Millions of children, adolescents, and adults in the United States and abroad participate in baseball or softball every year. While the rate of traumatic injuries in baseball and softball are low, greater numbers of throwing athletes participating in these sports are developing significant othropaedic and musculoskeletal injuries. As a physician practicing orthopaedic sports medicine, I have noticed a serious and concerning trend. Each year an increasing number of young throwing athletes are sustaining injuries to their throwing arms, particularly to their elbows and shoulders. Many of these injuries can be prevented simply by educating coaches, parents, and the athletes themselves.
Over the next year, I will be discussing a variety of topics related to Baseball Medicine. I will cover topics specific to the young skeletally immature athlete in addition to those injuries found in the more mature player. Articles will cover the recognition and treatment of these injuries and most importantly the prevention of these injuries. Future topics will include those specific to the young player including Little Leaguers Shoulder and Elbow; Osteochondritis Dessicans and Panners Disease; Osgood Schlatters Disease and injuries specific to the young spine. Other topics commonly found in the skeletally mature athlete including: shoulder and elbow instability, rotator cuff injuries, tendonitis in the shoulder and elbow, and nerve injuries will be reviewed. Finally, topics related to proper throwing mechanics, strength, flexibility training, and overall conditioning will be discussed. The first of the series of topics will be on Overuse Injuries.
Overuse Injures
Athletes routinely participate in organized and competitive sports and training programs demanding increasing levels of commitment resulting in many hours of high volume and intensity training. Fewer children today participate in a variety of sports, but rather participate in the same sport or activity for greater sustained periods of time or throughout the entire year. We have also observed increased participation of younger athletes in organized sport. With the increase of younger athletes participating in organized and competitive sports for longer periods of time, an increase number of injuries as well as a change in the injury patters sustained by these athletes have been observed.
Injuries in sports occur either from an acute event or as a result of repetitive trauma. Acute injuries are usually the result of macrotrauma, a single traumatic event such as a fall or a blow to the body. Common examples of acute injuries include ankle sprains, ankle and wrist fractures, dislocations and torn hamstring or quadriceps muscles.
Overuse injuries on the other hand, are the result of repetitive microtrauma to bones, muscles, ligaments, and joints. Over use injuries develop over time and are more subtle in their presentation. Common examples of overuse injures include Little League elbow, Little League shoulder, jumper’s knee, runners knee, shin splints, Achilles tendonitis, rotator cuff impingement and shoulder instability syndromes.
Overuse injuries are defined as those that occur from the repetitive application of submaximal stress to normal tissue. The volume of training and repetition undertaken by these athletes eventually overwhelms the normal reparative process, eventually leading to tissue inflammation.
Overuse injuries can occur throughout the body affecting a variety of tissue including: tendons (producing tendonitis), bone (producing stress fractures), bone-tendon and bone-ligament junctions (producing instability) and at the growth cartilage found in the epiphyseal plates, articular cartilage of the joint surfaces and apophysis at the attachments of muscles to bone.
Why Do Overuse Injuries Occur?
Overuse injuries develop when the fine balance between tissue breakdown due to training and tissue recovery is disrupted. Simply put, the tissue break down occurs more rapidly than the tissue build up or recovery leading to injury. The human body has a tremendous capacity to adapt to applied physical stress (exercise) resulting in an increase in muscle, tendon; ligament and bone function referred to as remodeling. A balanced tissue break down and build up occurs during the remodeling process.
Overuse injuries potentially will occur when we first begin a sporting activity performing too much too soon. This ultimately leads to inadequate recovery time.
Causative Factors
Overuse injuries result from either intrinsic or extrinsic factors. Intrinsic factors are those related to the athlete themselves such as: anatomic alignment (leg length differences, hip rotation, foot deformities); growth; muscle-tendon imbalance; underlying diseases (chronic disease, previous fractures or injuries inadequately treated or rehabilitated, previously unrecognized conditions) and cultural reconditioning (too much TV or computer games-too little physical exercise).
Extrinsic factors include training errors, environmental and equipment factors.
Training errors are the most common factors predisposing an athlete to overuse injuries. These injuries develop when the athlete performs too much too soon, increasing the volume, duration and/or intensity of the activity too quickly. These training errors result in inadequate recovery time, preventing the proper tissue adaptations from taking place. Overuse injury can also develop in people returning to a sport or activity after injury. Typically, they try to make up for lost time.
Training errors most commonly occur early on in the training program when a relatively unused tissue is subjected to stress that they may not be accustomed to. The potential for the development of overuse injuries occur when new skills are introduced into the program stressing different tissues, or when the training intensity is increased too rapidly. Overuse injuries also are noted to occur during the later phases of the training programs when the athlete is pushing towards peak performance. It is during this time in the training program that the tissues are close to their ultimate breakdown point and vulnerable to injury.
Inadequate or poor technique in the performance of a particular sport or activity (improper throwing mechanics), can place abnormal stress on musculoskeletal tissue leading to overuse injury.
Improperly fitting equipment or inadequate equipment for a particular activity have also been shown to predispose an athlete to overuse injures. A common example is seen in athletes wearing the poorly fitting or worn down shoes during heavy running activity.
Environmental factors such as playing surfaces, natural grass, artificial turf, hardwood floors, have also been shown to have an impact on the incidence of overuse injury.
How Are Overuse Injuries Diagnosed?
The diagnosis of overuse injuries can only be made after a thorough history and physical examination are conducted by a sports medicine specialist. Some cases will require additional diagnostic testing such as X-rays, bone scans or MRI studies.
How Are Overuse Injuries Treated?
The treatment of overuse injuries will depend on the specific injury diagnosed. Treatment might include oral medications and physical therapy. Decreasing the intensity, duration, or frequency of the offending activity may also be recommended by the clinician. Careful attention to technique, working with a coach, paying attention to proper warm up prior to activity, proper cool down after activity, in addition to the application of ice after exercise are also beneficial.
Prevention of Overuse Injuries.
The majority of overuse injuries can be prevented with proper training and using common sense during training. There is no truth in the saying “no pain, no gain”. The athlete must learn to listen to his own body and recognize the early signs of overtaining.
Generally, if increases in volume and intensity of training are kept below 10% per week, allowing the body adequate time for recovery and response, the majority of overuse injuries can be prevented.