Scribd Logo
Upload

Welcome to Scribd!

  • Risk Factors For Elbow and Shoulder Injuries in Adolescent Baseball Players - A Systematic Review - Enhanced Reader

    Uploaded by

    Jayne Pereira
    18 views9 pages

    Original Title

    Risk Factors for Elbow and Shoulder Injuries in Adolescent Baseball Players_ A Systematic Review _ Enhanced Reader

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    18 views9 pages

    Risk Factors For Elbow and Shoulder Injuries in Adolescent Baseball Players - A Systematic Review - Enhanced Reader

    Uploaded by

    Jayne Pereira

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 9
    (creck cpa Clinical Sports Medicine Update Risk Factors for Elbow and Shoulder Injuries in Adolescent Baseball Players A Systematic Review Ryan Norton,*t DO, Christopher Honstad,' MD, Rajat Joshi,* BS, Matthew Silvis," MD, Vernon Chinchilli,S PhD, and Aman Dhawan,' MD Investigation performed at Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA Background: The incidence of shoulder and elbow injuries amang adolescent baseball players is on the rise. These injuries may lead to surgery or retirement at a young age. Purpose: To identify independent risk factors for elbow and shoulder injuries in adolescent baseball players. A secondary aim was to determine whether the literature supports the Major League Baseball and USA Baseball Pitch Smart guidelines. Study Design: Systematic review. Methods: A systematic review was performed in accordance with PRISMA (Proferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines utilzing MEDLINE, SPORTDiscus, and Web of Science, Because of study heterogeneity, a quan- titative synthesis was not performed. A qualitative review was performed on 19 independent risk factors for elbow and shoulder injuries in adolescent baseball players. Level of evidence was assigned per the Oxford Centre for Evidence-Based Medicine Working Group, and risk of bias was graded per the Newcastle-Ottawa Scale, Results: Twenty-two articles met criteria for inclusion. Of the 19 independent variables that were analyzed, age, height, playing for multiple teams, pitch velocity, and arm fatigue were found to be independent risk factors for throwing arm injuries. Pitches per game appears to be a risk factor for shoulder injuries. Seven independent variables (innings pitched per game, showcase partic ipation, games per year, training days per week, pitch type, shoulder external rotation, and shoulder total range of motion) do not appear to be sighificant risk factors. The data were inconclusive for the remaining 6 variables (weight, months of pitching per year, innings or pitches per year, catching, shoulder horizontal adduction, and glenohumeral internal rotation deficit) Conclusion: The results from this study demonstrate that age, height, playing for multiple teams, pitch velocity, and arm fatigue are clear risk factors for throwing arm injuries in adolescent baseball players. Pitches per game appears to be a risk factor for shoulder injuries. Other variables are either inconclusive or do not appear to be specific risk factors for injuries. Keywords: baseball; adolescent; elbow and shoulder injuries; risk factors; overuse As the second most popular youth sport in the United States, it is estimated that over 5 million children participate in “Aeldrese correspondence to Ryan Notton, DO, Department of Family organized aseball each year and nearly 500,000 at. the Medicine, Oregon Health & Science University, 3181 Southwest Sam_ high school level." While serious acute traumatic inju- 12 years, is a risk factor for injuries, i Weight. There were 7 included studies'**!525%9 that investigated weight as a risk factor for arm injuries. Two studies were LOE 2, and 5 studies were LOE 3. Four studies found no difference in weight between injured and uninjured groups. Harada et al® (LOE 2) found no significant difference in weight between groups with and without ultrasound abnormalities of the elbow in a pro- spective cohort study of 294 players. ‘Two studies found increased weight to be a risk factor for elbow injuries but not for shoulder injuries. Last, Han et al* found increased weight to be a significant risk factor only for UCL injuries in junior and senior high school play- cers and SLAP tears in high school players. ‘Height. There were 7 included studies'**!575-%2* that examined player’s height as a risk factor for arm injuries, ‘Two studies were LOE 2, and 5 studies were LOE 3. Four of the studies found a significant relationship between increased height and throwing arm injuries, including a LOE 2 study by Harada et al’ that found that height >150 em doubled the risk for OCD of the cap- itellum or medial epicondylar fragmentation, One study found that