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LESS COMMON THROWING INJURIES

Mitchel  Storey,  DO  Team  Physician-­‐  Seattle  Mariner’s  The  Sports  Medicine  Clinic  (206-­‐368-­‐6100)  

• Adolescent  injuries  • Throwing  Injuries  in  Adults  • Common  causes  • Other  Injuries  

SUBJECTS

• Little  league  shoulder  • Little  league  elbow  • Ligament  injury  of  the  elbow  • SICK  scapula  

ADOLESCENT INJURIES

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• Main  cause  is  overuse  • Muscle  imbalance  •  Poor  preparation  •  Playing  on  more  than  one  team  

•  Playing  all  year  •  Pitcher  and  catcher  •  Throwing  the  wrong  pitches  

CAUSES

Age   2006  USA  Baseball  Guidelines   2010  Little  League  Baseball  Regulations    

Daily  Limits  

17-­‐18   N/A   105/day  

15-­‐16   N/A   95/day  

13-­‐14     75/game   95/day  

11-­‐12   75/game   85/day  

9-­‐10   50/game   75/day  

7-­‐8   N/A   50/day  

Weekly  Limits  

15-­‐18   N/A  

31-­‐45  pitches  =  1  day  rest  46-­‐60  pitches  =  2  days  rest  61-­‐75  pitches  =  3  days  rest  76+        pitches  =  4  days  rest    

13-­‐14   125/week;  1000/season;  3000/year  

21-­‐35  pitches  =  1  day  rest  36-­‐50  pitches  =  2  days  rest  51-­‐65  pitches  =  3  days  rest  66+        pitches  =  4  days  rest    

11-­‐12   100/week;  1000/season;  3000/year  

9-­‐10   75/week;  1000/season;  2000/year  

7-­‐8  

ASMI Position Statement for Youth Pitchers Example limits for number of pitches thrown in games 4/13

•  Poor  lower  extremity  and  core  strength  •  Poor  scapular  strength  •  GIRD  •  Poor  mechanics  and  technique  

EVALUATION

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SICK SCAPULA

• Ages  10  to  14  common  • Generalized  shoulder  pain  • Nonspecific  RC  findings  • Reproduced  by  crank  testing  • Tenderness  of  humeral  region  • Usually  gradual  

LITTLE LEAGUE SHOULDER

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•  Valgus  extension  overload  • Usually  medial  pain  at  epicondyle,  not  sublime  tubercle  

•  Not  easily  reproduced  by  milking  •  Tenderness  all  around  medial  epicondyle  •  Sometimes  history  of  pop  or  sudden  onset  but  usually  gradual  onset  

•  Lateral  pain  less  common  •  Loss  of  motion  and  effusion  common  

LITTLE LEAGUE ELBOW

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•  Always  consider  the  neck  for  shoulder  pain  •  Suprascapular  nerve  entrapment  •  Thoracic  outlet  syndrome  

NERVE PROBLEMS

•  Sphinoglenoid  notch  •  Aching  and  dead  arm  •  Sometimes  acute  scapular  pain  •  Progressive  weakness  of  the  cuff  •  Gradual  atrophy  of  the  scapular  fossa  • Often  permanent  •  Does  not  seem  to  affect  long  term  

SUPRASCAPULAR NERVE

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•  Unexplained  shoulder  or  arm  pain  •  Neuralgia’s  usually  ulnar  distribution  •  May  have  tinel’s  at  cubital  tunnel  •  EMG  generally  not  positive  •  Doppler  of  thoracic  outlet  may  help  •  Venous  and  arterial  issues  rare  •  Surgery  generally  not  needed  

THORACIC OUTLET

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LATISSIMUS INJURY Rare-­‐  few  reported  cases  in  the  literature  Generally  conservative  care  with  good  results  Surgery  results  still  an  unknown  due  to  small  sample  Generally  at  the  MT  junction  C/O  axillary  discomfort  

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•  Internal  rotation  of  the  humerus  • Adduction  of  the  shoulder  • Lies  adjacent  to  the  teres  major  • Both  have  similar  functions  • Often  injured  together  

