Call 281-633-8600 for an appointment. This article is based on a presentation that Dr. J. Michael Bennett gave to the players, coaches and parents of the Toros Baseball organization, in Houston, TX. Doctor Bennett specializes in treating injuries of the elbows, shoulders, and knees and certain hand and wrist injuries from his clinics in Sugar Land and Houston.
This video is the third of three sections of a talk given by Dr. Bennett to the parents, coaches and players of the Toros Baseball organization of Sugar Land, TX. The talk was hosted by Bases Loaded in Houston, TX.
Dr. J. Michael Bennett is a Board Certified Orthopedic Surgeon with a Certificate of Added Qualification (CAQ) in Sports Medicine. Doctor Bennett completed a Sports Medicine fellowship at the University of Miami and served as assistant team physician for the Tampa Bay Buccaneers and the University of Miami Hurricanes. He’s also served as a team physician consultant for the Houston Livestock Show and Rodeo and as a team doctor for the Houston Independent School District. An athlete himself, Dr. Bennett was captain of the varsity lacrosse team at the University of Texas.
This is the transcript of third portion of Doctor Bennett’s talk:
Moving on to the elbow. These are the growth plates we were talking about before, showing you what it looks like, and I’m going to show you some X-rays here. Basically the elbow is three joints: you have the distal humerus, the ulna and the radius, which are these three bones. These are the growth plates here. So a lot of times if you have a really young child, you won’t see these bones. These bones will ossify, meaning they’ll mature over time, so that’s just breaking down the anatomical thing that happens.
This is showing you some X-rays of a 6-year-old girl and a 13-year-old boy. The growth plate, that zone I was showing you where the cells were all replicating, this is the cartilage zone we looked at. Can you see the difference in the age? Between the 6-year-old and the 13-year-old, you see it starts to get narrow; he’ll probably completely get rid of his growth plate in two years. So that’s when the growth plate starts to narrow a bit. He’s less likely to have growth plate injuries than she is.
The medial collateral ligament, also known as the ulnar collateral ligament, which is the Tommy John ligament that you guys all hear about, this is the main ligament right here, this is the big one right here, and it’s a main stabilizer to varus stress. When you’re cocking up for your throw, and you step forward and have got that acceleration going through, that is an extreme amount of torque and stress on that ligament. So it really stresses out that area. What happens is the bones in that area of a really young child get overstressed; oftentimes the bone will break before the ligament will break. The bone structure provides stability to varus stress. As you’re following through on the pitch that’s called a varus stress, and it’s on the outside of the elbow. And once again, the growth plate is always the weak link.
There are around 4.6 million children in youth baseball at the time of this study, which was back in 1997. It’s probably blown through the roof now. Arm pain in one season: 20 percent of the kids aged 8 to 12 had arm pain and 45 percent of 13 to 14 years old had arm pain. I guarantee you it’s probably doubled by now.
Here is an interesting study they did in 2001. This is a survey done with 298 pitchers over two seasons, 9 to 12 years of age, frequency of elbow pain is 26 percent, shoulder pain is 32 percent. So you’re looking at about 62 percent or so had some sort of shoulder or elbow problem.
Risk factors for arm pain:
If they have arm fatigue, especially when they’re young and they have open growth plates, it’s not necessarily a good thing to keep working through the pain. You know, you’re probably injuring something there, so you’ve got to be careful.
This is another study here that they did regarding risk factors for shoulder/elbow injuries in adolescent baseball pitchers:
So you see there’s a big difference.
So the phases of throwing, this is basically what it looks like when you see everybody throw. Breaking it down, there’s: (1) the wind-up; (2) the early cocking phase; (3) the late cocking phase; (4) acceleration and (5) follow-through. Most of the compressive forces that occur are usually during the late cocking and acceleration phases. It starts with late cocking, there’s that stress on the inside of the elbow; acceleration and follow through is more compressive on the lateral or outside. Tensile forces are medial. So if you think about this elbow that we’ve talked about, during that phase you’re stretching out this ligament on the inside – this is called tensile forces – and you’re compressing the elbow on the outside and that’s called compressive forces laterally. So you can get injure a ligament in the inside or you can fragment the outside.