height was not a significant risk factor, and 2 of the studies had mixed results. Lyman et al" in 2001 actually found shorter stature to be a risk factor for elbow pain. On the contrary, the same study found that taller pitchers were at a higher risk for shoulder pain, although, his trend was not significant (P = .07). Pitches per Game. There were 5 included stud- jes 44525. that investigated pitches por game as an independent risk factor for throwing arm injuries. Three studies were LOE 2, The others were LOE 3. Olsen ct al”? found that pitchers who threw more than 80 pitches per game were 3.8 times more likely to undergo elbow or shoulder surgery. There were 2 prospective eohort studies by Lyman et al! in 2001 and 2002, ‘The 2001 study showed that pitches per game was a significant risk factor for shoulder pain (P <.01) but not elbow pain (P = 21). The 2002 study again showed a statistically significant rela- tionship between shoulder pain and pitch count (P < .01). There was a trend toward significance with regard to elbow pain (P = .07). Two studies did not find pitches per game to signifieantly increase the injury risk. A subgroup analysis was performed to determine whether pitches per game was a risk factor for shoulder injuries only. ‘The Harada et al” study was removed as it pertained only to ‘elbow injuries. Using the “shoulder” subgroups from the ‘The American Journal of Sports Medicine Olsen etal? study and both Lyman et al" studies, the data collectively show that pitches per game isa statistically significant risk factor for shoulder injuries in 3 of 4 studies. Innings Pitched per Game. There were 8 studies" that investigated innings per game as a risk factor for throwing arm injuries. None of these studies showed innings per game to be a significant risk factor. ‘Multiple Teams. There were 4 included studies!!2* that investigated pitching for multiple teams or leagues, 8a risk faetor for throwing arm injuries. The 2001 Lyman, ct al! study was LOE 2. All other studies were LOE 3. The included participants were all pitchers. Chalmers et al! found after a multivariate analysis that pitchers were 22% more likely to have sustained a throwing ‘arm injury if they reported pitching for more than 1 team, ata time. Lyman et al conducted a multivariable analysis, and found that playing baseball outside the league was an. independent risk factor for elbow pain in youth pitchers, ‘Two additional studies found that pitching for multiple teams was a significant risk factor for arm pain but not, for injuries. Collectively, these studies suggest that pitch- ing for multiple teams is an independent risk factor for throwing arm injuries. Showeases. There were 3 ineluded studies'*°** that investigated showeases as a risk factor for throwing arm injuries, all LOE 3. Chalmers ot al’ did not find showcase participation to be an independent risk factor after a multi- variate analysis. Olsen et al? demonstrated that injured pitchers threw in more showeases; however, when account ing for other variables using a multivariable analysis, showcase participation was no longer an independent risk factor. Rogister-Mihalik et al?* found that throwing in showeases was a significant risk factor only for elbow pain in Little League players, shoulder pain in high school, players, and elbow injuries in high school players. The risk of bias was somewhat increased in the Registor-Mihalik. et al® study because this was a descriptive epidemiological study that cannot determine causal relationships, as eon: founding variables were not accounted for. Collectively, these studies did not support showcase participation as an independent risk factor. ‘Months of Pitching per Year. Three studies“2**" looked at months of pitching per year as a risk factor for throwing arm injuries. All were LOE 3. Olsen et al? found that pitching for more than 8 months per year significantly inereased the risk for arm surgery (odds ratio [OR], 5.05, [95% CL, 1.89-18.32). Chalmers et al found that pitching ‘more than 9 months per year increased the isk for inju- ries, although this was not statistically significant (P 07). Because this variable was not significant after the univariate analysis, it was not entered into the multivari- ate logistic regression model to determine if it was an inde- pendent risk factor. Yang et al” did not find after a multivariable rogression analysis that pitching for ‘more than 8 months per year was a significant risk factor. Taken together, these studies are unable to support or refute months of pitching per year as an independent risk factor. AJSM Vol. 47, No. 4, 2019 Innings or Pitehes per Year. Four studies®"""® looked at cither pitches or innings per year as a risk factor. These pep ar oop sg mph a authors recognize that the number of pitches thrown per inning is somewhat variable. All included participants, wore pitchers. The Lyman et al" studies were LOE 2. ‘The other studies were LOE 3 ‘Two studies found pitching volume per year increased the risk, whereas 2 studies did not. Fleisig et al? found that pitching more than 100 innings per year inereased, the risk of arm surgery or retirement due to injury by 3.5, times. Lyman et al" in 2002 showed a statistically signif- icant relationship between reported shoulder and elbow pain and the number of pitches thrown in a season at the time of pain onset. On the other hand, in 2001, Lyman et al!