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?

Sorting out Causes of Elbow Pain in Young Throwers

Any type of elbow discomfort in a young thrower is not a good thing, and while the easiest kids to worry about are those who will openly report elbow pain or limited motion, other more subtle signs of a potential elbow issue might be:

• "shaking" of the arm between throws
•  less interest in throwing
•  throws going higher than usual
•  not being as accurate with the location of throws.

I get particularly concerned about kids who can use a fingertip to identify the exact location of pain and those throwers who have swelling around the elbow joint. I'm also particularly careful with any case of limited ability to straighten the elbow compared to the non-throwing arm; while this might be more acceptable in an adult thrower, it definitely is not normal in a child or early teenage thrower.

Likely culprits leading to elbow pain can include excessive throwing both in one game and over the course of season(s), poor shoulder internal rotation, lack of strength in the legs and back, and trying to snap the wrist or straighten the elbow with too  much force after releasing the ball.

I'll list several common causes  by organizing them according to location within the elbow. Of course, this post is not intended to diagnose or treat any form of pain and should not be considered formal medical advice, but rather should be used as a guide to seek care from a qualified pediatric sports medicine specialist.

A few definitions:  INSIDE OF THE ELBOW is above the pinky side of the hand, and the OUTSIDE OF THE ELBOW is above the thumb side of the hand.

Keeping in mind the following visual about the unique forces that throwing places on the elbow can greatly simplify thinking about potential elbow injuries:

source: http://radsource.us/ulnar-collateral-ligament-tears-of-the-elbow/

• Structures on the INSIDE OF THE ELBOW (BLUE ARROWS) are stretched when a ball is thrown
• Structures on the OUTSIDE OF THE ELBOW (RED ARROWS) are compressed or pushed together when a ball is thrown

Inside (Medial) Elbow Pain (again, most often caused by that stretching motion)

• Irritation of growth plate (aka: medial apophysitis or "throwers's elbow")
  • he medial apophysis is a growth center separate from the rest of the humerus bone (upper part of elbow). Both ligaments (connect bones together) and tendons (connect muscle to bone) have attachment sites to the medial apophysis, so any stretch of these attachments can pull on the growth center and cause a range of injury from more simple irritation to a frank fracture and increased separation of the growth plate
• Irritation or strain of flexor/pronator  muscles
  • These muscles start on the inside of the elbow and allow snapping and/or rolling over of the wrist. Often can be injured after learning new breaking pitches or throwing too many breaking pitches with improper form
• Stretching of Ulnar Nerve
  • The ulnar nerve runs along the inside of the elbow and repetitive stretching can lead to damage with numbness and tingling sensations that travel down into the ring and pinky fingers.
• Ulnar Collateral Ligament (UCL) Tears
  • opularly known as the "Tommy John ligament", the typical story of a UCL tear is immediate pain after one throw with inability to continue throwing. Less common in throwers who haven't completed growth- the apophysis tends to be the weaker link. In more mature throwers (high school and above), the UCL is at greater risk of injury. 

Outside of the Elbow Pain (caused by compression)

• Capitellum Injury
  • ocated at the end of the humerus bone, the capitellum can be damaged by repetitive compression leading to either damage of the entire bone (usually in throwers age 5-10) or more local areas of bone and overlying soft tissue cartilage injury (usually in thrower over the age of 13).
• adial Head Injury
  • Also caused by repetitive compression, injuries to the radial head can involve damage to the growth plate that could affect long-term growth
• xtensor-supinator muscle injury
  • These muscles control straightening and rolling of the wrist. requently known as "tennis elbow", injuries to these muscles are much more common in adults and if suspected in a younger thrower, damage to the capitellum or radial head must first be excluded before making diagnosis of extensor-supinator muscle injury.

Back of the Elbow Pain

• Olecrenon impaction syndrome
  • Repetitive straightening (extension) of elbow can cause irritation of triceps muscle insertion into the olecranon, or even bone spur formation in the olecranon region. Often caused by trying to whip the arm into the straightened position with too much force.

No matter the location of pain, any possible elbow injury in a young thrower deserve urgent and specialized evaluation to determine exact cause, review contributing factors, and provide appropriate recommendations for treatment and recovery. Trying to throw through pain may lead to more damage and ultimately reduce future ability to return to throwing activities.

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.