Three Sports Medicine Articles Co-Edited by Dr Koutures in January, 2016 Pediatric Annals

Pleased to see publication of three outstanding articles on Reducing Cumulative Arm Overuse Injuries in Young Throwers, En Pointe Readiness, and EKG Screening in Athletes for the January, 2016 edition of Pediatric Annals. This Sports Medicine themed edition is the first of a 2 part series, with the second set of articles running in February, 2016.

Some of the following content may require a subscription to Pediatric Annals for full access.

Click here to access my Guest Editorial co-written by trusted friend and colleague Valarie Wong, MD

The discipline of pediatric sports medicine deals not just with musculoskeletal care, but rather encompasses a host of medical and orthopedic concerns to optimize safe and lifelong participation in sports and activities. Pediatric health care providers' well-known general medical and anticipatory guidance skills absolutely make them a natural and trusted part of the sports medicine team.

lick here to access the article: Reducing Cumulative Arm Overuse Injuries in Young Throwers by John Schlechter, DO

Overuse injuries are preventable when underlying contributors (GIRD, scapula dyskinesis) are addressed and enforced pitch counts are consistent with recommended limits. The single most important and modifiable risk factor in preventing injury in young throwers is activity modification and adequate rest periods prior to the onset of arm pain.

Click here to access the article: Assessing Readiness for En Pointe in Young Ballet Dancers by Jeffrey Lai, MD and David Kruse, MD

As with any medical evaluation, a proper history and physical examination are the first steps in assessing readiness for dancing en pointe. Age, years of dance training, and hours per week of training are important details to collect during the history, as are the ballerina's dance aspirations. Prior injuries, especially to the lumbar spine, hips, knees, feet, and ankles, should be recorded. The physical examination focuses on anatomy and flexibility, whereas functional assessments of technique, strength, and postural control also help determine pointe readiness

Click here to access the article: Use of Electrocardiogram as Part of the Preparticipation  Exam by Kelly Chain, MD and Andrew Gregory, MD

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. During preparticipation evaluation (PPE) visits, clinicians are receiving more questions about incorporating electrocardiogram (EKG) screening to detect potentially lethal heart conditions. Many families are aware that several countries in Europe routinely use EKG screening and wonder why the United States has not instituted this recommendation. What are the pros and cons of preparticipation EKG screening in the US, and how might athlete-specific criteria assist in reviewing EKGs conducted in young athletes?

When Can Kids Throw a Curveball?

Want to ignite baseball passions perhaps even more than a Yankee-Red Sox or Dodger-Giant rivalry?

Ask the question “When should young pitchers throw a curveball?” and then stand back.

The basic concern is that the still developing bone and soft tissue structures in the shoulder and elbow may not be able to adequately handle the rotational forces needed to throw a curveball. A wicked curveball thrown early in a career could potentially lead to wicked damage and early termination of said pitching career.

Do scientific studies and articles offer any substantial help?

The USA Baseball Medical and Safety Advisory Committee has the recommendation that a curveball should not be thrown until age 14, with only fastballs and change-ups thrown before this age.

Why age 14? Most likely because most pitchers at this age have nearly full if not complete maturity of growth centers around the elbow and shoulder and thus these joints can better handle the forces of throwing a curveball.

• Now, not every child develops at the same point, and in pediatrics we are often trained not to use an absolute age to determine maturity, but rather to use certain milestone to better gauge individual development.
• A pretty solid (and simple) recommendation that maintain this spirit comes from a Major League team physician who states “Don’t throw breaking pitches until you nave shaved".
• The age or development-based recommendations are primarily based on baseball expert opinion and have no significant evidence-based supporting data.

On the other hand, a systemic review of published studies by Grantham et. al in Sports Health concluded that limited biomechanical and most epidemiologic data do not indicate an increased risk of injury when compared with the fastball in pitchers from Little League through professional ranks.

• The epidemiologic evidence to support limitations on the curveball is lacking rigor in study design
• The current biomechanical evidence (kinematic and kinetic analysis of the torso, shoulder, elbow and wrist) does not support limiting the use of curveballs at any level of baseball

         However, before one rushes off to the local diamond to teach the curveball to young throwers, I must share some other important conclusions:

• A young pitcher has a wicked curveball very likely will be perceived as a better pitcher and thus be asked to throw more often, leading to higher pitch counts which have been shown to contribute to  arm overuse injuries.

o   In my experience, anything that makes a young pitcher stand out (taller than peers, good control, stronger fastball) put more pressure on coaches and families to protect those talents and not let them be overused at too young an age.

• The “over the top” wrist snap motion routinely used to increase curveball spin may overload certain forearm supinator muscles, so training these muscle groups along with the shoulder rotator cuff muscles for the curveball.

o   Share this opinion, and would also recommend addressing any limitations in shoulder internal rotation range of motion that can also overload the elbow and wrist regions.

•  Do not underestimate the often unsung virtues of the change-up pitch. The authors found two studies found that throwing a changeup pitch reduced the incidence of elbow and/or shoulder pain and voiced support for USA Baseball’s recommendations to use the change-up to prevent arm injuries.