Once you follow through here that basically stresses the back of the elbow; most likely it’s more common on the inside than the outside of the elbow.
Chronic findings. If you have a kid that’s thrown for years, throwing through the pain, you’re having chronic changes now. You can even start seeing some evidence of arthritic changes in teenagers because of that chronic instability. This bone starts bumping into this bone over here, it starts pinching the nerve, and they start getting numbness in their fingers and you can actually start getting some fragmentation of these areas and collapsing of the cartilage if you’re not careful.
Okay, mechanics. The most at-risk players are your best kids who play in multiple leagues and play all the time. It’s not really the kids with poor mechanics because the kids with poor mechanics have poor form and so there’s less force generated. It’s a little bit different in the shoulder. In the shoulder we actually see more issues in the kids with poor mechanics, who have balance and other issues, but in the elbow it’s the opposite. So we’re actually seeing kids with great form overloading that joint.
Pitching recommendations. This is actually from JR Andrews in 1996, a big guru for shoulder and elbow in regards to pitchers. This breaks it down by age, maximum pitches per game and maximum games per week. You see the average. You know, 8 to 10 years of age, maximum of 52 pitches a game, two games per week. Eleven to 12 it’s 62 per week and that gradually increases up to teenagers, where it’s about 106 pitches per game, a maximum of two games per week. Those are actually the recommended numbers.
This is years for learning pitches. The type of pitches: fastball, it’s 8 years of age; change up, 10 years of age; curveball, it’s about 14 years of age; knuckleball, 15, and slider, 16 years of age.
This is an interesting study that they did. They actually interviewed a bunch of major league baseball players and asked them when they started learning their pitches. A lot of them learned their change up at 16, their curveball at 15 years of age, and their slider at 17. A lot of them didn’t really learn much prior to the age of 16. So then they asked them what they did with their own sons. With their own sons, they started the change up around 12 years of age, curveball at 15, slider at 17. So you can see they’re actually a lot more conservative with their own kids than the recommended teaching age of learning pitches. The average beginning pitching age is 10. That’s back in 2003 so I’m sure that’s changed now.
Little league elbow, we see it a lot with throwers. That’s not a single entity; it’s basically just elbow pain as a kid. There could be a lot of things going on with that elbow. It basically means they have a really sore elbow, they’re overloading something. And “little league elbow” was termed in 1960. So you want to find out what the problem is.
Usually there’s a history of elbow pain, usually on the inside of the elbow, and most often you’re going to see a decrease in velocity. Point tenderness: that hurt when you touch that bone on the inside of the elbow. You’ve got swelling, and sometimes you’ll even have flexion contractures. They’ll have one arm out here and the other arm like this; they can’t extend the arm. It’s called a flexion contracture, and sometimes those can become harmful if you don’t get them addressed appropriately.
An X-ray usually shows some irregularity in what we’re looking at. We’re looking at the growth plate again, and it looks abnormal to us. You start seeing some fragmentation of the bone sometimes. Treatment for this is usually resting, keeping it immobilized for two to four weeks, anti-inflammatories, stretching, strengthening. For throwing aspects, usually four to six weeks. We treat that like a broken bone, just like growth plate injuries. If the kids aren’t taking time to rest and heal, they’re going to overload and it’s going to cause more problems down the road.
This is the X-rays that we’re looking at. This is a bad situation. This is what you want to avoid, okay? Growth plates are open here. This little growth plate here has pulled off. The stress of this ligament here overloaded the growth plate. This large ligament here overloaded this little growth plate here and pulled it off. And this is what it looks like here, a fractured growth plate. Depending on how much space is between here between this growth plate and bone will determine what needs to be done.
Those that are actually minimally displaced, that means there is not a big gap or space between them, we keep them immobilized. We actually put them in a splint to protect them. No resisted flexor strengthening until the symptoms are resolved. No throwing for usually about two months. Some guys will go a little sooner, like four weeks, but we go six to eight weeks. Focus on strengthening. If they’re not using their elbow they’re working on other body parts, okay? There’s no such thing as sitting down and doing nothing. You work on something else. Cross training is good and also having your technique looked at by a pitching coach.