® showed that, throwing 300 to 599 pitches was actually protective against, ‘elbow pain (P = .03) compared with <300 pitches, whereas throwing >600 pitches was associated with the onset of elbow pain, although not statistically significant (P = (09). The same study showed that the risk of shoulder pain during a season actually decreases with the number of pitches thrown (P < 01) Last, Tyler et al® found that participants throwing more than 512 pitches per year tended to have a higher injury prevalence (P = .08). However, the injury incidence per 1000 pitches was not significantly different (P = 33), from that of throwing fewer pitches. Games Played per Year. There were 6 included stud- 383882528292" that investigated the number of games or appearances per year as a risk factor for throwing arm inj ries. One study was LOE 2, 4 studies were LOE 3, and 1 study was LOE 4. Matsuura et all? were able to show with @ multivariate analysis that playing more than 100 games per year significantly increased the risk of elbow pain (P < 01). The remaining 5 studies did not find the number of games played to be a significant risk factor for injuries. Of note, the LOE 2 study by Lyman et al!° found, that the risk of shoulder injuries actually decreased with, an increasing: number of games pitched (OR, 0.85; P < .01). ‘Training Days per Week. Four studies”! looked at training days per week as a risk factor for throwing arm, injuries. These studies did not specify whether “throwing” ecurred during each training day. Harada et al? was an LOE.2 study. The remaining studies were LOE 3, Harada cet al® showed that training 7 days per week significantly increased the risk of radiographic abnormalities of the elbow (OR, 1.96 (95% Cl, 1.02-3.79)). The remaining 3 studies did not find a significant relationship. Pitch Velocity. There were 3 studies™!°° that investi- xated pitch velocity as a risk factor for injuries. Two stud- ies were LOE 3. One study was LOE 4. All 3 studies demonstrated a significant relationship between pitch velocity and injuries. Olson et al®® found that throwing, faster than 85 mph led to a 2.5 times increased risk of ‘elbow or shoulder surgery. . Breaking Pitches. There were 7 studies!*1619252597 that investigated breaking pitches as a risk factor for arm injuries. Two LOE 2 studies and 5 LOE 3 studies, wore included. 2 Risk Factors for Arm Injuries in Adolescent Baseball Players 987 Lyman et al! in 2002 found that throwing a curveball was associated with shoulder pain (P = .04) but not elbow pain. The same study found that sliders are associated with, clbow pain (P =.03) but not shoulder pain, Yang etal" found that throwing curveballs significantly increased the risk of pain but not injuries. However, they also found that throwing a slider did not significantly increase the risk. Comparatively, 5 studies did not find a significant rela- tionship. Taken together, it does not appear that breaking pitches are an independent risk factor for throwing arm injuries. Fatigue. Five studies!" Jooked at subjective arm fatigue or tiredness while throwing as a risk factor for injuries. One study was LOE 2, and 4 studies were LOE 3. The Lyman et al!” study conducted postgame inter- views to determine whether the pitcher experienced arm fatigue during the game. The other studies were survey ased and collected data retrospectively on subjective arm fatigue or tiredness while throwing. ‘Arm fatigue or tiredness was a significant risk factor in 4 of 5 studies. Additionally, Register-Mihalik et af” found arm fatigue to be a risk factor for shoulder injuries (P = (018) but not for elbow injuries (P = .134). Glenohumeral Internal Rotation Deficit (GIRD). There were 7 studies!"*!