Prevent Little League Shoulder Syndrome

Casey Bass: Today on Clubhouse Gas, I am going to go and see Dr. Marshall. We've got to do something about this shoulder pain; stay tuned. We are lucky enough to be joined by friend of the show, and the Director of Sports Medicine here at Children's Healthcare of Atlanta, David Marshall and his son Grant. Guys thanks for joining us. Dr. David Marshall: Thanks for having us back. Casey Bass: Today I want to talk about something that I have never heard off until today. I have heard Little League Elbow, but not Little League Shoulder. What is Little League Shoulder? Dr. David Marshall: Well Little League Shoulder is another one of those pesky growth plate elements that seems to effect Little League baseball players between the ages of 8 and 13 when their growth plates are still open and it’s another one of those growth plate injuries rather than the elbow, the knee, the heel, this occurs at the top of the shoulder. Casey Bass: We'll use this good looking model; we have got here and show us exactly what's going on. Dr. David Marshall: Well in a nutshell there is a really two different types of growth plates we have in our body. One growth plate is called an Apophysis and that’s the growth plate that serves as an anchor points for muscles and tendons. So the Little League Elbow, Osgood Slaughters disease, Sever’s disease, other growth plate problems in the knee are called Epiphyseal; where this growth plate is little more important, it is called an Epiphysis, and that growth plate is made up of a cartilage bar that is found at the ends of all of our long bones in our body. And those growth plates are very important, because what they will do is lay down layer after, layer after, layer of new bone and that’s what allows our bones to grow in length. So if we injure those growth plates we have to be concerned about the bone prematurely stopping growth. Casey Bass: So where you told us in a previous show that we could -- even with a little bit of pain the kid could go and play, they are not going to hurt themselves anymore, this might not be the case. Dr. David Marshall: Absolutely not in if kids have Little League Shoulder, if they have an injury to the growth plate at the top of the Humerus or the arm bone, then we really have to be little more aggressive, and much more careful to treating these kids. We recommend that they do not throw for a period of sometimes of six to eight weeks. I tell the kids this is like a broken arm. Now it's not like your arm broken half, that happens when you fall of the monkey bars, but in terms of the growth plate it is a fracture of that growth plate. Casey Bass: Well all we have got Grant we just want you show us exactly what it is that causes it. Dr. David Marshall: This is where it hurts. A lot of the older kids will complain of rotator cuff pain, the high school pitchers, the college pitchers, they will complain of pain more in the top of the shoulder, sometimes back behind the shoulder. But the young athletes that have Little League Shoulder they complain of pain more down at the top of the arm. So they will grab their arm, or they will point here, and that’s a very concerning complaint if they come in with that. What happens anatomically is the rotator cuff muscles from the back attach right above the growth plate, right about here. And when they throw that follow through phase of throwing there is an awful lot of traction or torque forcing the shoulder this way. So the momentum is going that way, the rotator cuff muscles are pulling that way, and that’s what sets up that traction force on the growth plate and over time that growth plate will actually separate and that’s the fracture what causes the pain. Casey Bass: So it is not actually the act of throwing, it is act of follow-through? Dr. David Marshall: Yes, it's the deceleration phase of throwing. When the kids -- when they are in that cocking phase, or acceleration they are much more likely to get pain in the elbow, but as you are coming through, and the rotator cuff muscles in the back contract to try to slow that shoulder down, similar to a parachute on a dragster when the muscles are pulling backwards, momentum is going forwards, that puts way too much stress on that growth plate, and sometimes it fails. Casey Bass: Well you talked about how to prevent the Little League -- how to prevent here, but if it's a follow-through thing is there any way to prevent that, one of those freak accidents? Dr. David Marshall: Well you really can’t prevent it other than watching the pitch counts. Again this is an overuse injury, but it doesn’t involve a muscle or a tendon or a ligament, it involves a growth plate. And the best way to treat an overuse injury, like we said is to under use it. So minimize pitches, watch the position they are playing when they are not pitching such as shortstop, catcher, and third base. A lot of times in U.S. baseball the better athletes are the pitchers, and when they are not pitching they don’t sit on the bench, or go to the bullpen to wait for their next start. We put them in very important position like catcher, or third base, short stop. Casey Bass: Well Grant go eyes down, me and dad will talk a little more. Now I know what Little League Shoulder is, what exactly the symptoms, how do we start to recognize, you know this is a problem? Dr. David Marshall: Well the most important symptom I think is pain, that we have been encouraging these kids that have elbow issues and shoulder issues when they throw, they really shouldn’t try to throw through the pain. Some of the growth plate problems like in the heel, and the knee it's okay to endure some discomfort, but the shoulder and the elbow in young throwers they really should not throw with pain. Unfortunately one of the common things that brings them into the office is decreased performance, that they may not come in, because their shoulder aches a little bit. They come in, because they lose control, they lose velocity. They can’t get the ball near the plate with the zip that they used to. So unfortunately, that’s what brings them in rather than the discomfort. Casey Bass: And then you said unfortunately, because it's too late? Dr. David Marshall: Well, it's too late and of course I want kids to seek medical attention, because they have pain not because they lose performance and unfortunately it's the latter that usually brings them in. Casey Bass: You are not here to keep a kid throwing 70 