My bottom line: use stage of development, not simple a specific age, to help determine when a child is ready to throw the curveball. Realize that a good curveball sets a kid up for being asked to pitch more frequently, which can lead to overuse. Assessing shoulder, elbow, and arm strength and range of motion can reduce risk of injury when throwing a curveball.

Identifying and Preventing Arm Injuries in Youth Baseball Players Video

Thanks to colleagues at Intecore Physical Therapy for filming this video on Youth Arm Injury Prevention that has been distributed and shared with several local Little League groups.

Baseball Safety Tips for Coaches and Parents

Important for parents to carefully monitor pitch counts, innings pitched, number of teams, and rest months.

Immediately contact your pediatric sports medicine specialist with any concerns with pain, fatigue, change in slot angle or overall performance.

Do Colder Climates Foster More Sensible Development of Pitchers?

For years, I have heard claims that some Major League Teams favor drafting pitchers who grew up in colder climates.

The reason?

Fewer months able to be spent outside likely means fewer competitive pitches thrown, fewer innings pitched, and perhaps less risk of cumulative stress to shoulders and elbows. Practicing pediatric sports medicine in almost too sunny Southern California (yes indeed, we desperately need rain) I commonly encounter young throwers who pitch most if not almost all months of the year.

Now, thanks to the recent study Is Tommy John Surgery Performed More Frequently in Major League Baseball Pitchers From Warm Weather Areas?, there might actually be some scientific confirmation to these concerns.

Based on rates of elbow medial ulnar collateral ligament (UCL) reconstruction (commonly known as Tommy John Surgery) in Major League pitchers who played high school baseball in warmer vs. colder climates (defined by latitude on map and mean average temperatures), those who grew up in the warmth were found to have a more frequent and earlier UCL reconstructions than players who grew up in the colder environments.

I also found another interesting finding that almost 2/3 of the Major League pitchers in the study pool from 1974 to June 1, 2014 were from colder climates, while by the definitions utilized of warmer vs. colder climates, almost 2/3 of the 73 total studied areas were in colder climates while only 23 of 73 areas were defined as warmer. This correlation does make sense from a general statistical model, but when considering that the warmer areas contain purported baseball hotbeds such as California, Florida, Texas and countries in the Caribbean, Central and South America, the 2/3 proportion coming from colder climates again might support the higher risk cumulative stress and injury in warmer, more possible year-round baseball climates. Perhaps hibernating from too much pitching is ultimately a protective and positive thing and not just another reason to complain about bad weather in certain regions.

The published results on Major League pitchers should not be directly correlated with injury risk to pitchers at the pre-high school, high school and even collegiate or minor league levels. However, if similar studies were conducted at those levels with comparison of UCL reconstruction rates between  climates, I wouldn't be too surprised if the surgical frequencies were higher in warmer climates and possibly starting at younger ages as well.

The upshot of this post is not an endorsement or call for relocation to colder climates to foster a potential Major League Pitching career, but rather a cautionary tale that even in those fortunate and talented enough to pitch in the Major Leagues, the potential blessings to have year-round chances to competitively pitch must be tempered with the need for adequate rest and recovery. I think this need to not take undue advantage of virtually unlimited pitching opportunities does definitely correlate down to school-age and collegiate/minor league pitchers.

Once again, we are getting the message that more is not often better, especially in the long-term development of young athletes.

Getting Safety Info to Those in Need - Are We Best Protecting Young Arms?

The pediatric sports medicine community has diligently produced statements about common injuries and prevention/treatment strategies. We'd like to think that these recommendations are making their way to the playing fields to benefit coaches, parents and players. This is the first in a series of blog posts addressing the current realities of translating safety policy into actual practice. I welcome thoughts and suggestions on how to best perform this key role.

I've had the pleasure of coaching my young twin sons in baseball over the past two seasons, and like many coaches I constantly wonder about how well I am doing with teaching the basics and strategies of this great sport.

Put me in my pediatric sports medicine specialist role, and once again, I am constantly wondering about how well we in the injury prevention community are doing with teaching the basics of injury prevention and translating our knowledge to fellow coaches, parents, and ultimately, to our players.

Let's take the case of arm injuries in young pitchers as an example.

After the realization that too much throwing over the course of a single season and through an entire year both increase the risk of elbow and shoulder injuries in young pitchers, well-researched Pitch Count Recommendations in Young Pitchers were developed and promoted by many sports medicine groups and youth baseball organizations. These guidelines included not allowing young pitchers to throw with any aspect of shoulder or elbow pain.

So, with these great recommendations discussed in lecture halls, outlined on websites, and passed out on brochures and handouts, how are they actually playing out on the diamonds?

Based on the results of two recent studies, those efforts appear to be mostly striking out.

Allison Gilmore, MD and colleagues from Case Western University in Cleveland, OH presented some unique findings from a recent study indicating that pitch count recommendations are not routinely utilized by Little League coaches or parents.

