CHAPTER 33

Overuse Injuries

• Overuse injuries occur when an anatomic structure is subjected to repetitive stress, force, or trauma without adequate rest to allow for the structure to heal.

• Young athletes may sustain overuse injuries to bones, growth centers, tendons, muscles, and fascia.

• Training errors are the most common contributing factor causing these injuries. These include rapid increases in training loads, insufficient rest time in between training sessions, and long-term, high-level repetitive training, often associated with early sport specialization.

• Other contributing factors include preexisting deconditioning, suboptimal equipment, poor training surfaces or sudden change in training surface, improper technique, imbalances in muscle strength or flexibility, and variants of normal anatomic alignment such as pes planus or pes cavus.

• Overuse injuries involving the growth plates (physes and apophyses) are unique to children and adolescents.

— Unlike bone and tendon, which are composed of a strong extracellular matrix designed to withstand compressive and tensile loads, growth plates are composed mainly of cartilage cells and have less resistance to stress.

— Injuries to the apophyses are most common. These areas of secondary ossification, where muscle-tendon units attach to bone, are the weakest point in the immature biomechanical chain.

Little League Shoulder

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• Many terms have been used to describe the injury colloquially termed “Little League shoulder,” including osteochondrosis, epiphysiolysis, rotation stress fracture, and Salter-Harris I injury to the proximal humeral epiphysis.

• The injury results from repetitive overhead activity, causing microtrauma to the proximal humeral physeal plate.

• It can occur in any sport with repetitive overhead activity, including baseball, swimming, tennis, and volleyball.

• It is most common in high-level pitchers between 11 and 16 years of age.

SIGNS AND SYMPTOMS

• Shoulder pain with insidious onset, exacerbated by throwing or other overhead athletic activity

• Loss of throwing velocity or accuracy; or loss of strength in other overhead activities

• Tenderness with palpation of the proximal lateral humerus

• May have painful or decreased shoulder range of motion

• Usually have pain with resisted shoulder elevation or external rotation

DIFFERENTIAL DIAGNOSIS

• Rotator cuff tendinitis, impingement, or subacromial bursitis

• Proximal humeral fracture

• Biceps tendinitis

• Multidirectional shoulder instability

• Labral tear, including superior labral tear from anterior to posterior (SLAP) lesion

• Bone tumor

DIAGNOSTIC CONSIDERATIONS

• Diagnosis may be determined clinically.

• Radiographs (anteroposterior [AP] views in internal and external rotation, and a scapular Y-view) often show normal findings early in the course but may show classic finding of widening of the proximal humeral epiphysis when compared with the opposite shoulder (Figure 33-1). There may also be fragmentation, sclerosis, or demineralization of the epiphysis or metaphysis.

• Magnetic resonance imaging (MRI) is not usually indicated unless there is suspicion for alternative pathology. In Little League shoulder, MRI will demonstrate periphyseal edema and physeal widening.

Figure 33-1. Anteroposterior views of both shoulders showing widening of the proximal humeral physis (arrow) on the right (A), consistent with Little League shoulder (proximal humeral epiphysitis).

Courtesy of Mary Wyers, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago.

TREATMENT

• Rest from throwing and other overhead activities is necessary to allow the physis to heal.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) do not speed the healing process; rest from repetitive activity should be the primary treatment for pain relief.

• Begin range of motion and strengthening exercises when they can be performed without pain.

• Once the athlete has full pain-free range of motion and strength, return to sport begins. Throwing athletes will begin with light tosses over a short distance and progress gradually over 4 to 6 weeks to maximum effort pitching from regulation distance.

EXPECTED OUTCOMES/PROGNOSIS

• The average time from initial diagnosis to return to competitive activity is 3 months.

• Because this is a growth plate injury, symptoms resolve with skeletal maturity.

• Athletes who do not seek medical attention early in the course of their injury may be forced to stop overhead activity because of pain and impaired performance.