This is just showing you an actual case of a 13-year-old male who had a fracture of that epicondyle, that bone, and this actually could be treated non-operatively, without surgery, and I’m going to show you how it heals. Four weeks in a cast you’re starting to see that growth plate get narrow, and he actually healed at three months. If it doesn’t heal, then we have to put a screw across it. This is what it looks like with the screw across it.
Select athletes, if it’s less than a centimeter of open space, sometimes we’ll fix those because sometimes if there’s space between that bone fragment and that bone here it doesn’t heal well and they end up having pain so we’ve got to fix that. If it’s greater than a centimeter in space, that has to have a screw across it.
So ulnar collateral ligaments, this was actually originally identified in javelin throwers. They were the first ones to have that issue because of the type of position their elbows are in when they’re throwing. They get microtears of this ligament, this big ligament here that I was talking about, microtears occur, small tears. And it usually occurs during the cocking and acceleration phase of the throwing. Improper throwing mechanics, poor flexibility, and inadequate conditioning – those lead to failure of the UCL. That’s going to lead to a torn ligament.
This is the same basic anatomy that I showed you on this model here. This is the most important ligament regarding what we call valgus stress, which means stress on the inside of the elbow. As far as what you see, sometimes we’ll have an acute situation where an athlete comes in and said, “Look, I pitched and I heard a pop. And now I can’t throw anymore and it hurts.” That’s when you need to think about a ligament injury and having it looked at. The chronic is the gradual onset of pain, you start losing acceleration, you start losing velocity, it usually occurs in the late cocking or acceleration phase, throwing has dropped down 50 to 75 percent, and they have tingling in their fingers. The ligament is slowly stretching out and it’s stretching that nerve pathway as well. So we look at it, basically stress the elbow, test this inside of your ligament; if there’s any question, have it looked at.
Acute injuries, if they have a pop and they’re stable, it’s probably a strain of the ligament. A lot of times we just immobilize it for a couple of weeks, do some therapy, get a hinged elbow brace where they can actually move their elbow, we’ll do some therapy and strengthening for about six weeks. A lot of those will turn out fine; that’s just a strain.
Chronic injuries are when symptoms last greater than six months. A lot of times those ligaments will be completely torn. If they’re skeletally mature and they’re an elite thrower and they’ve got scholarships pending or something like that waiting on them, then you want to think about something like a reconstruction.
Partial tears of the ulna collateral ligament. Once again, that’s the ligament here, this is an echocardiogram, this is an MRI that we’re looking at. This is that ligament that is torn; it’s supposed to be a black band here. It’s got a lot of white in it, there’s a little line right here. This is like a partial or full tear here. We usually put on the hinge brace for about six weeks; have them move that elbow with the brace to protect it. We do strengthening, and begin a Throwers 10 program, which actually helps strengthen shoulders, elbows and wrists. And then basically a return to play. If it’s a partial tear, return to play usually comes around sometimes four to six, sometimes around three to four months.
Throwers 10 program like I said is a series of shoulder, elbow and wrist strengthening exercises to maintain balance and improve flexibility followed by a gradual return to pitching and throwing. We gradually get them back to the mound; short toss, long toss, gradually increase the distance and incorporating a certain pitch and get them back to the mound and back to throwing. Tommy John recovery, you know, usually can take up to a year to recover from this. Anyone that tells you, “Hey, I can get you back to pitching in three months after a Tommy John,” it’s going to fail, okay, and that’s not going to happen. It usually takes up to a year.
Osteochondritis dissecans, this is what you’re going to see more in the younger kids. Tommy Johns and ulna collaterals, that’s more in the high school age and teenagers; cartilage injuries are going to be in the younger kids. Osteochondritis dissecans, with this cartilage layer, think of a pothole. Think of a road that’s been run over a lot of times and you lose the foundation under that road, the foundation of the road collapses and eventually a pothole forms. This is what happens with cartilage. Underneath this white cartilage layer is another layer. That layer gets weak and starts to crumble, and then that cartilage collapses and creates basically a big pothole in this elbow. It causes a vascular compromise because blood supply is not able to get into this area and it can actually lead to a lot of arthritis. It’s usually associated with throwing. Once again, if you’re stretching this ligament here, then the compression of this bone here ends up compressing and fragmenting this bone. That’s something you’ve got to be careful about.
