Previous Work in the Area of Injuries in Youth Throwing Athletes

1. Previous Work in the Area of Injuries in Youth Throwing Athletes And Study Goals for AOSSM Jeff Dugas, MD

2. Albright JA, Shaw S, et al • 54 Youth pitchers over a season • Video and questionnaire • More injuries with side-arm throwing • 5 arm slots described • Lower slot leads to higher injury rate • No control or review of trunk position • May decrease validity

3. Fleisig et al 1999 • J Biomechanics 1999 • 23 youth, 33 HS, 115 college, 60 pro pitchers • 16 kinematic (11 pos, 5 velocity), 8 kinetic, 6 temporal parameters • 16/17 positional and temporal parameters were found to have NO DIFFERENCE • All 8 kinetic parameters increase with age • Children should be taught proper mechanics and gradual strengthening

4. Lyman S, et al • Med Sci Sports Exerc 2001 • 298 pitchers over 2 years • 26% elbow pain, 32% shoulder pain • Risk Factors Elbow: • Age, weight, decreased height, lifting weights during season, multiple teams, more than 600 pitches per season, pitching while fatigued • Risk Factors Shoulder: • Pitching with fatigue, more than 75 pitches per game

5. Lyman S, et al • AJSM 2002 • 476 pitchers (age 9-14) over 1 season • Pre-/post-season questionnaires, pitch cts, video • 52% increase in risk of shoulder pain with curveball use • 86% increase risk of elbow pain with sliders • # of pitches increases risk

6. Sabik M, et al • Video data on 14 youth pitchers • Fastballs only • 18 Nm peak elbow valgus torque just before max ER • Weight was closest correlation with force • Limiting exposure was best way to prevent injury

7. Petty D, et al AJSM 2005 27 High School UCL recon 74% return to same or higher level 85% had one or more risk factors 67% began throwing breaking pitches before age 14 Velocity average 83 mph (high)

8. Sabick M, et al • AJSM 2005 • 14 elite youth pitchers, age 12 • Video analysis • Peak ER torque =17.7Nm just before max ER • Shoulder distraction force of 214 N at ball rel. • Shear forces more than adequate to create physeal injury

9. Olsen S, et al • AJSM 2006 • 95 adolescents with Shoulder surgery • 45 with no surgery • Injured athletes had: • More months per year throwing, more games per year, more innings per game, more pitches per game, more pitches per year, more warm-ups per game, more starters than relievers • More showcases, pitched with pain, used NSAIDS, were taller and heavier • Private instruction made no difference • Age at onset of breaking pitches made no difference

10. Dun S, et al • AJSM 2008 • Biomechanics study with markers/video • Torques not different on three throws of fastballs and curveballs • Curveballs may not increase risk of elbow injury • Volume of throwing increases risk • Does fatigue of peri-articular musculature lead to increase stress on joint/ligaments?

11. Nissen et al • AJSM 2009 • Biomechanical study with three throws • Moments on shoulder and elbow are less with curveball than fastball

12. Study Goals • Utilize AOSSM resources, particularly its members to: • Create and maintain a database of youth throwing athletes • Collect epidemiologic and demographic information on a large group of at-risk athletes • Report on the injury risks, incidence and occurrence of injury • Make suggestions about injury prevention

13. Youth Baseball Pitching Studies Joseph H. Guettler, M.D. Member, AOSSM Research Committee and Study P.I. Director, Beaumont Sports Medicine Education and Research

14. IRB Approval: • William Beaumont Hospital Royal Oak, Michigan

15. The Study: • Nationwide project looking into the epidemiologic risk factors related to shoulder and elbow injuries in youth baseball. • This study will seek to define risk factors related to both acute and overuse injuries, as well as factors contributing to adaptive changes in the developing shoulder and elbow. • The goal of this project is to build on previous studies, and create the largest youth pitching database in the world. • With this information, the AOSSM will be able to make authoritative recommendations – that are based on firm science – to youth baseball organizations, parents, and coaches.

16. Study Description: Two Study Limbs: • Office-Based Questionnaire • League-Based Questionnaire

17. Inclusion Criteria: • As many AOSSM and ACSM members as possible • Youth baseball pitchers between the ages of 9 and 18 • Pitchers presenting with injuries to the physician’s office • Pitchers actively involved in youth and high school leagues who can describe their history via a questionnaire – whether they have had injuries or not

18. Design Rationale:

19. Design Rationale:

20. Treatment Patterns:

21. Treatment Patterns:

22. Study Hypothesis: • Certain risk factors, including throwing year-round, contribute to an increased incidence of shoulder and elbow problems in youth baseball pitchers