FUNCTION

• Tenderness  in  the  axilla  • Avulsions  often  with  palpable  mass  • Occasional  tenderness  on  humeral  attachment  

EXAM FINDINGS

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MARINER’S EXPERIENCE

2  injuries  in  past  2  years  Both  pitcher’s  with  very  overhead  delivery  Primary  fastball  pitcher’s  Both  treated  with  PRP  1  required  surgery  due  to  reinjury-­‐  still  not  preinjury  1  with  12  week  full  recovery  

• Arthroscopic  Findings:  Relocation  Test      100%  Contact  of  RTC  and  Glenoid        93%  Undersurface  RTC  Tear        88%  Posterosuperior  Labrum  Fray        36%  Anterior  Labrum  Fraying                                                                          Paley,  Jobe,  Pink  et  al.  Arthroscopy  2000  

INTERNAL IMPINGEMENT

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•  Jobe  – Loss  of  anterior  stability  can  permit  anterior  translation  of  the  humeral  head  from  within  the  glenoid  fossa.  

– Associated  with  a  normal  subacromial  space.  

CAUSES OF INTERNAL IMPINGEMENT

•  Evaluation:  –   Routine  history  –   Younger  Patient  (18-­‐36)  –   No  specific  injury  

INTERNAL IMPINGEMENT/INSTABILITY

•  Internal  Impingement-­‐Jobe  

INSTABILITY RAMIFICATIONS

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IMPINGEMENT - POSTERIOR

•  Walch  G  et  al.  (1992)  •  Jobe  CM  (1996)  •   Expanded  Spectrum  •   1-­‐  “throwing  injury”  

•  “To  know  the  offender…..Study  the  crime”  •               •  John  Douglas  FBI  Profiler  

INTERNAL IMPINGEMENT-PHYSIOLOGIC?

•  Glenohumeral  •  Internal  •  Rotation  •  Deficit  

GIRD

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GIRD

SCIENCE BEHIND THE CONCEPT

•  .  

The effect of posterior capsule tightening in glenohumeral translation in the late cocking phase of throwing. Koffler, Moyer, Kelley, et al. Possm 2001, Sub. for pub., 2002

Tightening of the posterior capsule resulted in significant superior translation with flexion of the shoulder. Harryman et al JBJS 1990

WHAT IS SIGNIFICANT?

•  38  Post.  slaps  in  throwers  •  All  had  IRD  >  25˚  

Mean  =  32.50˚  Range  =  26-­‐58˚  

Kibler 1995-1998

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•  All  with  >  25    IR  •  63%  Shoulder  problems  •  58%  Elbow  problems  •  37%  Shoulder  +  elbow  •  26%  Shoulder  +  LBP  •  15%  No  problems  

•  3  year  results:    •  No  innings  lost  •  No  intraarticular  lesions  •  No  surgical  procedures  

Verna 1991: 39 Prof. Pitchers

Cooper ‘97 - ‘99 22 Major League Pitchers

Stretched Daily

THE PATHOLOGIC CASCADE

• Internal  Rotation  Deficit  • Post  Sup.  GH  Shift  In  Abd  &  

Ext.  Rot.  

• Biceps  Tension  &  Peel  Back  Mech.  

• Slap  Lesion  • Internal  Impingement  

• RTC  Tear  

PRODROME

•  “Posterior  stiffness  or  tightness”  

•  ±  post  pain  in  cocking  •  No  mechanical  symptoms  •  Marked  IRD  at  90˚    

• Post.  Tightness  

Post.  Pain  

Slap  Event  

Mechanical  Sx’s  Pain  

Loss  of  Velocity  

Inability  to  Pitch  

PRESENTATION

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•  Burkhart-­‐Results:  Dead  Arm  – SLAP  repairs          87%  Return  to  Pre-­‐injury  level  for  two  or  more  seasons.  

Repair  the  SLAP=Repair  instability  

PEEL BACK

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