So it usually occurs in 10 to 14 years of age, more common in males than females, and complaints are usually: pain on the outside of your elbow; loss of motion – if you’ve got a contraction you can’t bend or extend all the way; locking – if a kid has locking where their elbow catches and they can’t bend it or can’t extend it, that means there’s probably a fragment there and there’s already ticked off and is floating around the joint. It’s like walking around with a piece of gravel in your shoe. And sometimes you can have a nerve injury with that as well with the stress on the ligament.
This is what it looks like on X-ray. When we’re looking at these X-rays, you can kind of see here this is normal bone, and you see this little lucency here, a little abnormal looking, this is kind of a red flag for us. You draw a line here around this side view, this looks a little abnormal as well and that tells me we want to get an MRI. This is another picture here, this is a plate X-ray showing there’s a little bit of a dent in this area here. You get an MRI, 3-D imaging, you see that pothole I’m talking about in the middle of that cartilage.
This is what it looks like on MRI, this dark area here is where the cartilage, where that bone has collapsed, that’s bad bone, it’s necrotic bone, it’s not alive because the blood supply to the bone has been disrupted. This is what it looks like in another view where there’s a lot of inflammation around here, so you know that that area, that would definitely be an area that involves osteochondritis. So the next thing you look for is to make sure this cartilage area did not flip off and become like a little loose fragment. If it’s still intact, you can actually treat it while being still intact and have a good outcome. If it flips off it becomes a little more difficult.
So the goal is to save native cartilage. You don’t want people to just go in there and pull the cartilage out without a plan. So if you have a stable fragment, like if it’s hinged open like a lid, you can actually pop that lid back down, put a couple of pins across it and let it heal. Usually get X-rays at 10 to 12 weeks and return to activity when they’re feeling better and when X-rays show that it’s healing.
If it’s unstable, meaning the fragment has fallen off and now it’s become this loose fragment floating around the elbow joint, one option is to debride it and then fix it with pins. Another option is to do an elbow scope, put a camera in there, take the piece out, and then do what’s called micro-fracture where you stimulate the bone which creates like a scab in that area and that will help as well. What we’ve been doing which is more cutting edge lately, and I have a number of kids that we’ve done this on, is osteochondral transplantation where we actually take a cartilage plug and we plug up that defect. We’ve actually taken a cartilage plug from a non-weight bearing area in the kid’s own body using the knee and putting it in the elbow. We very rarely do it; we do it in severe cases where the kid is an elite pitcher and he has a severe enough defect that none of these other options are going to work as well. It’s better than taking the fragment out and letting them get arthritis. Okay? You want to have something there to kind of smooth the plane of that area and I think it’s a good option.
USA Baseball put a position statement out there on what they recommend. They recommend:
So once again, prevention is the key. And you can do this a number of ways:
In a nutshell that’s really it. If you guys have any questions regarding this, I’m happy to answer them. I know it was kind of long, I apologize. We’re going to have this on the website, like I said, for anyone who wants to watch it, for any parents who want to watch it. I’m happy to answer your questions. I have an office in Sugar Land and like I said we treat all ages and I’m there every day of the week and also I’m board certified, that’s another thing, a lot of the guys out there are practicing with no board certification, I’m board certified and I also have a certificate … I’m also certified in sports medicine and have a certificate of added qualification meaning I did do a fellowship in sports medicine specifically looking at these issues, looking at sports medicine. A lot of guys out there say they’re sports docs but they didn’t do the extra training, they didn’t do the extra time. That’s a little bit that’s different about our practice, so we do a lot of everything, look at the models, if you guys have any questions, I’m here to answer them.
If you have questions about any aspect of Doctor Bennett’s presentation, please call our office for an appointment at 281-633-8600.
