Baseball in
pitching injuries growing athletes
A. BRANT LIPSCOMB, MD
Adams
in 19651 and 19662 reported on pitching injuries involving the shoulder and elbow joints in the 9 to 15 year age group and documented the pathological findings resulting from such injuries. Subsequently, these injuries have become known as Little League shoulder and elbow pitching injuries. In 1968 Slocum3 described pathological changes found in elbow joints of young pitchers and correlated with these findings the stress exerted on this joint in pitching a baseball. Tulloss and King’ in 1972 further described pathological changes occurring in the shoulder and elbow joints of adolescents as well as professional pitchers and correlated these findings with their excellent description of the pitching cycle.
baseball
It is the purpose of this report first to confirm the pathological findings previously reported by these authors and to report eight cases, emphasizing those lesions which frequently progress to traumatic arthritis resulting in permanent impairment of normal joint function irrespective of athletic participation, as well as lesions which are completely recoverable, resulting in normal joint function with opportunity for continued
pitching. The population
of
metropolitan
Nash-
ville, Tennessee, is relatively stable; each year there are approximately one thousand 9- to 12-year-old youths participating in Little League and Knot-Hole programs. Also, there are some 500 boys participating in the 12- to 15-year age group in the Junior Babe Ruth and Knot-Hole programs. These From the Vanderbilt Tennessee.
Department of Orthopedic Surgery, University Medical Center, Nashville,
are well organized and controlled, with regular practices and scheduled games, the entire season extends three months. In the 9-to-12-year age group a player is allowed to pitch six innings per week and in the older age group, seven innings. It is from this reservoir of growing athletes, that the following shoulder and elbow pitching injuries were obtained. In pitching a baseball, the goal of every pitch whether by a 9-year-old or a major leaguer, is to produce a rhythmic sequence of forces building up to a maximum velocity at the proper release angle, with as much accuracy or control as possible. The force and torque exerted on the extremity by a single pitch may be tremendous (Fig 1). The cycle of pitching4 begins by first cocking the arm and shoulder, followed by the delivery or acceleration phase, and finally the follow-through. The cycle begins utilizing the most powerful muscle groups first, progressing ultimately to the least powerful but most coordinate; that is, first the legs, then trunk, then shoulder girdle, arm, forearm, and finally hand. The center of gravity of the body is moved forward by the legs in throwing. In right-handed pitchers, planting of the left leg stops the initial forward movement. The trunk continues forward with an associated rotation. The shoulder then comes into the rhythm of throwing first, cocking the arm in extreme external rotation, abduction and extension. The force then continues into the arm with the elbow in valgus and forcefully thrust from the position of acute flexion into complete extension. Maximum force occurs in the delivery phase. Most of the pitching
programs
25
injuries- occur in this phase. In the 9-to-15-year age
group injuries differ from those of the adult because of the presence of the epiphyses. In the delivery phase of throwing, the powerful internal rotators and adductors exert tremendous force on the proximal humeral epiphysis. The pathology produced by repeated pitching is found to be fragmentation, widening and demineralization of the epiphyseal plate, and possibly also a definite metaphyseal fracture resulting from a single pitch. In the elbow, the tremendous force exerted in thrusting the forearm from acute flexion to maximum extension, results in a severe stretching force on the medial structures, and a corresponding impacting force at the radiohumeral articulation. These forces, together with strong volar wrist flexion, may result in avulsion of the medial epicondyle with a single pitch, or, with repetitious throwing, fragmentation and hypertrophy can result. The impacting forces exerted at the radiohumeral joint are most likely responsible for the development of osteochondritis of the capitellum and radial head, with necrosis and sloughing of the articular cartilage and subsequently, loose body formation. Because of the development of osteochondritis, pitching injuries to the radiohumeral joint are the most serious and most difficult to treat. The inevitable development of traumatic arthritis in this joint is the principal cause of permanent joint impairment in young pitchers in this age
’
group. CASES: ELBOW INJURIES -..--.....
Case 1.
A Little
League pitcher,
age 11,
was seen
at
the conclusion of the season; he had pitched regularly for four months. The patient had noted gradual onset of elbow pain in delivery and follow-through phase, with aching and soreness after pitching. Examination revealed tenderness without swelling over the radiohumeral joint. There was a loss of 20° extension and 15°° flexion. Pitching was discontinued. X-rays (Fig 2) showed osteochondritis of the radial head with fragmentation. Six months later, because of continued pain and tenderness, arthrotomy was performed. The synovium was thickened 26
Figure I-Severely comminuted fracture of the humerus resulting from the delivery of a fast ball by a sandlot pitcher. and the entire radial head was found to be the site of sloughing with soft and necrotic cartilage. This was excised but the patient did not do well during the postoperative period. Progressive and symptomatic traumatic arthritis with pain and limitation of motion developed over the next three years. Subsequently, excision of the radial head was performed with relief of pain and recovery of joint motion. Two years later this athlete continues to play high school base-
larly, continuing his college career on a baseball scholarship. He feels that he has never regained complete effectiveness and has had recurrent transient episodes of elbow pain after pitching. He has, however, maintained a winning record. Correct treatment dictated that this athlete give up pitching following his initial symptoms as a 15-year-old. However, his pitching ability has afforded the patient a college education which he otherwise could
not
have obtained.
