Return to Sport Following Little League Elbow and Shoulder

1. Return to Sport Following Little League Elbow and Shoulder Nathan Apple, MS PT

2. Little League Elbow • Medial epicondyle apophysitis • Radiographs can assist in diagnosis • Pain with throwing or palpation • General term for pain due to • Injury to the medial epicondyle and ulnar collateral ligament • Osteochondritis dissecans of the capitellum

3. Little League Elbow • During cocking and acceleration phase of pitching • Valgus stress occurs at the medial elbow, • Shearing forces in the posterior • Compression along the lateral elbow

4. Little League Shoulder • Proximal humeral epiphysitis • Salter-Harris type 1 fracture of proximal humeral physis • Typical around ages 11-14, when proximal physis of humerus is at its peak in growth (Osbahr)

5. Little League Shoulder • Diagnosis • Progressive pain with throwing in proximal humerus • Tenderness to palpation over physis of proximal humerus • Radiographs for widening consistent with epiphysiolysis • Contralateral shoulder needed for comparison (Osbahr)

6. Physical Therapy Evaluation • Accurate history • Past injuries • Pain- aggravating and alleviating factors • Recent growth in height • Comorbidity • Growth deficiencies • Diabetes

7. Physical Therapy Evaluation • Sport specific history • Number of current sports • Number of current teams per sport • Sport specific demands • What positions • What specialty • What events • Current pitch counts • Better still, are they counting • What pitches thrown

8. Physical Therapy Evaluation • Sport specific history continued • Hours per week (total games/practice) • Include outside training • Speed and conditioning • Positions specific • Current coaches • How many • Who are they

9. Clinical Exam • Pain • Joint specific range and strength • Uninvolved extremities and core • Check posture, strength, and range • Scapula stabilizers • LE and core flexibility • Eccentric control • Imbalances cause compensation • Compensation results in injury

10. Acute PT Intervention • Appropriate sport specific rest • Modalities • Cryotherapy and iontophoresis • NMES and US? • Pain free range of involved joint • Pendulums, finger wall walks, wands, etc.

11. Acute PT Intervention • Once full pain free range is obtained • Begin joint specific strengthening • Open chain as tolerated due to sport demands • Weights and theraband • Closed chain loading • Seated, standing, quadruped, plank • Assists with core and eccentrics • Loads tissues to promote healing

12. Acute PT Intervention • Don’t forget the rest of the kinetic chain • PROM and strength as found in deficit • Range of motion • Pectoralis, latissimus, and lower extremities • Scapula stabilizers strength • Cardiovascular and endurance • Athletes will want to return as soon as possible • Fatigue will need to be addressed

13. Progression of Core Stability • Stress good posture and eccentric control • Physical vs. cognitive maturity • Mat exercises • Kneeling push up static • Planks • Full push up static • Bird dogs • Bear crawls • Unstable kneeling push up • Unstable full push up

14. Progression of Core Stability • Swiss ball exercises • Prone walk outs • Prone walkouts with shoulder flexion • Prone walkouts into push ups • Prone walkouts into push ups, unstable surface

15. Preparation for Return to Sport • Are they ready for this? • UE plyometrics • UE shuffle • quadruped, kneeling push up, full push up • UE cone stack • quadruped, kneeling push up, full push up • UE step ups • Up and down same side • Up and over

16. Preparation for Return to Sport • Are you sure they are ready for this? • UE fall arrest • Begin kneeling at wall • Gradually increase distance of “fall” to arrest forward fall from kneeling to floor • DO NOT PROGRESS PAST THEIR ABILITY

17. Preparation for Return to Sport • Are you really sure they are ready for this? • UE box jumps • Begin with “jumping” down first • Land with elbows bent • Start in quadruped, progress to kneeling then full pushup • Progression in each stage • Depth of box • Amount of elbow flexion at start • Unstable surfaces

18. Keys for good outcomes • Limiting factors • Pain • Fatigue • Loss of eccentric control • Trouble with progression • Vary resistance • Static vs. dynamic • Remember body awareness and age

19. Sport Specific Return to Play • Return to limited play during practice • Respect fatigue and loss of eccentric control • Limit specific training drills per sport • Modify position to limit distance and number of throws • Know the sport, if you don’t educate yourself • Pitch counts, types, and required rest • Interval Throwing Programs

20. Pitch CountsMaximum Pitch Counts

21. Age Recommended for Learning Various Pitches

22. Rest Periods RequiredAfter Number of Innings Pitched

23. Data Based Return to Sport • Internet is abound with Interval Throwing Programs • Most based on gradual progression perceived demands and one size fits all • Baseball • Axe, Wickham, Snyder-Mackler • For multiple age groups • Data based

24. Data Based Return to Sport • Softball • Axe, Windley, Snyder-Mackler • Data based • Only college age • Other Sports • Programs limited in data based progression or simply limited at all

25. Interval Throwing Program(Axe et. al.) • Age based program- 3 versions • Little League, ages 9-12 • 46 ft from mound to home • 6 innings per week • 13-14 years of age • 60 ft 6 in mound to home • 9 innings per week • High School, College, and Professional • 60 ft 6 in mound to home • No set limits on innings, only pitch counts

