Identify signs/symptoms/risk factors for: Understand issues of overtraining and signs of pediatric burnout

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2 Identify signs/symptoms/risk factors for: Little League Elbow Apophysitis including Osgood-Schlatter and Sever s Slipped Capital Femoral Epiphysis Understand issues of overtraining and signs of pediatric burnout

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4 Overuse injury, classically described in skeletally immature throwers resulting in: Distraction forces medially, with resultant medial epicondyle apophysitis Compression forces in the lateral compartment potentially leading to OCD lesion formation

5 Risk factors: High pitch counts Lyman et al, MSSE 2001 studied 300 youth baseball pitchers age 9-12 over 2 seasons 47% had shoulder or elbow pain at some point during study Elbow pain reported in >50% when pitching >75 pitches/game Cumulative pitch count >600 pitches increased risk of elbow pain during study Findings supported by further study by Lyman et al published in 2002 AJSM

6 Risk Factors Curveball/slider Lyman et al, AJSM 2002 followed 476 pitchers 9-14 yo for one season Throwing slider increased risk of elbow pain by 86% Throwing curve increased risk of shoulder pain by 52% Dun MS et al, AJSM 2008 biomechanical study demonstrating higher forces during fastball when compared to curve/change Suggests that curveball may not be a strong risk factor for LLE

7 Risk Factors Improper / poor pitching technique JT Davis et al, AJSM 2009 video analysis of pitchers age 9-18 revealed correct performance of pitching biomechanical parameters (at least 3 of 5 studied) reduced humeral internal rotation torque and valgus load

8 Typical clinical picture: Medial elbow pain Loss of velocity on throwing Swelling Mechanical symptoms if OCD present Physical Findings: Tenderness over medial epicondyle Pain with valgus load / moving valgus stress test +/- laxity with moving valgus stress test

9 Treatment options: REST! Typically 4-6 weeks out of throwing entirely, then 6-8 week throwing progression, with average pt taking 12 weeks to return to pitching Acetaminophen, NSAIDs, PT Occasionally bracing, splinting, or casting, particularly if avulsion fx present Evaluation of and correction of pitching/throwing mechanics

10 Surgical options: Fixation of widely displaced (>5mm) medial epicondyle avulsions Reconstruction of UCL if torn ( Tommy John surgery) Debridement or fixation of OCD lesions, OATS (osteochondral autologous transfer) procedures, excision of loose bodies

11 Paucity of data exists: Pubmed search for little league elbow = 27 results, search for medial epicondyle apophysitis results in 4 papers, all reviews Torg JS, Am Fam Physician 1972 Non-operative treatment for classic Little League Elbow results in resolution of symptoms Kocher M et al, Sports Med Results of treatment of little league elbow are generally favorable when instituted early.

12 Since LLE is an apophysitis, once the physis closes the primary problem of LLE should abate However, it s the sequelae of LLE that are likely to be problematic long term

13 Capitellar OCD lesions and loose body formation Related injury Ulnar collateral ligament injury Does appropriate timely treatment of LLE reduce the likelihood of the above? Probably so, but no studies published in the literature support this assumption

14 Grading of lesions via imaging modalities important for evaluating/understanding outcomes Type 1 (very early and early lesions): Capitellar flattening and/or lucency on radiographs, stable lesions Type 2 Sclerotic margin, well defined fragment Type 3 (chronic lesions with loose bodies) Sclerotic margins, fragmentation, loose body formation

15 Grade 1-2: Acute Grade 2: Chronic

16 Mihara et al, AJSM Case series of 39 pts with OCD in the capitellum, avg age 12.8 yrs, all baseball players, mean f/u 14 mos Early lesions present in 30/39, advanced lesions in 9/39. All treated with rest 25/30 early lesions (Type 1 and 2) healed or almost healed on final radiography, 4 worsened, 1 unchanged Only 1/9 advanced lesions had healed 22/39 pts were able to fully return to sport w/o sxs Another 5/39 pts returned to sport with residual sxs

17 Matsuura T et al. AJSM 2008 Cohort of 176 male baseball players, avg age 12.8 yrs Type 1 and Type 2 OCD lesions present Suggested rest x 6 months as primary treatment 101/176 complied with the treatment protocol and completed f/u, mean f/u 24 months 91% of Type 1 lesions that rested healed by xray Healed Type 1 lesions, 87% returned to baseball Healed Type 2 lesions, 100% returned

18 Matsuura T et al. AJSM % radiographic healing rate among the 101 pts who complied with rest as primary treatment Of the 75 patients who did not rest / restrict sports activities 22.7% demonstrated radiographic healing

19 McManama GB, Micheli LJ, et al. AJSM 1985 Case series of 14 pts, all male, avg age 16 yrs Capitellar OCDs related to overuse in 7 pts, trauma in 5 pts, undetermined in 2 pts Open arthrotomy with loose body excision, subchondral drilling. No ORIFs or grafting Avg f/u 2 years 8 excellent results (full return to sport), 5 good results (returned to sport with decreased performance) and 1 fair result (improved function, changed sport)

20 Multiple studies, all small case series (10-25 pts) Medium term outcomes (3-5 years post-op) Excellent (near 100%) pain relief Variable return to sport (25-100%) No long term data Ruch DS, 1998; Takeda H, 2002; Byrd JWT, 2002; Iwasaki N, 2006; Jones KJ, 2010

