Juvenile and adolescent elbow injuries in sports

Rehabilitation following ulnar collateral ligament injury of the elbow in a female acrobatic athlete: A case report

BACKGROUND

The mechanism of injury and the conservative rehabilitation of the ulnar collateral ligament of the elbow (UCL) are well studied and reported in overhead athletes, while research on gymnastic athletes is sparse. Evidence suggests exercise as the mainstay in UCL injury rehabilitation. With this report, we aimed to provide a complete rehabilitation protocol following a partial UCL tear of an acrobatic athlete, where exercise and adjunct treatments, such as manual therapy, were used in a progressive staged rehabilitation.

CASE DESCRIPTION

A 16-year-old female acrobatic athlete was diagnosed with partial tear of the anterior band of UCL. The rehabilitation included progressive exercise loading in conjunction with manual therapy for 10 sessions in 8 weeks. Pain, UCL special tests, the Disabilities of Arm, Shoulder and Hand Score Questionnaire (DASH), and the Upper Limb Functional Index (ULFI) were assessed and administered at baseline and at 3, 6, 10 weeks, and 3 months.

RESULTS

Improvement in all outcome measures was noted at the 3-month follow-up indicating a substantial reduction in pain and disability, and an increase in stability of the elbow joint. Return to training was achieved at 8 weeks from the initial visit, while return to sport at the pre-injury level was achieved at 3 months.

CONCLUSION

Progressive exercise loading along with the addition of manual therapy is an effective intervention for the rehabilitation and return to sport following a partial UCL tear. A progressive staged rehabilitation guideline for acrobatic athletes with UCL injuries has been provided to be used and guide clinical practice.

LEVEL OF EVIDENCE

Level IV.

Number of Months of Baseball in the Previous Year and Preseason Olecranon Tenderness: Risk Factors for Shoulder and Elbow Injuries in High-School Baseball Players

OBJECTIVE

To identify risk factors for shoulder and elbow injuries in high-school baseball position players and pitchers in the preseason history and physical examination.

DESIGN

Retrospective cohort study.

SETTING

Community high-school baseball.

PARTICIPANTS

Three hundred seventy-one male baseball players' mean age 15.0 ± 1.8 years.

OUTCOME MEASURES

A preseason history and physical examination was performed on all athletes. Injury information was collected by weekly self-report and athletic trainer injury logs throughout the season. Comparisons between injured and noninjured players were performed using t tests and χ 2 analyses. Binary logistic regression models were developed to identify risk factors for injury.

RESULTS

Seventy-six injuries were recorded over the season. In univariate analysis, the injured group had greater months of baseball participation ( P = 0.007) and shoulder visual analog scale for the past year ( P = 0.003). The injured group also had more olecranon tenderness ( P < 0.0001, odds ratio [OR] 2.9) and decreased elbow arc of motion. All other factors were not significantly different ( P > 0.05). In multivariable logistic regression, months per year of baseball participation was the only factor significantly associated with injuries ( P = 0.010, OR = 1.21).

CONCLUSIONS

Baseball players who developed arm injuries during a season were more likely to play more months of baseball and report shoulder pain in the previous year. The presence of preseason olecranon tenderness was associated with nearly triple the risk of injury during the season. Every additional month of baseball participation in the previous year was associated with a 1.2× increased odds of injury. The presence of glenohumeral internal rotation deficit was not a predictor of injury.

The Influence of Chronic Medial Epicondylar Apophysitis on Medial Ulnar Collateral Ligament Insufficiency - Retrospective Cohort Study

Background

This study aimed to investigate the effect of chronic traction apophysitis of the medial epicondyle (MEC) on medial ulnar collateral ligament (MUCL) insufficiency in high school baseball players.

Methods

In this retrospective cohort study, 3034 of 6069 high school baseball players were enrolled. A self-reported questionnaire was distributed to investigate past history of elbow pain and elbow pain during the previous season. Physical examinations to assess tenderness on the MUCL and the elbow valgus stress test (EVST) were performed. Ultrasonography was performed to determine the presence of morphological abnormalities of the anteroinferior aspect of the MEC (MEC lesions).