26. Interval Throwing Program(Axe et. al.) • Data based • 9-12 year old from 400.5 innings • 13 year old from 203.5 innings • 15-18 year old from 234 innings • Div I from 440 innings • Professional 6 seasons from 80’s and 90’s • Counted number of total pitches per inning, total number of warm up pitches per inning, and innings and number of pitches thrown by each pitcher per game were recorded for all • For older athletes this was further divided by starting, relief, and closing pitches as well as pick off attempts

27. Interval Throwing Program(Axe et. al.) • Little League Program • Starts at Phase 1 • Regardless of diagnosis • After medical clearance • 2-3 day rest between each Phase • Pain is limiting factor • 9 Phases total • Each Phase has long and short toss component • Distance, reps, intensity increase each Phase

28. Interval Throwing Program(Axe et. al.) • Little League Program • Short toss • Starts at 20 ft, increase to 46 ft by Phase 4 • 3 sets, progression of 15-25 reps/set • Intensity • Work to tolerance Phase 1-3 on flat ground • Begin ½ speed by Phase 4 • Begin ¾ speed by Phase 5 • Full speed off mound by Phase 6 • Set times between throws and for rest • 12 sec per throw • 6-8 minutes per set for 3 sets

29. Interval Throwing Program(Axe et. al.) • Little League Program • Long toss • 10 minute rest between Short and Long toss • Distance age dependent • Starts at 65% • Increase 5% each Phase • Refer to table 5 in the article • 10 y/o throwing 45 mph • Estimated max of 107.3 ft, • 65% equals 69.73 ft

30. Interval Throwing Program(Axe et. al.) • Little League Program • Long toss continued • Begin throwing 10 ft for 3-5 throws and increase 10-15 ft every 3-5 throws until distance is reached • 12 seconds/throw • 25 throws total • Ends with a simulated game (Phase 9) • Soreness Rule • Will determine overall time to complete

31. Interval Throwing Program(Axe et. al.) • Soreness Rule- applies to all levels • If no soreness after a step (or phase) • Advance one step every day • Of scheduled practice, not calendar days • If sore during warm-ups • Soreness gone after warm ups repeat previous workout • If become soreness during this workout, stop and rest 2 days, return one step down from last workout

32. Interval Throwing Program(Axe et. al.) • Soreness Rule continued • If sore more than one hour after workout or the next day • Take one day off, repeat most recent workout • If sore during warm up and soreness continues through first 15 throws • Stop, take 2 days off, upon return drop down one step.

33. Interval Throwing Program(Axe et. al.) • 3 Phases older athlete programs • Return to Throw • Return to Pitch • Intensified Pitching • Ends with a simulated game • Medical clearance required to begin

34. Interval Throwing Program(Axe et. al.) • 13-14 year-old program • Phase 1- Return to Throwing • 3 steps (1-3) • Phase 2- Return to Pitching • 3 steps (4-6) • Fastballs from ground • Phase 3- Intensified Pitching • 10 steps (7-16) • Pitch from the mound • Off-speed begin step 13

35. Interval Throwing Program(Axe et. al.) • Beginning step for the older athletes is determined by type of injury • Location anywhere other than the throwing arm • Throwing arm, not involving the joint • Throwing arm, mild injury to joint • Throwing arm, severe injury to joint • Must refer to tables to know at what step to begin the program

36. TABLE 7. Pitching program instructions for 13- or 14-year-old players (Axe) A. Baseline/Preseason To establish a base for training and conditioning, begin with step 3 and advance one step daily to step 14 following soreness rules. B. Non-throwing arm injury After medical clearance, begin step 3 and advance one step daily to step 16 following soreness rules. C. Throwing arm- Bruise or bone involvement After medical clearance, begin with step 1 and advance program as soreness rules allow throwing no more than every other day. D. Throwing arm- Tendon/Ligament injury (Mild) After medical clearance, begin with step 1 and advance program to step 3 throwing every other day as soreness rules allow. Throw every third day on steps 4–8 as soreness rules allow. Return to throwing every other day as soreness rules allow for steps 9–16. E. Throwing arm- Tendon/Ligament injury (Moderate, severe, or post op) After medical clearance, begin throwing at step 1. For steps 1–3, advance no more than 1 step every 3 days with 2 days of active rest (warm-up and long tosses) following each workout. Steps 4–8 advance no more than 1 step every 3 days with 2 days active rest (see step 11) following each workout. Advance steps 9–16 daily as soreness rules allow.

