Preventing Child Elbow & Shoulder Injuries – Pt 2

Call us at 281-633-8600.  In this article, Orthopedic Surgeon Dr. J. Michael Bennett talks about shoulder injuries and elbow injuries to youth baseball players.  Doctor Bennett specializes in treating injuries of the shoulders, elbows, and knees and certain injuries of the hands and wrists such as carpal tunnel syndrome.

This video is the second of three sections of a talk given by Dr. J. Michael Bennett to the parents, coaches and players of the Toros Baseball organization of Sugar Land, TX.  The talk was hosted by Bases Loaded in Houston, TX.

Dr. J. Michael Bennett is a Board Certified Orthopedic Surgeon with a Certificate of Added Qualification (CAQ) in Sports Medicine.  Doctor Bennett completed a Sports Medicine fellowship at the University of Miami and served as assistant team physician for the Tampa Bay Buccaneers and the University of Miami Hurricanes.  He’s also served as a team physician consultant for the Houston Livestock Show and Rodeo and as a team doctor for the Houston Independent School District.  An athlete himself, Dr. Bennett was captain of the varsity lacrosse team at the University of Texas.  We serve patients from all over Metro Houston from clinics in Sugar Land and Houston, near the Houston Galleria.

Here’s the transcript of the second portion of Dr. Bennett’s talk on elbow and shoulder injuries in children.

Shoulder injuries.  This shows you how much growth is attributed to each one of these bones.  Eighty percent of your humerus – your arm bone – comes from this growth plate right here, so if you shut that down prematurely, if you injure that growth plate, you’re injuring 80 percent of the growth of this bone.  That’s a real big deal.  Twenty percent is in the elbow region.  So it’s less serious in the elbows. 

Physeal injuries, this is a growth plate injury, it’s a fancy name for growth plate.  Usually the proximal humerus, which is the shoulder bone up here, is the most common one that’s injured.  It’s called “little league shoulder,” it’s usually secondary to repetitive movement, repetitive poor throwing technique.  I’m going to show you guys what makes it obvious for us.  A lot of people when you go out there and get an X-ray you’ve got to make sure you look at the growth plates; some doctors don’t know what to look for.  This is a normal growth plate right here, this little sliver of line right here, it means that they’ve got a normal growth plate, they’ve got a permanent growth going.  When you see a lot of space here in the growth plate, and there’s a lot of pain and they don’t want to move their shoulder, for all intents and purposes that’s a broken bone.  This is what it looks like on MRI, this separation, this is bone, that’s the cartilage, there’s the growth plate that’s separated.  And like I said that’s when a child is holding their arm, they don’t want to lift it, and they hurt when you push on it.

The treatment is always based on the age and discomfort.  If it’s non-displaced like I just showed you, you can just put them in a sling, no surgery, limit their throwing for about eight to 10 weeks depending on the severity of the fracture – and we’ve got to let it heal; it’s like a broken bone.  Sometimes they can come back sooner; it just depends on the age of the child.  If it is angulated or displaced or if there’s actually a big space there, you may have to fix that.  Sometimes if they have about four of five years of growth left, they can actually remodel that and you don’t have to have surgery.

So, shoulder instability, this is another issue we see in kids.  Shoulders are usually the most commonly dislocated joint in extremities, more common than the elbow.  This is the ball, this is the socket here.  This needs to be on top of that.  Think of it like a golf ball and a golf tee.  You see this in athletes who perform a lot of overhead motion:  volleyball players, swimmers, and pitchers in particular.  Generalized ligamentous laxity:  what seems to be a mechanical advantage for these kids – which is external rotation in this very lax joint – is also what puts them at risk.  You’ve got to make sure you’re doing the proper exercises to prevent dislocation to the shoulder.  

This is showing the ball and the socket that I was talking about.  And around it you’ve got these little bumpers of tissue called labrum, and sometimes if you have a dislocation of the shoulder something pops out of the joint and it rips off one of these little bumpers here and that’s what we’ve got to fix.   

Uually the type of instabilities that we see in the clinics are of two types:  

This is what a dislocated shoulder looks like.  We had this kid that was playing out here and he fell down and his shoulder is drooped down like that and you can see some tension here compared to the other side:  that shoulder is out of joint and it needs to be popped back into joint.  This is what it looks like on X-ray.  I showed you guys the golf ball and golf tee; this is the golf tee that’s popped out of joint.  So you’ve got to get those back immediately.  A trainer or somebody like myself needs to be available to pop the joint back in or get them to the emergency room where they can make them comfortable and pop it back in.  You need to put it in immediately. 