#°° that investigated GIRD as an independent risk factor for arm injuries. There were 2 LOE 2 studies, 4 LOE 3 studies, and 1 LOE 4 study. Four studies did not find GIRD to be an independent risk factor. Among these studies, Tyler et al? also found that the injury risk was aetually higher in those partici- pants with no internal rotation loss compared with partic- ipants who had >20° loss of internal rotation. ‘Two studies found that GIRD was an independent risk factor for injuries, including Shanley et al” who, in 2011, found that a side-to-side internal rotation difference of >25° significantly increased the relative risk of injuries (RR, 48 [95% CL, 21-11.3). Last, in 2015, Shanley et al” found that adolescents (age 13°18 years) with a dif ference of >13° sustained more injuries (P =.05),"The same study did not find GIRD to be a risk factor in 8- to 12-year- old participants. External Rotation. There were 9 studies'79919%9428 that aimed to determine whether external rotation is, a risk factor for throwing arm injuries. There were 4 LOE 2 studies, 4 LOE 3 studies, and 1 LOB 4 study. Garrison et al” found that UCL tears in pitchers were associated with decreased external rotation of the domi: nant arm (P = .011), Harada ot al® found that external rotation <130° was associated with radiographic abnor- malities of the elhow. However, the other 7 studies did not find a significant relationship. Total Range of Motion. There were 6 studies that looked at total range of motion as a risk factor. There wore 2 LOE 2, 3 LOE 3, and 1 LOE 4 studies. Garrison, et al’ were able to show that loss of total range of motion, was an independent risk factor for UCL injuries. The other 5 included studies did not find a significant relationship. Horizontal Adduction (HA), There were 3 studies’ that looked at HA of the throwing arm, Included were 2 LOE 2 studies and 1 LOE 8 study. Garrison ot al” did 988 Norton et al not find a significant relationship between HA and inju- ries. In 2011, Shanley et al°? found a significant difference in HA of the throwing arm between injured and uninjured players (P = .01). However, side-to-side loss of HA (differ- ‘ence in dominant and nondominant arms) was not associ- ated with an increased injury risk. In 2015, Shanley et al"! found that adolescent pitchers (age 13-18 years) with a side-to-side difference of HA of >15° were 4 times more likely to get injured. This did not hold true for youth, pitchers (age 8-12 years). Position. There were 4 studies®**"®* that compared injury rates in pitchers versus nonpitehers. All 4 studies found pitching to be a risk factor. ‘The data regarding the position of catcher were less definitive. There were 4 LOE 3 studies that specifically looked at the position of eateher as a risk factor. Matsuura etal” found that both pitchers (P <.0001) and eatehers (P <..01) had an increased risk of elbow pain compared with other positions. Fleisig ot al® demonstrated that pitehers who also played as catchers were more likely to be injured, although this trend was not statistically significant (P (09). On the contrary, Yang et al’? did not find that assum- ing the position of eatcher when not pitehing inereased the injury risk (OR, 0.71 [95% CI, 0.36-1.43)), and Tajika ct al™ did not find catching to be an independent risk fac- tor for ultrasound findings of the elbow. DISCUSSION Of the 19 independent variables studied, our analysis found 6 to be clear risk factors for throwing arm injuries in adolescent baseball players. These variables include age, height, pitching for multiple teams, pitch velocity, arm fatigue, and pitches per game (shoulder injuries only). ‘There were 7 independent variables that were not found to be literature-supported risk factors for throwing arm juries, including innings per game, showcase participa- tion, games per year, training days per week, pitch type, shoulder external rotation, and shoulder total range of motion. We were unable to support or refute the remaining 6 variables after a systematic review of the literature. ‘These variables include weight, months of pitching per xyear, innings or pitches per year, position (catcher), shoul- der HA, and GIRD. A subgroup analysis demonstrated that pitches per game is an independent risk factor for shoulder injuries and speaks to the benefit of instituted pitch counts. We did not find that pitch counts per game was clearly associ ated with elbow injuries, revealing other factors such as pitch velocity, arm fatigue, height, and inadequate rest to ‘be more likely the responsible causes. Additional studies are needed to objectively support or refute months of pitching per year and innings or pitches per year as independent risk factors. Undoubtedly, there is a risk with seasonal and yearly overuse, but limited throwing may also be a risk factor. Petty et al found that patients who underwent UCL reconstruction aver- aged 8 months of baseball per year and that 69% played year-round. On the contrary, Lyman ot al"® in 2001 showed ‘The American Journal of Sports Medicine that throwing up to 600 pitches per year was actually pro- tective against elbow pain. The same study showed that the risk of shoulder