• Rare potential complications include physeal arrest and arm length asymmetry.

WHEN TO REFER

• Refer to a pediatric sports medicine specialist

— Pain that persists despite 4 to 6 weeks of rest from overhead activities

— Pain at rest, instability, or significant weakness

PREVENTION

• Pitchers should be advised to follow published guidelines for pitch count maximums and number of rest days between pitching appearances (Table 33-1).

• Breaking pitches (eg, curveballs, sliders) and poor throwing mechanics may contribute to overuse injuries such as Little League shoulder, although causation has not been proven.

• Children and adolescents should not throw competitively for more than 9 months out of the year.

• Additional age-appropriate guidelines for injury prevention in youth baseball can be found at https://www.mlb.com/pitch-smart/pitching-guidelines. Throwing mechanics should be reviewed by a knowledgeable pitching coach.

• Cardiovascular fitness and core strength should be maintained year-round.

• Pitchers who throw through pain or fatigue have higher rates of injury and surgery. Children in sports involving repetitive overhead activity should be encouraged to report any discomfort in the upper extremity immediately. Such reports should be promptly evaluated.

Table 33-1. Pitch Count Limits and Required Rest Recommendations

Abbreviations: Max, maximum; N/A, not applicable.

From Major League Baseball. Guidelines for Youth and Adolescent Pitchers. Available at: https://www.mlb.com/pitch-smart/pitching-guidelines. Accessed April 3, 2020. Major League Baseball trademarks and copyrights are used with permission of Major League Baseball. Visit MLB.com.

Rotator Cuff Tendinitis/Impingement

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• Inflammation and thickening of rotator cuff tendons or subacromial bursa cause impingement under the coracoacromial arch when the arm is elevated.

• This injury commonly occurs in overhead sports such as tennis, baseball, softball, volleyball, and swimming.

• In younger athletes, rotator cuff tendinitis or impingement is usually caused by shoulder ligamentous laxity or muscle imbalance, rather than narrowing of the subacromial space seen in adults.

• Additional etiologic factors include improper throwing technique and excessive pitching, oversized tennis rackets, and use of hand paddles and drag suits by swimmers.

• Tears of the rotator cuff due to overuse are rare in pediatric and adolescent athletes.

SIGNS AND SYMPTOMS

• Pain with overhead activity that does not improve with warm-up

• May progress to pain with activities of daily living, pain at rest, or nighttime pain

• Patients may report diminished strength with overhead activities.

• Tenderness with palpation of the rotator cuff tendons in the subacromial space

• Shoulder range of motion, especially elevation, may be limited and strength may be diminished.

• Resisted strength testing of individual rotator cuff muscles may reproduce symptoms.

• Neer or Hawkins impingement tests may be positive (see Chapter 4, Physical Examination, Figure 4-19).

DIFFERENTIAL DIAGNOSIS

• Little League shoulder

• Biceps tendinitis

• Glenohumeral instability

• Acromioclavicular sprain

• Proximal humeral fracture

• Labral tear, including SLAP lesion

• Thoracic outlet syndrome

DIAGNOSTIC CONSIDERATIONS

• Diagnosis may be determined clinically. Imaging is usually not necessary.

• When the diagnosis is uncertain, radiographs may be helpful to rule out bony injury such as Little League shoulder, and they may be helpful in identifying predisposing anatomy such as type II or III acromion that narrows the subacromial space.

• MRI or in-office ultrasonography may be useful in cases refractory to conservative management or if there is concern for other injuries.

— In most cases of rotator cuff tendinitis or impingement, MRI and ultrasonography demonstrate fluid, inflammation, or thickening of the rotator cuff tendons or subacromial bursa.

• If there is concern for a labral tear, MRI with arthrography is the diagnostic study of choice.

TREATMENT

• Athletes should temporarily rest from overhead activities until they can perform them without pain.

• NSAIDs can reduce inflammation and may be used for pain with activities of daily living or at rest.