Case 3.
A Junior Babe Ruth
Figure 2-(Case I) Osteochondritis of the radial head with fragmentation occurring in an 11- year-old pitcher. ball as an outfielder, but throws ineffectively. There remains moderate impairment of joint function and strength, and x-rays show traumatic arthritis of a moderate degree
(Fig 3). Case 2.
A fifteen-year-old who had pitched regularly in Little League, Junior Babe Ruth and High School baseball for a total of six years, was seen with elbow pain. He developed the gradual onset of pain during delivery and follow-through, with aching and soreness after pitching. Localized tenderness was present over the radiohumeral joint without loss of motion. Initial x-ray was negative. He continued to pitch and one year later x-rays (Fig 4) revealed osteochondritis of the capitellum, with loose body formation. Arthrotomy was carried out with removal of loose bodies, some roughening of the capitellum was found, but not excised. Following recovery and rehabilitation, the patient resumed pitching and has been followed regu-
pitcher, age 13, noted sudden pain over the lateral aspect of the elbow joint after a single pitch. Severe tenderness and slight swelling was found over the lateral epicondylar area with 15° limitation of extension. X-ray (Fig 5) showed osteochondritis of the capitellum with avulsion of a small osteocartilagenous body. No further athletic participation was permitted. X-rays six months later showed the development of a single loose body arising from the lateral epicondyle. This patient was advised arthrotomy but has been asymptomatic for two years since giving up baseball. Case 4.
sixteen-year-old pitcher, with a sucessful extending over four years of participating in Little League and Junior Babe Ruth baseball, had repeatedly noted aching pain in the lateral aspect of the elbow joint, both while pitching and following compleA
record
tion of the game. The symptoms were never severe enough to require medical consultation, nor did he discontinue pitching. Examination at the conclusion of his fourth season revealed tenderness to pressure over the lateral epicondyle with a loss of 20° extension and 25° flexion. X-rays (Fig 6) showed a large area of osteochondritis of the capitellum. Conservative treatment which included the discontinuance of baseball has been carried out for two years with improvement. The pain has subsided, but there remains a residual loss of 10 degrees extension, and 155 degrees flexion. X-rays (Fig 7) at this time revealed a persistent osteochondritis of the capitellum. This patient represents a typical example of permanent disability resulting 27
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pitching injuries growing athletes
A. BRANT LIPSCOMB, MD
Adams
in 19651 and 19662 reported on pitching injuries involving the shoulder and elbow joints in the 9 to 15 year age group and documented the pathological findings resulting from such injuries. Subsequently, these injuries have become known as Little League shoulder and elbow pitching injuries. In 1968 Slocum3 described pathological changes found in elbow joints of young pitchers and correlated with these findings the stress exerted on this joint in pitching a baseball. Tulloss and King’ in 1972 further described pathological changes occurring in the shoulder and elbow joints of adolescents as well as professional pitchers and correlated these findings with their excellent description of the pitching cycle.
baseball
It is the purpose of this report first to confirm the pathological findings previously reported by these authors and to report eight cases, emphasizing those lesions which frequently progress to traumatic arthritis resulting in permanent impairment of normal joint function irrespective of athletic participation, as well as lesions which are completely recoverable, resulting in normal joint function with opportunity for continued
pitching. The population
of
metropolitan
Nash-
ville, Tennessee, is relatively stable; each year there are approximately one thousand 9- to 12-year-old youths participating in Little League and Knot-Hole programs. Also, there are some 500 boys participating in the 12- to 15-year age group in the Junior Babe Ruth and Knot-Hole programs. These From the Vanderbilt Tennessee.