When I look at a patient that has chronic instability, these are tests we do to evaluate the shoulder to see how active they are.  If it’s painful in any of these motions, usually that means we’ve got to get an MRI or further tests.

Treatment like I mentioned before if it dislocates you’ve got to pop it back in, if it’s chronic and you’ve got multiple shoulders that pop out of joint or they’ve got loose joints, you’ve got to get them to therapy, they’ve got to work on bands, work on strengthening, the internal rotation/external rotation, really strengthening that shoulder.  Rotator cuff strengthening is just like I showed you here.  Scapular stabilization is something that baseball players need to work on specifically.  If you have a weak scapular, or muscles underneath the scapular, it throws off the whole mechanics of the shoulder and then you can really injure yourself.  Range of motion and core strengthening is also important.

Here are some basic exercises regarding strengthening exercises to prevent shoulder injuries.  It’s just a matter of isolating the muscle and working with the bands.  I typically like resistance bands better than free weights because it’s a smaller, controlled motion, and you’re less likely to drop it on your foot and you just gradually increase the resistance as desired. Starting with the back, the scapula is important.  What you do with the kids if you want to work on the back scapula stabilizer muscles, tell them they’re holding a quarter between the shoulders blades and tell them to pinch that, okay, and then relax.  Pinch it and hold back.  That keeps the scapula toward the rib cage so it doesn’t flail out, what’s called the winging scapula.  That way your shoulder doesn’t go into too much external rotation and injure the shoulder.  So that’s an important exercise; it’s simple but it’s very important.  If you’re using the bands, this shows using the bands in different directions, you can find this on the Internet, my website has it as well.  It’s really just tying a band to a post and working it one way, then the other way, work it up, just isolating each muscle of the shoulder.

Indications for surgery in regards to shoulder.  Kids that are skeletally immature, like really young kids that have dislocation, usually will not do surgery, a lot of them will heal up and are okay with strengthening and stabilization.  If they are mature and have a dislocation and their growth plates are closed, like your teenagers now, then they have a higher rate of dislocation, and in that case there’s about an 80 percent chance of risk of re-dislocation after a traumatic dislocation of the shoulder.  Every time that shoulder pops out of joint it wears down that cartilage so you’ve got a higher risk of arthritis long term.  You want to make sure you get it looked at if it keeps on popping out.  Multi-directional instability means voluntarily popping your shoulders out of joint, then popping them back in – these are the kids that can bend their thumb back to their wrist or have really loose joints – strengthening is all you need for that, just physical therapy working on the muscles.  

Impingement.  You see this in pitchers primarily.  It’s mechanical because there’s something actually physically wrong with the joint itself .  What happens is you have a little bit of instability and then you’re creating a stiffness in the back of the shoulder and I’ll explain that here.  It starts with a muscle-tendon imbalance; that’s what I mean by saying to make sure you’re doing strengthening exercises on every single muscle in the skeletal joint of the shoulder area.  If you’ve got one area that’s weak it’s going to overload and it’s going to weaken another area and then you’re just completely out of whack and it’s going to injure the rest of the shoulder.  An overloaded posterior capsule; if we’re looking at the shoulder joint here, the shoulder joint is a ball and socket and in the middle is the rotator cuff.  This ball is also held in the socket here by an envelope, we call it a capsule, and it’s underneath this rotator cuff.  So when you have somebody that’s doing this motion here, let’s say the muscles are imbalanced, this area in the front becomes more lax and the back becomes tighter and restricted.   So these muscles in the back are left overcompensating for the muscles in the front.  And then you lose internal rotation.  So a lot of kids that are pitchers I see, they’ve got a great external rotation for their arm, and they’re doing their cock up, and they’re reaching all the way back here whereas the other arm is not nearly as loose, and then their internal rotation only goes to about here and the other side can go to here.  So that creates an imbalance in the shoulder and that can lead to problems.  

This is the area of the shoulder, this is the ball and socket, and this is the capsule here.  This is lax in the front, this gets tight in the back.  So you go through the cock up phase, this is what creates the laxity in the front, being the looseness in the front of the joint, you go through the deceleration here, these muscles in the back are firing, trying to keep that shoulder joint from not pulling out, and so they try to hold it in place but it overloads the capsule, the lining, of the back and that lining becomes very thick and irritated and it becomes tight in the back. So it’s these two motions that end up causing problems in the shoulder. 