• The most important aspect of treatment is a physical therapy program to correct muscle imbalance. A comprehensive program focusing on range of motion, rotator cuff and core strengthening, and periscapular stabilization should be initiated as soon as possible.

• Sport-specific technique and equipment should be evaluated.

• Surgical intervention is rarely needed in the pediatric and adolescent athlete. In cases unresponsive to nonoperative management, shoulder arthroscopy may be helpful for identification of additional pathology or débridement of chronically inflamed and injured rotator cuff tendons.

EXPECTED OUTCOMES/PROGNOSIS

• Response to nonoperative management is usually excellent, resulting in return to full participation in previous activities.

• Return to sports depends on the severity of symptoms, ranging from 2 to 4 weeks to 4 to 6 months.

• Symptoms can progress if the underlying muscle imbalance and joint instability are not addressed. This may ultimately lead to inability to participate in the inciting activity.

• If biomechanical or equipment issues are not addressed, or if proper muscular balance is not maintained, symptoms may recur.

WHEN TO REFER

• Refer to a pediatric sports medicine specialist when there has been no improvement after 6 to 8 weeks of rest and physical therapy.

PREVENTION

• Pitchers should follow published guidelines for pitch count maximums and number of rest days between pitching appearances (see Table 33-1).

• Children and adolescents should not throw competitively for more than 9 months out of the year.

• Additional age-appropriate guidelines for injury prevention in youth baseball can be found at https://www.mlb.com/pitch-smart/pitching-guidelines.

• All overhead athletes should be encouraged to pay close attention to correct technique. Throwing mechanics should be reviewed by a knowledgeable coach.

• Cardiovascular fitness and core strength should be maintained year-round.

• Specific strengthening programs exist for pitchers that focus on scapular stabilization (eg, Thrower’s Ten Program).

• Initiating a preventive rotator cuff strengthening program may be useful in at-risk athletes.

• Continuing a rotator cuff maintenance program after recovery can help prevent recurrent episodes.

• Children in sports involving repetitive overhead activity should be encouraged to report any discomfort in the upper extremity immediately. Such reports should be promptly evaluated.

Little League Elbow

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• Apophysitis of medial epicondyle caused by repetitive valgus force at the elbow that occurs with the pitching motion is termed “Little League elbow.” The valgus force causes tension forces on the medial side of the elbow and compression forces on the lateral side.

• Little League elbow is the most common cause of medial elbow pain in young pitchers.

• While classic Little League elbow refers to an apophysitis of the medial epicondylar growth plate, the term is sometimes used more broadly to describe a constellation of overuse pitching injuries in the immature elbow, including medial epicondyle apophysitis, flexor-pronator muscle strain, and olecranon apophysitis.

• Annual incidence of elbow pain in baseball pitchers between 8 and 12 years of age has been reported to be 20% to 30%.

• Young athletes other than pitchers can be at risk for medial epicondyle apophysitis, including American tackle football quarterbacks, non-pitching baseball players, gymnasts, and tennis players.

SIGNS AND SYMPTOMS

• Medial elbow pain during or after pitching or other throwing or overhead activity

• May have stiffness, swelling, limited elbow extension, and, occasionally, mechanical symptoms such as locking and popping

• Impaired performance, including loss of pitching accuracy and reduced velocity, may be reported.

• Patients have localized tenderness over the medial epicondyle (Figure 33-2; see also Chapter 4, Physical Examination, Figure 4-22a).

• Medial elbow swelling or effusion may be present.

DIFFERENTIAL DIAGNOSIS

• Medial epicondyle avulsion fracture

• Flexor-pronator tendinitis

• Ulnar collateral ligament sprain or tear

• Ulnar nerve injury or entrapment, ulnar neuritis

• Neoplasm

• Referred pain from the neck or shoulder

DIAGNOSTIC CONSIDERATIONS

• Diagnosis may be determined clinically.

• Radiographs are often negative in the early stages of injury.