pain during a season actually decreases with the number of pitches thrown. ‘There appears to be a window for the ideal amount of throwing in the course of a year, or a “sweet spot,” that allows for the necessary physiological adaptations to occur without developing overuse injuries. This should be a focus for future research, Biomechanical studies®* have determined that the fastball creates the greatest amount of stress on the elbow and shoulder, not the curveball. This review further dem- onstrates that throwing breaking pitches is not an inde- pendent risk factor for elbow or shoulder injuries. Petty et al” found that 67% of patients threw breaking pitches before the age of 14 years. However, these were not com- pared with a healthy control group, and the authors acknowledge that the cohort threw with an unusually high average velocity (83 mph). As a breaking ball is typi- cally thrown with signifieantly reduced velocity compared with a fastball, the biomechanical data suggest that adding off-speed pitches including a changeup or curveball may be protective to adolescent pitchers, especially those who have other risk factors for shoulder or elbow injuries. This is an area for future research. ‘The assumption that pitchers are at an increased risk for shoulder and elbow injuries is well supported by the studies in our review that address the question, Whether being a eatgher is an independent risk factor is not elear. Yang et al” and Fleisig et al® are the only studies to specifically address whether pitchers who also play as catchers are at an increased risk, and they published conflicting results. Petty ct al” reported in a case study of 27 baseball players that the only nonpitchers to undergo UCL reconstruction were catchers (327 or 11%). The theoretical increase in stress on the elbow when repetitively throwing from the squatting or kneeling position over the course of a game likely increases the injury risk in eatchers. Despite the equivocal results of our review, we agree that pitchers should be discouraged from also playing as catchers to limit the cumulative workload on the throwing arm. (One additional consideration is the biological develop- ‘ment of an immature athlete, who during the critical high school years undergoes a growth spurt, allowing for a pitch to be thrown with suddenly inereased velocity before the growth plates have closed or the supportive musculature has adapted to the increased stress placed on the elbow. One study found that none of the baseball players who underwent UCL reconstruction had a clinically relevant elbow flexion contracture, a finding thought to be an adaptive change that protects the UCL in most pitch- cers.”” This scenario, in which a young athlete has the abil- ity to perform at a level before his body has fully developed to withstand the resulting stress, is one that likely occurs during a finite period of time during development, is diffi- cult to predict, and is even harder to prevent. ‘When compared against the current MLB and USA Baseball Pitch Smart guidelines, our systematic review agrees that arm fatigue, pitches per game, and pitching for multiple teams are clear risk factors. We did not find AJSM Vol. 47, No. 4, 2019 that showease participation and throwing breaking pitehes at a young age are clear risk factors for injuries. The current, literature neither supports nor refutes the remaining Pitch ‘Smart risk factors, It is reasonable to conelude that the dis- crepancies between our systematic review and the current guidelines result in part from the expert opinions that shaped the Pitch Smart guidelines. Furthermore, we recog- nize that certain Pitch Smart guidelines, despite the paucity of sound scientific research, have the potential to reduce injury rates, and in the absence of data, common sense and logie should prevail in keeping the equivocal guidelines. Our findings are not meant to discount the potential utility of such recommendations but instead to encourage further investigation into this important subject. Just as we have learned that breaking pitches actually do not inerease the injury risk, following years where this pitch was strongly discouraged, there are almost certainly addi- tional revelations to come as the body of evidence graws. Par ticular attention should be placed on ensuring that the ‘current pitch count recommendations do in fact lead to a decrease in throwing arm injuries. One study!” has been referenced as evidence that pitch count rules decrease shoul- der injuries by 505%; however, this was not published in 1 peer-reviewed journall and is in need of further validation. Limitations ‘There were several limitations to this study, many of which are inherent to a systematic review. The authors Grew conclusions