Results

Participants with MEC lesions had a significantly higher prevalence of past history of elbow pain, elbow pain during the previous season, MUCL tenderness, and positive EVST than those without MEC lesions (P < .05). Multivariate logistic regression analysis revealed that the participants with the fragmented type had the highest risk of past history of elbow pain (odds ratio [OR] = 3.94), elbow pain during the previous season (OR = 2.27), positive EVST (OR = 3.49), and the second highest risk of MUCL tenderness (OR = 2.01) followed by the irregular type (OR = 2.31). Participants with the hypertrophic type had the lowest risk of past history of elbow pain (OR = 2.08), elbow pain during the previous season (OR = 1.42), MUCL tenderness (OR = 1.09), and positive EVST (OR = 1.47).

Conclusion

The presence of chronic non-healed traction apophysitis of the MEC in high school baseball players presented a significantly high risk of elbow pain and MUCL insufficiency.

Association Between Osteochondritis Dissecans of the Humeral Capitellum and Medial Epicondyle Lesion in Baseball Players

Background:

Osteochondritis dissecans (OCD) of the humeral capitellum occurs in adolescent overhead athletes, and medial epicondyle (ME) lesions are also common in this population.

Purpose:

To evaluate the association between elbow OCD and ME lesions in adolescent baseball players.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

This study retrospectively evaluated adolescent baseball players with unstable elbow OCD who underwent surgery between January 2000 and February 2020. Patients were excluded if they had osteoarthritis of the elbow. A total of 139 elbows were included in this study (138 male and 1 female athlete; mean ± SD age, 13.6 ± 1.5 years). The patients were first divided into 2 groups based on OCD location: a central lesion group (72 elbows) and a lateral group (67 elbows). Next, patients were divided according to OCD size into a localized group (56 elbows) and a widespread group (83 elbows). Finally, OCD lesions that were both lateral and widespread were defined as lateral-widespread (60 elbows), resulting in 5 groups. ME apophyseal fragmentation and elongation were evaluated and defined as ME lesions. We then compared the relationship between OCD and ME lesions.

Results:

Of the 139 elbows, 63 (45.3%) had ME lesions. The prevalence of ME lesion was higher in the lateral group than the central group (56.7% vs 34.7%; P = .009) and higher in the widespread group than the localized group (55.4% vs 30.4%; P = .004). Furthermore, the prevalence ratio of ME lesion was significantly higher in the lateral-widespread group than for other lesions (58.3% vs 35.4%; P = .007).

Conclusion:

In patients undergoing surgery for capitellar OCD, the presence of ME lesions was more commonly associated with lateral and widespread capitellar lesions when compared with central and localized lesions.

Olecranon Stress Fracture

Olecranon stress fractures are a rare upper extremity fracture that primarily affects throwing athletes. The incidence of olecranon stress fractures are increasing owing to the number of patients playing and the volume of engagement in competitive sports, especially in the pediatric population. However, olecranon stress fractures can present a challenge from a management and a rehabilitation perspective owing to their vague presentation, thereby affecting how these patients are diagnosed and managed. Therefore, it is imperative to further evaluate the disease process, diagnosis, and treatment of this condition to best manage our patients.

Age-Specific Prevalence and Clinical Characteristics of Humeral Medial Epicondyle Apophysitis and Osteochondritis Dissecans: Ultrasonographic Assessment of 4249 Players

Background:

Traction apophysitis of medial epicondyle (MEC) lesions and osteochondritis dissecans (OCD) of the capitellum are common elbow injuries in adolescent baseball players. However, the age-specific prevalence of these pathologies and their influence on elbow pain remain unknown.

Purpose:

To investigate the age-specific prevalence of each MEC lesion and capitellar OCD and to identify the incidence of elbow pain in each condition.