37. Appendix C.13/14-Year-Old Baseball PitchersInterval Throwing Program (Axe) Phase II—Return to Pitching Fastballs are from level ground following crow hop- 60 feet Step 4 Warm-up toss to 105 20 Fastballs (50%)* 16 Fastballs (50%)* 16 Fastballs (50%)* 25 Long tosses to 105 Phase I—Return to Throwing All throws are at 50% effort Distances listed in feet Step 1 Warm-up toss to 60 15 Throws at 30* 15 Throws at 30* 15 Throws at 30* 20 Long tosses to 60 * Rest 6 minutes after these sets

38. Appendix C.13/14-Year-Old Baseball PitchersInterval Throwing Program (Axe) Phase III—Intensified Pitching Pitches are from mound with normal stride Step 7 Warm-up toss to 120 20 Fastballs (50%)* 20 Fastballs (75%)* 20 Fastballs (75%)* 20 Fastballs (50%)* 25 Long tosses to 160 * Rest 6 minutes after these sets Simulated game Step 16 1) 10 Minutes Warm-up of 50–80 Pitches With Gradually Increasing Velocity 2) 5 Innings 3) 22–27 Pitches Per Inning, Including 15–20 Fastballs 4) 6 Minutes Rest Between Innings

39. Interval Throwing Program(Axe et. al.) • High School, College, and Professional • Phase 1- Return to Throwing • 7 steps (1-7) • Phase 2- Return to Pitching • 5 steps (8-12) • Fastballs from ground • Phase 3- Intensified Pitching • 10 steps (13-21) • Pitch from the mound • Relief and closing pitchers (after step 15 go to 21) • Off-speed start step 15

40. TABLE 8. High school, college, professional pitching program instructions (Axe) A. Baseline/Preseason To establish a base for training and conditioning, begin with step 4 and advance one step daily following soreness rules. B. Non-throwing arm injury After medical clearance, begin step 4 and advance one step daily following soreness rules. C. Throwing arm- Bruise or bone involvement After medical clearance, begin with step 1 and advance program as soreness rules allow throwing every other day. D. Throwing arm- Tendon/Ligament injury (Mild) After medical clearance, begin with step 1 and advance program to step 7 throwing every other day as soreness rules allow. Throw every third day on steps 8–12 as soreness rules allow. Return to throwing every other day as soreness rules allow for steps 13–21. E. Throwing arm- Tendon/Ligament injury (Moderate, severe, or post op) After medical clearance, begin throwing at step 1. For steps 1–7, advance no more than 1 step every 3 days with 2 days of active rest (warm-up and long tosses) following each workout. Steps 8–12 advance no more than 1 step every 3 days with 2 days active rest (see step 14) following each workout. Steps 13–16 advance no more than 1 step every other day with 1 day active rest (see step 14) between steps. Advance steps 7–21 daily as soreness rules allow.

41. Appendix D.High School College And Professional Baseball PitchersInterval Throwing Program (Axe) Phase I—Return to Throwing Throws at 50% Effort Distances listed in feet Step 1 Warm-up toss to 60 15 Throws at 30* 15 Throws at 30* 15 Throws at 30* 20 Long tosses to 60 * Rest 9 minutes after these sets. Phase II—Return to Pitching Throws at Effort Level Given Step 8 Warm-up toss to 120 15 Throws at 60’ 6” (75%)* 20 Throws at 60’ 6’’ (75%)* 20 Throws at 60’ 6” (75%)* 15 Throws at 60’ 6 “(75%)* 25 long tosses to 160

42. Appendix D.High School College And Professional Baseball PitchersInterval Throwing Program (Axe) Phase III Intensified Pitching Step 13 Warm-up toss to 120 25 Fastballs (75%)* 20 Fastballs (100%)* 10 Fastballs (75%) 15 Fastballs (100%)* 25 Fastballs (75%)* 25 long tosses to 160 * Rest 9 minutes after these sets. Simulated game Step 21 1) 10 Minutes warm-up of 50–80 pitches with gradually increasing velocity. 2) 5–8 Innings for starters, 3–5 innings for relievers, 2–3 innings for closers. 3) 15–20 Pitches per inning, including 10–15 fastballs. 4) 9 Minutes rest between innings.

43. Interval Throwing Program (Axe et. al.) • Progression of older athletes • Time between throwing days determined by type of injury • Varies from every other day, to every three days with active rest on off days • Based on 4 types discussed earlier, must reference chart to determine (Tables 7 & 8) • Soreness rule • Process could be lengthy

44. Prevention • Home program to maintain • Include PROM and core strength • Avoid overtraining • Cross train • One sport at a time • Education to all involved • Coaches, parents, players • Good equipment and proper technique

45. References Articles • Axe M, Wickham R, Snyder-Mackler L. Data-Based Interval Throwing Programs for Little League, High School, College, and Professional Baseball Pitchers. Sports Medicine and Arthroscopy Review. 2001;9: 24-34. • Axe M, Windley T, Snyder-Mackler L. Data-Based Interval Throwing Programs for Collegiate Softball Players. Journal of Athletic Training. 2002;37: 194-203. • Marsh, Darrin. Little League Elbow: Risk Factors and Prevention Strategies. Strength and Conditioning Journal. 2010;22: 22-37. • Osbahr D, Kim H, Dugas J. Current Opinions in Pediatrics. New York, NY: Lippincott Williams & Wilkins. 2010, 35-40. Websites • http://www.childrensmercy.org/sportsmedicine/ • http://www.stopsportsinjuries.org/ • http://stopsportsinjuries.reingoldweb.com/files/pdf/AOSSM_Baseball.pdf • http://stopsportsinjuries.reingoldweb.com/files/pdf/AOSSM_Softball.pdf