from data across generally low LOE stud- ies with heterogeneity in the study design and outcome measures. There were 3 included studies determined to be LOE 4, primarily for their small sample size. Addition ally, there were 2 studies that were given an NOS seore of <6, suggesting that these studies have a heightened risk of bias, To check the internal validity of our results, the authors repeated the systematic review without the inclu- sion of these 5 studies and did not find that removing them would change the results that. we have reported. ‘The primary outcome (dependent variable) included pain, injury, surgery, and radiographic abnormalities. It was thought that this was necessary to comprehensively evaluate our study population. We recognize that some par- ticipants with pain or radiographie findings will never miss time due to injury. However, we believe that these may be concerning in and of themselves and should not be dis- counted. Studies that enrolled pitchers only versus pitchers plus field players were both included, Pitching-specific var- iables would not be affected by this, but variables such as range of motion and player size may affect position players differently from pitchers. We used the WHO definition for adolescents when determining the age range for our inchi- sion criteria. Narrowing the age range for a future study, such as targeting the 15- to 19-year-old age group, may be beneficial because this age group may be at- an increased risk.* Recall bias was likely a factor in some studies as there may be inaccuracies in the retrospective reporting of pitch ‘counts and joint pain in adolescent boys ‘There were multiple studies out of the Birmingham, Alabama, area, some of which utilized similar patient Risk Factors for Arm Injuries in Adolescent Baseball! Players 989 cohorts. These studies were all included based on the var- ious study variables, timing of data collection, outcome measures, and unique follow-up periods, Demographics unique to this geographie region may not apply to cohorts in different regions of the country. CONCLUSION Our systematic review of the literature found that player age, height, playing for multiple teams, pitch velocity, and arm fatigue are clear risk factors for throwing arm injuries in adolescent baseball players. Pitches per game also appears to be a risk factor for shoulder injuries. ‘The MLB and USA Baseball Pitch Smart. guidelines should help to reduce injuries and are a great tool for ath- letes, coaches, and parents. We have identified several potential risk factors that remain unproven and for which additional high-quality evidenee is needed, ‘An online CME course associated with this artile is avail- able for 1 AMA PRA Category 1 Credit™ at https! ‘www.sporsmed.ongaossmimis/Members/Education/AJSM. Current. Concepts Store.aspx. In accordance with the Standards of the Accreditation Counel for Continuing Med- ical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, edi- tors, and planners disclose to the learners al financial rela tionships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, ‘marketing, re-selling, or distributing health eare goods or services consumed by, or used on, patients), Any and alll disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy authors, editors, and planners’ participation in this educa~ tional activity will be predicated upon timely submission and review of AOSSM disclosure, Noncomplianee will result in an authorieditor or planner to be stricken from participating in this CME activity. REFERENCES 1. Chalmers PN, Sgro T, Ff Al etal. Corelats with history of injury in youth and adolescent pitchers. troscopy. 2015:31(71349-1387. 2. Colins CL, Comstock RD. Epidemiological features of high school baseball injuries in the United States, 2005-2007. Pediatrics 2008;121(6;1181-1187. 8, Dun SC, Lottie J Fleisig GS, Kingsley D, Andrews JR. A biomechan- ical comparison of youth baseball pitches: isthe curveball potentially harm? Am J Sports Med. 2008;96(4)'686-682. 4, Endo ¥, Sakamoto Mi, Conelation of shoulder an bow injures wth muscle tightness, cove stably, and balance by longtucnal meas- lemons in junior high schoo! baseball players. J Phys Ther Sci. 2014:265:880-693. 5. Erickson Bu, Nuachukwy BU, Rosas S, etal. Trends in medial ulnar collateral igament reconstruction inthe United States: a retrospective review of a large private-payer database trom 2007 to 2011. Am J ‘Sports Med. 2015:497):1770-1774 6. Fosig GS, Ancrows JR, Cuttor GR, ot a. Fisk of serious injury for young baseball pitchors. Am J Sports Med. 2011:39(2)258-257 990 Norton et al 7. Garrison JC, Cole MA, Conway JE, Macko MU. Thigpen C, Snanoy E ‘Shoulder range of motion defies in baseball players with an ulnar

    You might also like