Study Design:

Descriptive epidemiology study.

Methods:

Study participants consisted of 4249 baseball players aged 6 to 17 years. A questionnaire was used to assess history of elbow pain, and morphological changes of the elbow joint were assessed using ultrasonography.

Results:

Regarding MEC lesions, fragmented (FG) and irregular (IR) lesions both reached their greatest respective prevalence at 11 to 12 years of age. After 14 years of age, IR decreased sharply, whereas FG was maintained at approximately 10%. Hypertrophic (HT) lesions increased sharply, reaching over 50% at 16 years of age, while there was a decrease in IR and FG lesions in the same age group. The prevalence of capitellar OCD remained the same (approximately 2%) throughout all ages except for in players aged 7 to 8 years (>7%). Players with MEC lesions had significantly greater prevalence of a history of elbow pain compared with those without (68.0% vs 39.1%) and were at a significantly greater risk for FG lesions (odds ratio [OR], 4.04; 95% CI, 3.16-5.22) compared with IR (OR, 3.22; 95% CI, 2.44-4.27) and HT lesions (OR, 2.03; 95% CI, 1.75-2.36). Players with capitellar OCD also had a significantly greater risk of a history of elbow pain (OR, 2.34; 95% CI, 1.40-4.11).

Conclusion:

Controlling the amount of practice and its intensity according to the condition of each player in the preadolescent and adolescent periods may be important in accelerating bony healing and decreasing preventable elbow pain in adulthood.

Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging

Pediatric musculoskeletal system is particularly prone to traumatic and sports-related injuries, both acute and chronic, i.e., overuse injuries, because of inherent conditions of weakness, such as the open physis, representing the weakest aspect within the bone, the ligamentous supports and changing biomechanics. Being aware that a quick diagnosis is essential to preserve the good functionality of the limb involved, it is mandatory for the radiologist to recognize the most common patterns of these injuries, identifying those requiring a prompt surgery, as well as be confident with the technique performed, and be supported by an important background experience and knowledge skills.

Unique Issues in the Rehabilitation of the Pediatric and Adolescent Athlete After Musculoskeletal Injury

Youth sports participation is on the rise, resulting in an increase in sports-related injuries in the pediatric and adolescent population. The presentation of injury, pathology, and disease in this younger population is often unique and may require customize and novel medical and rehabilitation interventions to optimize the outcome. The purpose of this review is to highlight unique considerations in the rehabilitation management of the pediatric and adolescent athlete. General guidelines for progression of this population through a criteria-based rehabilitation program with a focus on a systematic return to sport algorithm will be reviewed.

Ulnar collateral ligament in the overhead athlete: a current review

Ulnar collateral ligament (UCL) injuries are most commonly reported in baseball players (particularly in pitchers) but have also been observed in other overhead athletes including javelin, softball, tennis, volleyball, water polo, and gymnastics. Partial injuries have been successfully treated with appropriate nonoperative measures but complete tears and chronic injuries have shown less benefit from conservative measures. In these cases, surgical reconstruction has become the treatment modality for overhead athlete who wishes to continue to play. This article discusses the functional anatomy and biomechanics of the UCL as related to the pathophysiology of overhead throwing, as well as the important clinical methods needed to make accurate and timely diagnosis. It also gives an updated review of the current clinical outcomes and complications of surgical reconstruction.

The approach to elbow pain in the pediatric and adolescent throwing athlete

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

Elbow injuries in the young athlete--an orthopedic perspective

Elbow injuries in young athletes are increasing with these athletes specializing in a single sport at an early age and participating in their chosen sport at a high level year-round. The majority of these injuries occur from valgus loading of the elbow, either repetitively causing an overuse injury or more acutely resulting in a fracture or dislocation. Capitellar osteochondritis dissecans, medial epicondyle injuries and ulnar collateral ligament injuries are three of the most common elbow injuries occurring in young athletes.

