The Shoulder and Elbow in the Young Athlete

Introduction

Shoulder and elbow injuries are, unfortunately, common in young athletes. In part this is due to the repetitive nature of many overhand sports, such as baseball, tennis and swimming which subjet the shoulder and elbow to repetitive loads over extended periods of time. Athletes who play these sports often develop chronic overuse type injuries. In contrast, those athletes who play contact sports such as football or ice hockey are more likely to suffer acute, traumatic injuries. In either case, it is important to have a good understanding of the major anatomic structures at risk, after which we can discuss how they get injured and what to do to get them better.

The shoulder is a ball (humerus) and socket (glenoid) joint. In the shoulder, the structures most commonly at risk for injury include the rotator cuff, the labrum/capsule, and the humeral physis (growth plate). The rotator cuff is a group of muscles around the shoulder that help rotate the arm. They play a significant role in accelerating and decelerating the shoulder during the throwing motion. Around the socket or glenoid is the labrum and capsule. The capsule is comprised of ligaments that function with the labrum to provide stability to the shoulder. In other words, they work to prevent the shoulder from popping out of place (or dislocating). the phuysis is where growth of the bone occurs.

In the elbow, the humerus articulates with the radius laterally and the ulna medially. The ulnar collateral ligament connects the humerus to the ulna. This ligament provides stability to the elbow during the throwing and tennis serving motion. On the humerus, the ligament attaches to the medial epicondyle. Between the medial epicondyle, which is the prominent bump on the inner aspect of the elbow and the humerus is the medial apophysis.

Common Shoulder Injuries

Shoulder injuries can be divided into those that occur more acutely versus those that are more chronic in nature. Contact sports such as football, ice hockey and wrestling are more likely to result in acute, traumatic injuries. The most common such injury is a shoulder dislocation in which the ball pops out of the socket. For this to occur, save for very rare instances, the labrum and ligaments that form the shoulder capsule tear away from the socket or glenoid. Typically this has to be reduced in the Emergency Room. This injury requires immediate evaluation by an orthopedic surgeon, as an athlete that suffers a shoulder dislocation under the age of 20 has close to a 95% chance that it will happen again if the problem isn’t corrected with surgery.

In sports such as baseball or tennis, the repetitive overhand motion and stresses result in more chronic, overuse type injuries. Little Leaguer’s shoulder is one of the most common injuries in young kids who play overhand sports. Repetitive forces lead to inflammation in the growth plate or physis. As athletes get older and the growth plates close, tendons become the weaker link during the throwing motion. Symptoms include pain when throwing, decreased velocity, pain with overhead activities. In older athletes, rotator cuff tendonitis (inflammation in the tendon) becomes more prevalent. Without appropriate treatment, tendon inflammation can progress to tearing. Rotator cuff tears are usually encountered in older patients but occasionally these do occur in teenagers.

Diagnosis of these injuries begins with evaluation by a physician who will perform a history and physical exam. Diagnosis is confirmed by x-rays and/or MRI. Conservative treatment is the mainstay for overuse-type shoulder (and elbow) injuries in young athletes. This involves rest from the offending activity and, often, a period of structured physical therapy. Therapists will focus on decreasing inflammation and increasing joint range of motion and strength. Anti-inflammatories and icing of the injured body part can help speed up the recovery.

Common Elbow Injuries

Three of the most common elbow injuries in young athletes include little leaguer’s elbow, osteochondritis dissecans, and ulnar collateral ligament injury. Little Leaguer’s Elbow, as the name implies, typically affects throwing athletes. The throwing motion puts significant stress on the elbow in three places: medially on the medial epicondyle and ulnar collateral ligament; laterally on the radial head and capitellum; and posteriorly on the olecranon. Repetitive throwing can cause inflammation in the growth plate of the medial epicondyle or even fractures of the epicondyle. Fracture due to overuse often follows a prodrome of pain in the area without treatment. For this reason, any young athlete with medial-sided elbow pain should refrain from throwing until asymptonmatic. In these cases, physical therapy and anti-inflammatory medications can help speed up recovery.

Ulnar collateral ligament tears can also cause medial sided elbow pain, though these injuries more commonly affect older athletes. While a detailed history and physical exam can diagnose such an injury, MRI is used to confirm the diagnosis. Particularly in young athletes, a trial of conservative treatment should be attempted prior to considering surgery. If conservative treatment fails, ulnar collateral ligament reconstruction (Tommy John Surgery) can provide excellent outcomes. However, a long recovery, up to a year after surgery, is required.

On the lateral side of the elbow, compression of the radial head into the capitellum during the throwing motion commonly causes osteochondrosis of the capitellum (Panner’s Disease) or osteochondritis dissecans (OCD) of the capitellum. Panner’s Disease preferentially affects young children under the age of 13 and presents with activity-related pain. This is a self-limiting condition that typically resolves over time with rest. In contrast, OCD of the capitellum is seen in teenagers. It is a localized injury to the cartilage and underlying subchondral bone in the capitellum. In addition to being painful, swelling and decreased range of motion are common symptoms. In some cases, the lesion will break off resulting in a loose body in the joint. Younger patients with more mild lesions respond well to rest; whereas the older patients with more sever lesions may require surgery.

Injury Prevention / Recovery

When is it ok to start strength training?

Strength training can increase muscle strength and edurance, which can help athletes perform better and prevent injury.

While some experts suggest that it is ok to start strength training about 7 or 8 years old, the key is waiting until your child has appropriate balance and posture control. Moreover, it is important to define our terms… strength training, which involves the use of weights, tubing or even body-weight resistance exercies to increase strength, differs from body-building or weightlifting where the goal is to get bigger.

The keys to strength training in young athletes are focusing on form and safety. Proper technique should be emphasized. Lifting weights that are too heavy can put too much stress on developing tendons, ligaments and growth plates. Young children are much better off doing one set of 10-12 repetitions at a lighter weight focusing on perfect form. Make sure to supervise young children when they are working out. And, make sure the kids are having fun! Young children should not be foreced to strength train.

About the Author

Josh Dines MD is an orthopedic surgeon at Hospital for Special Surgery who specializes in Sports Medicine. His is an Assistant Team Doctor for the NY Mets, a consultant for the LA Dodgers and was team doctor for the US Davis Cup tennis team for 5 years. Josh has published numerous papers and given talks nationally and internationally on elbow injuries in baseball players, rotator cuff tears, shoulder replacement surgery and Tommy John Surgery. Dr. Dines recently completed two textbooks written for orthopedic surgeons:Sports Medicine Injuries in Baseball and Sports Injuries of the Foot and Ankle.

Posted in: Elbow, Rotator Cuff, Shoulder, Throwing Injuries, Uncategorized