Department of Orthopedic Surgery, University Medical Center, Nashville,
are well organized and controlled, with regular practices and scheduled games, the entire season extends three months. In the 9-to-12-year age group a player is allowed to pitch six innings per week and in the older age group, seven innings. It is from this reservoir of growing athletes, that the following shoulder and elbow pitching injuries were obtained. In pitching a baseball, the goal of every pitch whether by a 9-year-old or a major leaguer, is to produce a rhythmic sequence of forces building up to a maximum velocity at the proper release angle, with as much accuracy or control as possible. The force and torque exerted on the extremity by a single pitch may be tremendous (Fig 1). The cycle of pitching4 begins by first cocking the arm and shoulder, followed by the delivery or acceleration phase, and finally the follow-through. The cycle begins utilizing the most powerful muscle groups first, progressing ultimately to the least powerful but most coordinate; that is, first the legs, then trunk, then shoulder girdle, arm, forearm, and finally hand. The center of gravity of the body is moved forward by the legs in throwing. In right-handed pitchers, planting of the left leg stops the initial forward movement. The trunk continues forward with an associated rotation. The shoulder then comes into the rhythm of throwing first, cocking the arm in extreme external rotation, abduction and extension. The force then continues into the arm with the elbow in valgus and forcefully thrust from the position of acute flexion into complete extension. Maximum force occurs in the delivery phase. Most of the pitching
programs
25
injuries- occur in this phase. In the 9-to-15-year age
group injuries differ from those of the adult because of the presence of the epiphyses. In the delivery phase of throwing, the powerful internal rotators and adductors exert tremendous force on the proximal humeral epiphysis. The pathology produced by repeated pitching is found to be fragmentation, widening and demineralization of the epiphyseal plate, and possibly also a definite metaphyseal fracture resulting from a single pitch. In the elbow, the tremendous force exerted in thrusting the forearm from acute flexion to maximum extension, results in a severe stretching force on the medial structures, and a corresponding impacting force at the radiohumeral articulation. These forces, together with strong volar wrist flexion, may result in avulsion of the medial epicondyle with a single pitch, or, with repetitious throwing, fragmentation and hypertrophy can result. The impacting forces exerted at the radiohumeral joint are most likely responsible for the development of osteochondritis of the capitellum and radial head, with necrosis and sloughing of the articular cartilage and subsequently, loose body formation. Because of the development of osteochondritis, pitching injuries to the radiohumeral joint are the most serious and most difficult to treat. The inevitable development of traumatic arthritis in this joint is the principal cause of permanent joint impairment in young pitchers in this age
’
group. CASES: ELBOW INJURIES -..--.....
Case 1.
A Little
League pitcher,
age 11,
was seen
at
the conclusion of the season; he had pitched regularly for four months. The patient had noted gradual onset of elbow pain in delivery and follow-through phase, with aching and soreness after pitching. Examination revealed tenderness without swelling over the radiohumeral joint. There was a loss of 20° extension and 15°° flexion. Pitching was discontinued. X-rays (Fig 2) showed osteochondritis of the radial head with fragmentation. Six months later, because of continued pain and tenderness, arthrotomy was performed. The synovium was thickened 26
Figure I-Severely comminuted fracture of the humerus resulting from the delivery of a fast ball by a sandlot pitcher. and the entire radial head was found to be the site of sloughing with soft and necrotic cartilage. This was excised but the patient did not do well during the postoperative period. Progressive and symptomatic traumatic arthritis with pain and limitation of motion developed over the next three years. Subsequently, excision of the radial head was performed with relief of pain and recovery of joint motion. Two years later this athlete continues to play high school base-
larly, continuing his college career on a baseball scholarship. He feels that he has never regained complete effectiveness and has had recurrent transient episodes of elbow pain after pitching. He has, however, maintained a winning record. Correct treatment dictated that this athlete give up pitching following his initial symptoms as a 15-year-old. However, his pitching ability has afforded the patient a college education which he otherwise could
not
have obtained.
Case 3.
A Junior Babe Ruth
Figure 2-(Case I) Osteochondritis of the radial head with fragmentation occurring in an 11- year-old pitcher. ball as an outfielder, but throws ineffectively. There remains moderate impairment of joint function and strength, and x-rays show traumatic arthritis of a moderate degree
(Fig 3). Case 2.
A fifteen-year-old who had pitched regularly in Little League, Junior Babe Ruth and High School baseball for a total of six years, was seen with elbow pain. He developed the gradual onset of pain during delivery and follow-through, with aching and soreness after pitching. Localized tenderness was present over the radiohumeral joint without loss of motion. Initial x-ray was negative. He continued to pitch and one year later x-rays (Fig 4) revealed osteochondritis of the capitellum, with loose body formation. Arthrotomy was carried out with removal of loose bodies, some roughening of the capitellum was found, but not excised. Following recovery and rehabilitation, the patient resumed pitching and has been followed regu-
pitcher, age 13, noted sudden pain over the lateral aspect of the elbow joint after a single pitch. Severe tenderness and slight swelling was found over the lateral epicondylar area with 15° limitation of extension. X-ray (Fig 5) showed osteochondritis of the capitellum with avulsion of a small osteocartilagenous body. No further athletic participation was permitted. X-rays six months later showed the development of a single loose body arising from the lateral epicondyle. This patient was advised arthrotomy but has been asymptomatic for two years since giving up baseball. Case 4.
sixteen-year-old pitcher, with a sucessful extending over four years of participating in Little League and Junior Babe Ruth baseball, had repeatedly noted aching pain in the lateral aspect of the elbow joint, both while pitching and following compleA
record
tion of the game. The symptoms were never severe enough to require medical consultation, nor did he discontinue pitching. Examination at the conclusion of his fourth season revealed tenderness to pressure over the lateral epicondyle with a loss of 20° extension and 25° flexion. X-rays (Fig 6) showed a large area of osteochondritis of the capitellum. Conservative treatment which included the discontinuance of baseball has been carried out for two years with improvement. The pain has subsided, but there remains a residual loss of 10 degrees extension, and 155 degrees flexion. X-rays (Fig 7) at this time revealed a persistent osteochondritis of the capitellum. This patient represents a typical example of permanent disability resulting 27
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