miles an hour; you are here to keep a kid healthy and unhurt. Dr. David Marshall: Exactly. Casey Bass: So that makes perfect sense. Dr. David Marshall: Individual health of the athlete always takes top precedence over the success of the team, or success of the league. Casey Bass: And we here at Clubhouse Gas could not agree more. So, we know what it is. Alright we have talked a little bit about what causes it, but could you explain a little bit on the idea of the follow-through and the extension of that growth plate? Dr. David Marshall: Yeah, the growth plate in the Little League Shoulder, remember it's not one of those Apophyseal growth plates, it's not really an anchor point for a muscle or a tendon. It's actually the growth plate at the top of the arm bone or the Humerus that's going to contribute to the arm getting longer. So with these types of growth plates we have to be a little more aggressive with encouraging and requiring rest for these kids. If they have that type of injury to the wrist, they leave my office with a cast. If they have that type of injury to the growth plate in the ankle, they leave my office with a cast. Unfortunately that's too high up in the elbow, I really can’t put a cast on their arm, unless that include their head, and that’s not very nice thing to do. So we really try to encourage these kids just to stop throwing and I like to use a sling. I think a sling, number one acts a nice reminder that they can’t pick up their 800 pound book bag with their arm. They can’t pickup that ball and whip it back to their buddy during PE class during Texas battle ball. They can’t open a car doors and use it. So it pretty much acts as a nice reminder and allows that shoulder to rest which exactly what it needs. Casey Bass: Is there a specific motion? We talked about a Little League Elbow there is different motions and they enhance, the Little League Elbow. Is this purely an overuse, or is there a way that the kids can have a poor motion that would enhance their chance of having an injury? Dr. David Marshall: I think it is an overuse injury, and it's like we said before, it's not necessarily from a muscle pulling on that growth plate, like Osgood Slaughters, or the elbow, but what it is, it's traction force during the deceleration, or the follow-through phase of throwing. We have already talked about the elbow when the kids are back in this position, it puts a lot of torque and stress on their growth plate there, but Little League Shoulder is during the follow-through phase. And the problem is there is traction force setup at that cartilage bar or that growth plate. Momentum is going forward, the rotator cuff muscles that come from the back have to pull to slow the arm down. So momentum doesn’t allow your shoulder to dislocate off the front of the socket. So with momentum going forward, the rotator cuff muscles pointing backwards, that’s what sets up that tugging and what happens is the growth plate gaps, and they actually get a separation, or a fracture of that growth plate. Casey Bass: Is there anything that a kid to do to accelerate their process such as dropping out those slot or maybe throw one of poor curve ball too early, as far putting more pressure on the shoulder, is it just -- Dr. David Marshall: I think all those things can be a factor. The main thing as it is with Little League Elbow is peer volume. The kid with the absolute dead-on perfect mechanics, there are still going to be a number of pitches where that growth plate is going to fail. If the kids has lesser mechanics or they drop down too soon, or they may open up their hips too soon, and that allows their shoulder to lag behind, then they have to use a lot more torque and stress to catch that shoulder up during a throwing motion. So clearly proper mechanics is the first place to start and then we also worry about volume after that. Curve ball's breaking pitch, well that's kind of gotten a bad wrap and it’s Little League Elbow. We can talk about that on another show, but I don’t think curve balls are breaking pitches per se have a lot to do with the shoulder, it's volume. Casey Bass: Yeah, that’s big muscles work too. Dr. David Marshall: Volume and velocity. Casey Bass: We talked about putting kids in the sling, how do you treat your Little League Shoulder? Dr. David Marshall: Well the sling actually rest, that’s the most important thing we can do for an overuse injury is to avoid the offending activity so the sling takes cares of that. I like icing, it's an inflammatory process. It's an actual fracture of the arm, so ice is the way to go. Kids can do what is called ice cup massage where they take a styrofoam coffee cup and fill it to the top with water and freeze it. Peal back an inch of paper around the bottom of the cup, then they can do some circular massage over that shoulder. They shouldn’t need to do that this a lot because remember, they are not allowed to have pain. This is one of those injuries where you cannot throw with pain. So I don’t want them needing to ice their shoulder everyday that means they are doing too much. There is also anti-inflammatory medicines such as Advil or Motrin relieve that might get them through first couple of nights when they are sore. But avoidance of throwing till the thing completely heals sometimes six to eight weeks is the best way to treat this. Casey Bass: My kid has got Little League Shoulder, can he pitch tonight? Dr. David Marshall: Absolutely not. If he has got Little League Shoulder, he definitely cannot pitch; he needs to go to the game in the sling, the glove needs to stay locked in the trunk so they don’t sneak out there and catch in a batting practice and he cannot throw. Casey Bass: What kind of time frame we are looking at? Dr. David Marshall: Well six to eight weeks, I like to see the kids back in about a month, and if they do what we tell them, they really don’t cheat, keep their arms in the sling often times they are pain free in a period of a month. And then we start a rehab program in the Sports Medicine Gym to look at their mechanics and slowly reintroduce throwing to that freshly healed growth plate. So it's usually about another three to four weeks and after that they are starting to throw. Casey Bass: With that, thank you so much, we really appreciate you join us. Dr. David Marshall: My pleasure thank you. Casey Bass: That's going to wrap it up for us today. We will see you right back here next time for another great edition of Clubhouse Gas.