shuld be paid t ROM because verhead athletes are at significant risk fr GIRD GIRD Defined as a decr in ROM greater than 25º but it has been suggested that 15º can affect activity f daily living 5 Strength Rtatr Cuff Supraspinatus test: Empty can Lift Off: Subscapularis External Rtatin Neurvascular Special Signs Neer - "Impingement" Passive frward flexin w/ scapular depressin Psitive test prduces pain Hawkins - "Impingement" Shulder in Frward flexin t 90º Elbw flexed t 90º Passively internal rtate shulder Psitive test prduces pain Speed - "Biceps Tendnitis" Straighten pts arm and resist elbw flexin Psitive test prduces pain Yergasn - "Biceps Tendnitis" Hld pts hand and resist supinatin Psitive test prduces pain SLAP N ne single test is recmmended t make the dx Tests are very specific s a ps test incr clinical suspicin Thrwing Overhead Sprts Page 3 f

4 3. Diagnstic Testing It is recmmended that the examiner perfrm multiple maneuvers 5 O'Brien Test - (Part A) - Shulder frward flexed 90º, Shulder adducted 10º, Elbw full extensin, Shulder maximally internally rtated s that pt's thumb pints t flr Push dwn n the arm and have pt resist O'Brien Test - (Part B) - Same psitin, but have the pt's palm face ceiling Repeat test Psitive test is pain r click n thumb dwn but nt with the palm up Anterir slide test Have pt place injured arm w/ hand n hip Examiner places axial lad n the pts arm while palpating the antr shulder with the ther hand Internal pain r palpatin f a click is a pst test Biceps lad II test Lying n back 120º f shulder abductin 90º f elbw flexin Have pt flex at the elbw against resistance Psitive test is pain r click Little League Shulder Clinical diagnsis frm Hx &PE is acceptable 1 Diagnstic imaging May be necessary t cnfirm the diagnsis X-Ray bth shulders fr cmparisn AP internal rtatin AP external rtatin Lateral Y view r axillary view Findings: Widening f prximal physis Physeal fragmentatin Physeal sclersis and demineralizatin Other studies If there is suspicin fr additinal pathlgy r neg x-rays w/ high clinical suspicin: Bne Scan MRI MRI SLAP Nn-cntrast MRI 98% sensitive 3 Rtatr Cuff Cntrast MRI is 84% sensitive n tears that are <25% 3 95% sensitive fr sever rtatr cuff disease 3 Thrwing Overhead Sprts Page 4 f

5 Differential Diagnsis 1. Biceps tendnitis See: Biceps Tendnitis (Orth) 2. Glenhumeral instability 3. Impingement syndrme See: Shulder impingement syndrme in athletes 4. Labral pathlgy/slap tear 5. Prximal humerus stress injury (little leaguer's shulder) 6. Rtatr cuff tendnitis r bursitis See: Rtatr Cuff Tendnitis Extensive Differential Diagnses 1. Acrmiclavicular sprain r injury See: Acrmiclavicular Jint Injuries 2. Fracture 3. Bne tumr 4. Brachial plexus injury 5. Distal clavicle stelysis 6. Thracic utlet syndrme See: Thracic Outlet Synd Therapeutics 1. Little League Shulder Acute Treatment Ice Analgesics Rest frm thrwing Lng-Term Care Rest frm thrwing fr 3 mnths 4 Cntinued ice and analgesics if needed 1 OTC NSAID's may decr inflammatin and prvide analgesia 4 Strengthening Exercises Physical therapy targeting ROM and flexibility can ptimize shulder functinality 1 Interval thrwing prgram at nset f thrwing 4 Evaluatin f mechanics at this time Begin w/ light tss and prgress with distance and velcity Rtatr Cuff NSAIDS, rest fr minr lesins Physical therapy Refer t rthpedic surgery fr advanced lesins SLAP Refer t Orthpedics Fllw-Up 1. Little League Shulder Pt shuld fllw up if Thrwing Overhead Sprts Page 5 f

6 2. SLAP Pain returns during thrwing prgram fllwing the 3 mnths rest perid N recmmendatin fr surgery in any case Physical therapy fr preventin f re-injury ptinal Lesins shuld be referred t rthpedic surgery Prgnsis 1. Little League Shulder Self-limiting cnditin w/ prper rest perid N knwn cmplicatins 2. Partial Rtatr Cuff Tear One Year 3 20% Heal r decrease in size 53% Incr in size 28% Prgress t full thickness tears Preventin 1. Pre-participatin Physical 1 Assess fr GIRD Inquire abut changes in mechanics Inquire abut hx f shulder pain/injuries 2. Guidelines fr Pitch Cunt frm USA Baseball Medical & Safety Advisry Cmmittee y 50 per game 75 per week 1000 per seasn 2000 per year y 75 per game 100 per week 1000 per seasn 3000 per year y/ 75 per game 125 per week 1000 per seasn 3000 per year Warm-up pitches, practice pitches, thrwing frm ther psitins, and thrwing drills are nt included in these recmmendatins Players w/ arm pain shuld be remved frm cmpetitin immediately Players shuld nly cmpete in verhead sprts f any kind fr 9 mnths f the year with a break perid frm all verhead sprts fr 3 cnsecutive mns 3. Stretching Tennis players w/ daily pst. capsule stretching had a 38% reductin in shulder prblems 3 Thrwing Overhead Sprts Page 6 f

7 Patient Educatin 1. Umpires/fficials, caches, parents, and participants need t be educated n the guidelines utlined abve fr preventin 2. Pitch cunts must be enfrced References 1. Osbahr DC, Kim HJ, Dugas JR. Little league shulder. Curr Opin Pediatr Feb;22(1): Limpisvasti O, ElAttrache NS, Jbe FW. Understanding shulder and elbw injuries in baseball. J Am Acad Orthp Surg Mar;15(3): Draks MC, Rudzki JR, Allen AA, Ptter HG, Altchek DW. Internal impingement f the shulder in the verhead athlete. J Bne Jint Surg Am Nv;91(11): Cassas KJ, Cassettari-Wayhs A. Childhd and adlescent sprts-related veruse injuries. Am Fam Physician Mar 15;73(6): McFarland EG, Tanaka MJ, Papp DF. Examinatin f the shulder in the verhead and thrwing athlete. Clin Sprts Med Oct;27(4): USA Baseball Medical and Safety Advisry Cmmittee. Yuth Baseball Pitching Injuries. Accessed nline March 16, 2010, at: &vkey=news_usab&gid= Authrs: Jeffrey Rwand, MS3, & DngSheng Jiang, MD, Penn State Hershey Medical Center, PA Editr: Kristen Grine, MD, Penn State Hershey Medical Center, PA Thrwing Overhead Sprts Page 7 f