Pediatric sports elbow injuries

Elbow injuries in the pediatric and adolescent population represent a spectrum of pathology that can be categorized as medial tension injuries, lateral compression injuries, and posterior shear injuries. Early and accurate diagnosis can improve outcomes for both nonoperative and operative treatments. Prevention strategies are important to help reduce the increasing incidence of elbow injuries in youth athletes.

Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement

PURPOSE

The purpose of our study is to show that arthroscopic debridement is an appropriate intervention for midterm to long-term subjective symptom relief of osteochondritis dissecans (OCD) of the elbow.

METHODS

A retrospective case series of 13 patients undergoing arthroscopic treatment of OCD of the elbow over a 10-year period was studied. Patients were assessed with a mean follow-up of 3.6 years (range, 12 months to 8 years). The disability/symptom section of the Disabilities of the Arm, Shoulder and Hand (DASH) was used to measure patient-reported outcome. Additional questions were used to assess other injuries to the elbow and return to sports activities.

RESULTS

Of 13 patients, 8 reported participating in repetitive valgus stress sports associated with overhead throwing. Two participated in gymnastics. Ten patients provided follow-up data greater than 1 year after surgical intervention. The mean follow-up DASH score for surgically treated patients was 8.6 (range, 0.0 to 22.41). Four patients reported a complete return to their sports activities, and six reported complete cessation of at least 1 sport. By use of intraoperative reports, the OCD lesions were graded according to the Classification System for OCD Lesions established by the American Sports Medicine Institute. No difference in mean DASH score between grades was found.

CONCLUSIONS

In our small group of patients, arthroscopic debridement of OCD of the capitellum resulted in a functional elbow with subjective symptom relief for the majority of patients, as evidenced by DASH scores. However, despite a functional outcome, many patients reported ceasing at least some sporting activities because of their elbow.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

MR imaging in congenital and acquired disorders of the pediatric upper extremity

Various congenital and acquired disorders can affect the upper extremity in pediatric and adolescent patients. MR imaging can provide unique anatomic and diagnostic information in the evaluation of many of these disorders, including inflammatory, infectious, neoplastic, and arthritic conditions. This article rounds out the issue on pediatric musculoskeletal MR imaging. It focuses on the evaluation of more common congenital disorders, and mainly sports-related injuries of the shoulder, elbow, and wrist in children. MR imaging can be more challenging in diagnosis of some of these disorders. Features of overuse injuries in skeletally immature athletes are a unifying theme throughout the article.

Imaging of sports injuries in children and adolescents

Sports injuries may be unique in childhood and adolescence due to the inherent weakness of the growing skeleton at specific sites, mainly the cartilaginous parts. Many injuries are predictable based on the known mechanism of injury encountered in certain sports. There are two distinct patterns of injury in sports; acute, and chronic or overuse. Imaging plays an important role in the diagnosis and management of these entities. Radiologists should be familiar with the advantages and limitations of the various imaging modalities when evaluating the injured young athlete. The present review focuses on the radiological findings and appropriate imaging approach in injuries that are typically or most commonly encountered in the skeletally immature athletes.

Imaging of sports injuries of the upper extremity in children

Competitive athletics in school-aged children has become the norm rather than the exception. The increased repetitive stresses placed on the upper extremity in a wide variety of sports result in a host of injuries unique to the skeletally immature athlete. This article focuses on a discussion of the more common upper extremity injuries encountered in the child athlete and the role of radiography and MRI in diagnosis and management.

Baseball and softball injuries

Baseball and softball injuries can be a result of both acute and overuse injuries. Soft tissue injuries include contusions, abrasions, and lacerations. Return to play is allowed when risk of further injury is minimized. Common shoulder injuries include those to the rotator cuff, biceps tendon, and glenoid labrum. Elbow injuries are common in baseball and softball and include medial epicondylitis, ulnar collateral ligament injury, and osteochondritis dissecans. Typically conservative treatment with relative rest, medication, and a rehabilitation program will allow return to play. Surgical intervention may be needed for certain injuries or conservative treatment failure.