— AP, lateral, and oblique views of both elbows should be obtained for comparison.

Figure 33-2. Palpation of the medial epicondyle.

From Metzl JD. Sports Medicine in the Pediatric Office. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Figure 33-3. Anteroposterior radiograph of the elbow showing widening at the medial epicondylar apophysis (arrow). In this case, radiographic findings indicate that the problem is more advanced. Most patients with medial epicondyle apophysitis will have normal radiographic findings.

From Metzl JD. Sports Medicine in the Pediatric Office. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

— Positive findings may include medial epicondyle physeal widening, enlargement, fragmentation, or avulsion of the medial epicondyle (Figure 33-3).

• MRI or ultrasonography may be helpful to evaluate for other conditions, such as osteochondritis dissecans of the capitellum (typically visible on radiographs, but MRI helpful to evaluate severity), ulnar collateral ligament injury, and flexor-pronator tendinitis.

TREATMENT

• Initial treatment includes complete rest from throwing until pain and tenderness resolve (usually 4–6 weeks).

• Ice and NSAIDs are rarely needed because pain typically occurs only with throwing or overhead activity, but they may be helpful if swelling is present.

• As symptoms improve, a physical therapy rehabilitation program is initiated, beginning with stretching and range of motion exercises followed by progressive strengthening of upper body and core muscles.

• Once the athlete has no tenderness and full, pain-free range of motion and strength, return to throwing begins with light tosses over a short distance and progresses gradually over 4 to 6 weeks to maximum effort pitching from regulation distance.

• The athlete should work with an experienced coach to evaluate and correct any underlying errors in throwing or pitching technique.

EXPECTED OUTCOMES/PROGNOSIS

• If treated properly early in the course, most athletes can return to pitching.

• The average time from initial diagnosis to return to competitive activity is 8 to 12 weeks.

• Some may not be able to return to their previous level of play, even with timely, proper treatment.

• Athletes who continue to throw with pain and disregard recommendations for treatment are at risk for long-term, possibly permanent, sequelae.

— Complications may include growth disturbance around the elbow; joint stiffness, including flexion contracture; chronic, progressive medial elbow pain; bony deformity, including premature elbow arthrosis; and acute displacement of apophysis that may lead to nonunion requiring surgery.

WHEN TO REFER

• Refer to a pediatric sports medicine specialist if

— There is no improvement in symptoms after 6 to 8 weeks of rest

— Guidance is needed for supervision of physical therapy or clearance for return to throwing

• Refer to a pediatric orthopaedic surgeon for

— Widening or displacement of the medial epicondyle apophysis of more than 5 mm, which may require surgical fixation (see Chapter 44, Common Fractures of the Upper Extremities, Figure 44-6)

PREVENTION

• Pitchers should be advised to follow published guidelines for pitch count maximums and number of rest days between pitching appearances (see Table 33-1).

• Children and adolescents should not throw competitively for more than 9 months a year.

• All overhead athletes should be encouraged to pay close attention to correct technique. Throwing mechanics should be reviewed by a knowledgeable coach.

• Cardiovascular fitness and core strength should be maintained year-round.

• Children in sports involving repetitive overhead activity should be encouraged to report any discomfort in the upper extremity immediately. Such reports should be promptly evaluated.

Osgood-Schlatter Disease

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• Osgood-Schlatter disease (OSD) is an apophysitis, or osteochondrosis, of the tibial tuberosity caused by repetitive, forceful contraction of the quadriceps muscle.

• Onset is usually associated with a period of rapid growth combined with activity.

• The disease usually affects boys between 10 and 15 years of age and girls between 8 and 13 years of age.

•

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Miscellaneous Infections Angular Variations: Genu Varum (Bowleg) and Genu Valgum (Knock-Knee) Metatarsus Adductus and Metatarsus Varus Stages of Fracture Healing Spondylolysis and Spondylolisthesis Foot and Ankle: Miscellaneous Conditions

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