It basically leads to what’s called a SLAP tear.  You read about this, you hear about it a lot, it’s the superior labrum tear.  All it is is the biceps tendon, it inserts into the joints – I’ll show you a picture of it here.  Basically what happens is think of that biceps tendon, if you go pull a weed out of the ground, you rock it back and forth, and you pop it out of the ground, that’s what’s happening to the biceps; the constant repetitive movement of the shoulders, pulling on that biceps, pulling it back and forth to the point where it weakens and actually pulls off its insertion site in the bone.  And it causes a painful popping and clicking sensation when they’re throwing.  

This is what it looks like in the shoulder.  There’s the ball, this is the socket, this is where that noodle-like biceps inserts, this is where it rips off, and this is where the tear occurs.  We have to fix this so they don’t lose any more velocity or have any more degeneration or tearing of this biceps.  This is that labrum I was telling you about, the bumper around that ball and socket so the biceps goes right along all the way around to the top here.

So the key is prevention at this stage.  Throwing technique: you’ve got to correct poor mechanics.  Trunk rotation occurring too early in the pitch is an issue.  They rotate their trunk too early and the rest of the body can’t catch up, that creates added rotation in the shoulder and creates hyperextension of the shoulder and overloads the joint.  So it has to be a matter of timing.  We have to have someone watching the pitch, somebody watching their trunk, watching how they throw, making sure it starts with the foot, rotating their head and then follow-through with the shoulder.  I see kids that all they do is concentrate on their upper body, everything’s about the arm, about whip-lashing their upper body; it’s got to start with the feet and move up, okay?  Prevent overload with muscular balance.  Don’t forget the strengthening exercises we talked about.  Once again the scapula is important; you can get something that’s called the SICK scenario, which is the scapular instability of the shoulder blade, and that can also throw the mechanics off as well.  

So prevention as far as if you do have a kid or a thrower that already has a tight capsule – one arm’s like this and the other arm’s like this and they can’t rotate any further than that and they’ve got great external rotation but need to work on this internal rotation.  You want them stretching out that posterior capsule and one of the stretches you want to do is called the sleeper stretch.  You have them lie on their side, prop their elbow up, prop their arm up at 90 degrees, and push down on that elbow with the other hand.  This is actually one of the more popular types of stretches out there.  The other way to do it is to lean that elbow across your body or bring it across the front of your body; whatever you can do to stretch out that posterior capsule. 

Now, vascular problems in the shoulder.  You see this in older kids.  I had a pitcher who came in to see me the other day from Louisiana actually, and when he pitches – and these are classic symptoms – he feels numbness and tingling in his fingers and his hands turn white. And it’s only when he pitches.  What’s happening is actually the nerves and the vessels that travel through this little tunnel here through the shoulder called the thoracic outlet are getting pinched.  And it has to do with tight muscles in the top as well as the first rib down below.  If they keep on having problems with that sometimes that can lead to vascular occlusion or thrombosis, a blood clot forms, and that can become devastating.  You want to catch it early.  Luckily these shoulder injuries can be prevented by doing a lot of stretching exercises; very occasionally surgery is indicated and surgery is actually taking out the first rib.  I typically don’t recommend it if you can get away with doing the therapy and the stretching exercises.

This is just a picture of what I’m talking about.  These are the vessels that come through here, the nerves, and they actually go through this tunnel right here and then you’ve got the first rib right here between these two muscles.  When you go into a pitching motion – abduction external rotation – in the cock up phase here, it pinches off these neurovascular structures and causes that discoloration of the hand and causes numbness and tingling.  So prevention is the key just like everything else.  Stretching, muscular balance and proper mechanics.  These are just some basic stretches here, stretching the neck, stretching those muscles that pinch those nerves and vessels, by tilting your head to the side, then tilting to the other side.  There’s also the pectoralis stretch, which is where you lean into a doorway with your arms folded out, lean forward, and stretch out that area.  There’s also the scapular squeeze like we talked about earlier. 

If you have questions about shoulder injuries or elbow injuries for kids playing sports like baseball, please call our office at 281-633-8600 to make an appointment to discuss your question with Dr. Bennett.  Dr. Bennett sees his patients at his Sugar Land office near First Colony Mall and in Houston, near the Houston Galleria.

Dr. J. Michael Bennett

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