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
  physicians 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 investigators 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 institutions forms
• Submit all required forms to your IRB and wait
  for the good news

29
If You Dont Have An IRB

• Email me (bart_at_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 Im 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 Hospitals IRB?
• Probably not. You can check with your IRB or
  Research Department to see if they would defer to
  Beaumonts 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 dont have any research support and Ive 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 Injury vs. 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 Outfielders 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 Infielders 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
Mechanics of Delivery vs Symptoms Little League
only
47
Change of Pitching Form

• 8 changed form on own
• 5 changed form with coaching
• All improved symptoms

48
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

49
Phase 1 Identifying the problem

• Identify magnitude of problem
• 1975 study vs. 2010
• Identify blue chip" volunteers
• initial data collection
• Phase 2 participation

50
Phase 2 Pilot study

• Step 1 validate 2 camera screening
• Compare 2 to 6 camera system
• 10 Injured vs. Controls
• Multiple test sites

51
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?

52
Effects of Sequential Body Motion on Elbow Valgus
Loading during Baseball Pitching

• Arnel Aguinaldo, MA, ATC
• Henry Chambers, MD
• Center for Human Performance, San Diego, CA
• Childrens Specialists of San Diego

53
Purpose
To determine which parameters most influence
valgus loading _at_ elbow
54
MLB Study Results

• higher valgus load in pitchers who initiated
  trunk rotation before front foot contact

55
Phase 2 Pilot study

• Step 2a Development of Dick Tracey
  wristwatch (accelerometer)
• Gill (MGH)55

56
Phase 3 Pilot study

• AOSSM membership office based
• 2 camera video study
• final classiciation?
• Screen to biomechanics lab?
• examination
• 100 Injurd vs. controls

57
Phase 4 NIH proposal

• This NIH field study will require that all
  pitchers on every team studied will need to be
  entered into the study prior to the beginning of
  the season.  
• This will be a prospective random block selection
  intervention study. 
• By the end of the study we will have established
  a means of reduction of 50-75 of throwing
  related upper extremity injuries in youth
  baseball.

58
Phase 4 NIH proposal

• Those pitchers with poor mechanics (therefore
  high risk of UE injury) will be identified

59
Phase 4 NIH proposal

• Instructors will be assigned randomly to teams to
  teach proper mechanics to the high risk group
• No pitchers on the selected teams will be allowed
  to pitch until they have demonstrated proper form
• All pitchers will be removed from the mound
  whenever their gyroscope data indicates they have
  changed their mechanics to fall into the
  high-risk pattern of throwing.