• 100% of the 61 studied coaches were aware of the pitch count recommendations and did limit pitches thrown by players in some way, and 92% of the coaches knew that arm fatigue was a risk factor for future injury
• However, when asked about actual implementation of pitch counts to address injury concerns, 44% did not use pitch counts on a regular basis

• Less than 10% of coaches regularly monitored and set safe limits for amount of pitching over the course of a year, and 41% reported having players who were at-risk for arm injuries due to playing on more than one baseball team during a particular season. These findings probably fall at least equally on the shoulders of parents who allow the year-round or multiple team participation.

• The apparent acute impact of this lack of compliance? More than 1/3 of coaches had a player unable to play due to an overuse injury.

• Reasons cited for not following the recommendations?
  • Lack of knowledge
  • Lack of staff to track pitch counts
  • Lack of desire to want to do what was viewed as a tedious task

These results echo those of 2012 study on Knowledge and Compliance With Pitch Count Recommendations: A Survey of Youth Baseball Coaches which had 228 Little League (age 9-15) coaches complete an 18 question survey testing knowledge of pitch count recommendations that indicated:

• Only 43% of questions were correctly answered
• 73% reported following pitch count recommendations
• 53% of coaches felt that other coaches in same league followed the recommendations
• 35% stated that their pitchers reported shoulder and elbow pain during the season, with 19% reporting one of their pitchers threw with a sore or fatigued arm during the season.

Significant conclusions included concerns over difficulties of coaches following unfamiliar recommendations and potential of greater enforcement efforts by leagues.

As I mull over the findings of these studies, I struggle with the apparent gap between policy and practice and how to best bridge the gap.

Perhaps we in the sports medicine field are the victims of outstanding results of our surgical and rehabilitative efforts? The growing list of pitchers returning to star on the field after potentially career-threatening arm injuries may give an elevated or almost false hope that injury prevention is less important because amazing treatment results are readily available.

Perhaps its because as parents and coaches we still hang on to the adolescent vibe of invincibility- that nothing bad will happen to our kids.

Perhaps the teachers haven't found out the optimal ways to best reach and teach. Is it social media, videos, 1:1 tutorials, high profile pleas?

For now, the wondering will go on.

Developing a Proper Mindset in Raising Gifted and Talented Athletes

I'm going to be honest, I tend to have red lights go off in my sports medicine specialist brain when I hear phrases like "she's the best athlete in her school" or "he's the superstar of the team."

Not that I can't handle bravado or a bit of embellishment.

I am genuinely excited to share the accomplishments of many of my young patients, but also do get worried about what the "gifted label" means for the athlete and just as importantly,  for those around him or her. 

Human nature tends to draw us closer to those who are physically gifted- we admire their talents, rarely tire of seeing them perform such wonderful feats, and often want them to be on the best teams and in the star positions. It can be a the stuff that is seen in dreams:  to be asked to play "up with the older kids",  frequently get asked to play on multiple teams, and often get the ball in crunch time. 

However, this seemingly gratifying situation can quickly lead to bad dreams when we also realize that overburdening our most talented young athletes can possibly deter if not destroy their future sport and exercise ambitions. In his moving piece Are We Destroying Our Biggest Talents?, prominent sports research scientist Roald Bahr laments the consequences of such overload and quite eloquently advocates for extra caution in managing expectations and workload for our most gifted athletes. 

Dr. Bahr's work centers mostly around repetitive jumping and hitting in volleyball (a shared passion) but also cites examples of frequent throwing in baseball and cricket as additional evidence of the propensity of excessive overload in star young athletes.

The development of pitch counts in baseball is but one effort to objectively measure and hopefully limit cumulative overload, and similar possibilities including jump counts and monitoring the number of hours per week in sport activity are sensible avenues to consider. Sufficient rest, attention to proper nutrition, and adhering to the principles of periodization which include coordinated, individualized, progressive changes in training intensity, frequency and volume are all necessary components of a comprehensive sport program for all young athletes, particularly those perceived to have the most talent.

I also will bring to your attention a summary of the seminal work of Carol Dweck, a prominent psychologist who developed a comparison between the fixed mindset and the growth mindset. All credit for graphic below  to Ray Lokar from the Positive Coaching Alliance.

Many have seen gifted young athletes perceive their talents to be innate and developed from birth leading to diminished effort, avoiding of challenges, a fear of failure, and eventual early plateau. Combing early success with a growth mentality that embraces challenge and growth, even through failure, may lead to unprecedented levels of future success. 

Check out a great review of the Fixed vs. Growth Mindset by the Huffington Post (courtesy of Positive Coaching Alliance).

So if you are one of the best or a parent/coach/instructor of one of the best our there,  I offer both my sincere admiration and professional reminders about certain responsibilities:

• Take extra care of the talents
• Seek out qualified professional assistance
• Don't forget importance of rest and nutrition
• Look at the long-term big picture
• Don't let ego focus on immediate gratification and potentially destroy future goals and aspirations
• Always be growing and learning- never become complacent

My best wishes to keep young athletes playing at their best!