21 Repetitive stress to the UCL as result of repeated distraction forces during throwing can result in attritional tearing of the UCL Tearing typically occurs as result of one hard pitch following prolonged period of overuse Typically occurs in older adolescents / adults rather than skeletally immature throwers Weak link in skeletally immature is the physis and results in either LLE or medial epicondyle avulsion

22 Rising incidence In HS baseball players Fleisig GS et al. Curr. Sports Med. Rep., Vol. 8, No. 5, pp. 250Y254, 2009

23 Rettig AC et al, AJSM throwing athletes, mean age 18, with UCL injury Mostly collegiate baseball pitchers Mix of insidious onset (overuse) and traumatic injuries 42% returned to sports at the pre-injury level at an average of 24.5 weeks after diagnosis (range weeks) 6/15 (40%) patients with overuse injury returned to sport Conclusion: non-operative treatment of UCL injury results in relatively low rate of returning to sport

24 Savoie FH et al, AJSM Primary repair of UCL injuries of the elbow in young athletes Case series, 60 patients, avg age 17 yrs, f/u 59 mos Primary ligamentous repair at an avg of 18 months after onset of elbow symptoms 56/60 patients returned to sport 93% with good/excellent outcomes on the Andrews/Carson Functional Outcome score

25 Petty et al, AJSM UCL Reconstruction in High School Baseball Players Retrospective cohort study on 27 HS baseball players, avg age 17.4 yrs, f/u at 35 months post-op UCL tears treated by graft reconstruction 10/27 pts had progressive medial elbow pain prior to moment of injury, 3 pts had had pain which had resolved prior to injury 21/27 pts received avg of 6 weeks of conservative rx before operation 20/27 pts returned to baseball, avg 11 months postop

26 Most appropriate treatment for Little League Elbow, attritional UCL tears, medial epicondyle avulsions associated with overuse, and capitellar OCDs is Prevention USA Baseball and Little League have recommended pitch limitations which should be strictly followed Outcomes data from institution of these limitations is not presently available

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28 Athlete age x 10 per 7 day period 8 yo => 8 x10 = 80/7d Recommendations available on line!

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30 Apophysitis: overuse syndrome with degeneration at site of tendinous insertion on unfused apophysis Common Sites: Calcaneus: Sever s Disease Tibial Tubercle: Osgood-Schlatter Inferior Pole of Patella: Sinding-Larsen-Johansson Disease Medial Epicondyle of Elbow: Little League Elbow

31 Common History: Insidious onset of pain Swelling, warmth, and tenderness over affected apophysis Typically occurs among yo patients Worse with activity Better with rest/ice

32 Common Physical Findings: Inspection: swelling, erythema Palpation: +TTP over apophysis, warm ROM: normal MMT: increased pain with resistance Special Tests: normal

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36 Treatment: Rest Ice NSAIDs Local Measures: Cho-pat strap in Osgood Schlatter Heel cup or pad in Sever s PT for stretching/strengthening once acute symptoms have settled down

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38 SCFE: posterior/inferior slippage of the proximal femoral epiphysis on the femoral neck A Salter Harris -1physeal fracture must be present

39 Epidemiology: Occurs in adolescents Males 2.5x more likely than females Left hip > right hip Occurs more commonly in obese individuals Bilateral in 25-40% of cases More common in African Americans and Polynesians

40 Etiology: Most cases idiopathic Some cases due to endocrine abnormality: GH administration Hypothyroidism Some cases due to renal osteodystrophy

41 History Limp, inability to fully weight bear Hip pain, referred to thigh, groin, knee Insidious onset in 50%, trauma in 50% Physical Gen: obese? Gait: Trendelenberg? ROM: restricted IR/ER Special: Passive flexion of hip leads to ER of leg

42 DDx: AVN Femoral Head (Perthes) Femoral neck fx Femoral neck stress fx Toxic synovitis Chronic DDH Femoral hernia Inguinal hernia Groin strain Osteitis Pubis

43 X-rays: AP and Lateral ( Frog Leg ) of Pelvis and Both Hips Weight bearing Klein Line Grading/Degree of Slip: Grade 1: <33% slippage Grade 2: 33-50% slippage Grade 3: >50% slippage

44 Klein Line: line along superior border of femoral neck should intersect fem. head

45 Treatment: Casting/Immobilization ineffective Surgical fixation percutaneous pin in situ Controversy: pin unaffected side too? Generally, no, just follow closely Consider prophylactic pin in kid with underlying endocrinopathy Complications: AVN, chondrolysis

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47 Occurs during hard training Characterized by: Fatigue Underperformance Mood symptoms depression Persists for at least 2 weeks despite adequate rest

48 Other characteristics Sleep disturbance Appetite loss Weight loss Frequent infections: URI, minor infections Hormonal changes Stress hormones (cortisol, adrenaline) are higher in underperforming/overtrained athletes

49 2007 AAP Clinical Report Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes Report indicates that a combination of factors including overuse injury may lead to cessation of sporting activity Sport drop-outs might represent the worst possible long term outcome after youth sports injury

50 Treatment Relative rest Advance activity slowly over a 6-12 week period Cross training Prevention in Kids Keep workouts interesting and ageappropriate 1-2 days off per week from organized sport Longer breaks every 3 months

51 Little League Elbow prevention is key Technique and limit pitch count Apophysitis: Osgood Schlatter, SLJ, Sever s rest, modify activity, resolve indefinitely with closure of physis Slipped Capital Femoral Epiphysis check hip exam in kids with knee pain! Consider overtraining and pediatric burnout when not getting better

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