23. Ultimate Study Objective: • What separates this kid from…

24. This kid?

25. Thank You!Please Encourage Your Colleagues to Get Involved!

26. The Institutional Review Board (IRB) Process Bart Mann AOSSM Director of Research

27. Determining IRB Coverage • Am I already covered by an IRB through my hospital or academic institution? • If yes, you most likely will need to submit an application through them • The exception is if you are able to get your Research Department to write a letter of deferral • If no, you may obtain coverage through the IRB at the study principal investigator’s institution (William Beaumont Hospital in Michigan)

28. If You Are Already Covered… Obtain the forms required by your IRB for Expedited Review (usually available on the website of your institution) Download the IRB templates for the studies from the AOSSM website (www.sportsmed.org/tabs/research/youthbaseballstudies.aspx) Cut and paste elements from the templates into your institution’s forms Submit all required forms to your IRB and wait for the good news

29. If You Don’t Have An IRB… • Email me (bart@aossm.org) to obtain Research Conflict of Interest Forms • Register for the on-line course in research through the Collaborative Institutional Training Initiative (CITI; www.citiprogram.org) • Select “William Beaumont Hospital Research Institute” as the Participating Institution • for Item #1, “Course in the Protection of Human Subjects,” just check the box by MANDATORY.  • On the next page, check No that you do not want to be affiliated with another institution.  • Then you are set to take the course which will take about 3 hours • Email me the Certificate of Completion along with the signed and dated Research COI forms and a signed and dated CV

30. Frequently Asked Questions • Do I need to get IRB approval even if I’m just handing out the survey away from my institution? • Yes. Even though there is really no risk to subjects, the studies involve minors which triggers a mandatory IRB review • My IRB is notorious for taking a long time and making the process difficult. Is it possible to use Beaumont Hospital’s IRB? • Probably not. You can check with your IRB or Research Department to see if they would defer to Beaumont’s IRB but in most cases they will want to conduct their own review. • My IRB charges a fee for review. Are there any funds to help me with this? • Not at this time. We are hopeful that we may get funds for this purpose from the STOP Sports Injury Campaign at some point in the future. Other sites have had success with getting the fee waived by describing the nature of the study and the sponsor (not-for-profit medical professional society) • I don’t have any research support and I’ve never completed IRB forms. Is there any assistance available? • Yes. Just email me the required forms for your institution or the link to download the forms. I can complete most of the items for you and send them back to you to do the rest. Depending on my schedule, it may take a few weeks to get them back to you.

31. www.stopsportsinjuries.org

32. Sports Tips

33. Community Presentation PowerPoint

34. Understanding & ManagingRelationship Between Throwing Mechanics & Injury John Albright, MD University of Iowa

35. Perspectives on Risk Factors • “Every pitcher is the same” • Pitch count • Pitch speed • Breaking ball count • “Some individuals at greater risk” • Anatomical variations ( Mayo Cl) • Mechanism of delivery ( SDCH)

36. Hypothesis: Main Risk Factor W h i p action

37. Clinical Study of Baseball Pitchers:Throwing Arm Injuryvs.Method of Delivery J Albright, P Jokl, R Shaw, J Albright AJSM 1978

38. Robert Shaw “How to last longest in the Major Leagues” Throw in downward plane Faster Less effort Never miss inside-outside Only miss high-low Curve drops

39. Classic Outfielder’s Pattern(maximum speed & distance) • “Long arm” delivery • throws in “downward plane” • ball high above head • scapula/arm vertical to ground • elbow extended (long lever arm) • minimum force on ligaments • triceps muscle enhancement • “Effortless” arm 1st (no whip)

40. Classic Infielder’s Pattern(quickest ball release time) • “Short arm” delivery • elbow flexed (short lever arm) • arm abducted 90 ° • whiplash mechanism • body first (“opens up”) • scapular entrapment • Maximum force on ligaments • shoulder • elbow

41. on-field demo

42. Materials • 109 little league • 18 college

43. Methods • Slow motion videos • 2 views • Questionnaire • Physical exam • swelling • tenderness • limited motion

44. Symptoms

45. Mechanics of Delivery vs Symptoms All Pitchers

46. Change of Pitching Form • 8 changed form on own • 5 changed form with coaching • All improved symptoms

47. Conclusions • Arm Pain related to pitching form • Poor form related to “whipping action” • short arm delivery • rushing • opening lead shoulder • lifting back foot too soon

48. Phase 1: Identifying the problem Identify magnitude of problem • 1975 study vs. 2010 Identify “blue chip" volunteers initial data collection Phase 2 participation

49. Phase 2: Pilot study Step 1: validate 2 camera screening Compare 2 to 6 camera system 10 Injured vs. Controls Multiple test sites

50. Phase 2: Pilot study Step 2: biomechanics lab correlation of kinetics to Shaw-Albright classification system Can we easily ID very bad form that will cause injury? Who needs sophisticated lab evaluation?