Baseball and Softball Injuries Quincy Wang, MD

Corresponding author Quincy Wang, MD Team to Win/Harbor UCLA/Kaiser South Bay Primary Care Sports Medicine Fellowship, Family and Sports Medicine, Kaiser Permanente, 3900 E. Pacific Coast Highway, Long Beach, CA 90804, USA. E-mail: [email protected] Current Sports Medicine Reports 2006, 5: 115-119 Current Science Inc. ISSN 1537-890x Copyright© 2006 by Current Science Inc.

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Introduction Baseball and softball are generally safe sports. Potential injury comes from being hit by a thrown or batted ball, being hit with the bat, impact with the ground during a slide or dive, and overuse.

Soft Tissue Injuries Contusions are one of the most common but minor injuries suffered in baseball and softball. Common contusion areas include the wrist, lower leg, chest, and face. Contusion treatment revolves around minimizing the inflammatory response and pain control. Icing for about 20 minutes two to three times per day will assist with decreasing inflammation and associated swelling as well as provide pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are also effective in pain management. Return to play is possible if the area affected is not impaired by the contusion [1]. Protective equipment can play a role in lessening the risk of contusion. At the wrist, contusions often occur

to the heel of the glove hand with fielding ground balls. Padded extensions to the heel of the glove can be used to limit injury. Foul-tipped, batted balls that strike the lower leg are a source of very painful contusions. Soccerstyle shin guards and those with extensions to protect the medial ankle and foot can be used as a protective measure. Contusions to the chest and face are usually a result of being hit by a pitched ball. At the Little League baseball level, there are advocates for the use of softer than normal baseballs and softballs, as well as helmet face masks while batting to lessen the injury from a pitched ball [2]. The softer ball is also felt to lessen the risk of commotio cordis, an impact-induced ventricular arrhythmia (3-6]. Abrasions often occur on the hands, forearms, elbows, knee, thighs, and buttocks, usually due to sliding or diving. Treatment consists of thorough irrigation, topical antibiotics, and dressings to protect from recontamination. Tetanus status should be reviewed and universal precautions should be followed when treating open skin injuries. Protective measures using gloves, pads, and sliding shorts are advised to allow for wound healing during participation. Abrasions can plague the athlete with discomfort for the whole season if allowed to be recurrent. Laceration treatment consists of anesthesia, copious irrigation, debridement, suturing, and/ or bandaging under sterile conditions. Again, tetanus status and universal precautions should be followed. Return to play is allowed for simple abrasions and superficial lacerations that can be definitively treated on the sideline/ dugout quickly. For more serious abrasions and lacerations, the team physician must decide if temporary wound management with delayed treatment after the contest is appropriate. If return to play will worsen the wound by increasing risk of further tissue damage, wound contamination, or the contamination of others, the athlete should not return to play.

Shoulder and Rotator Cuff Injuries The rotator cuff consists of the supraspinatus, infraspinatus, teres minor, and subscapularis. They are also known as the "SITS" muscles. Aside from abducting and externally rotating the arm in the early phases of throwing, the function of maximal stress to the rotator cuff is to decelerate the arm during the follow through phase of throwing.

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Repetitive throwing can cause inflammation and pain resulting in rotator cuff tendinitis. Symptoms include painful throwing followed by a decrease in distance and velocity of throws. Often pain accompanies any overhead motion during daily activities. On examination, there may be pain to the proximal humerus, near the tip of the acromion. Pain may be referred down the lateral aspect of the arm. Weakness with external rotation and abduction of the arm secondary to pain is present. Impingement signs such as Neer's and Hawkin's maneuvers are typically positive with significant injury [7]. If the rotator cuff tendinitis is severe, often the athlete will report pain at night and at rest. Rotator cuff tendinitis develops as an overuse injury. The mainstay of treatment involves relative rest. For severe pain with throwing, total rest typically between 2 to 4 weeks is suggested before resuming throwing activity. Once throwing resumes, repetitions and velocity should be limited below the threshold of pain. If no pain is experienced after several low-intensity throwing sessions, advancing through a progressive throwing program can continue under the supervision of the team physician, athletic trainer, and coach. Adjunct treatment includes medications, icing, and a rehabilitation program. For medications, an NSAID of choice if tolerated is an effective tool in limiting pain. For the adult or college-aged athlete, subacromial steroid injection is effective in treating severe and persistent pain and inflammation [8]. Recommend at least 1 week of no throwing before initiating a progressive throwing program. Icing for 20 minutes two to three times per day during injury recovery will also aid in control of pain and inflammation. Once pain is controlled, starting a rehabilitation program will help speed recovery as well as help prevent future injury. It is common to start with exercises for the rotator cuff muscles; however, it is advised to enlist the help of a physical therapist to include exercises for shoulder flexibility, scapular stabilization, back strength, and leg strength to maintain the "kinetic chain" of body parts involved with throwing (9]. Recurrent or chronic rotator cuff tendinitis that is not responsive to these conservative therapies may require surgical intervention. Aside from chronic overuse, chronic impingement may be the cause if radiographs reveal a type II (curved) or type III (hooked) acromion [7]. Consider orthopedic consultation to see if a procedure is warranted. Chronic impingement syndrome and rotator cuff tendinitis may cause degeneration of the rotator cuff tendons leading to full or partial rotator cuff tears. Rotator cuff tears can be full or partial tears of the tendons at their attachment to the proximal humerus. Generally this type of injury is seen in older athletes over 50 years of age due to chronic overuse. In the younger athlete, rotator cuff tears are rare, but can occur from an acute injury or trauma. With symptoms of a rotator cuff tear, the athlete will report weakness or being unable to raise the arm overhead.

On visual examination, there may be muscular atrophy of the rotator cuff muscles on the scapula if the injury is longstanding. Motor testing will reveal weakness with abduction and/or external rotation of the shoulder. The degree of abduction and the amount of pain experienced can vary depending on the severity of tear. Typically the patient with a full thickness tear cannot abduct the shoulder and if chronic, can have very little pain when trying. For full thickness tears, the drop arm test will be positive. With the examiner lifting the arm to 90° of abduction, the athlete is unable to lower the arm smoothly and slowly and drops it quickly to his or her side, especially when the examiner lightly taps the arm downward [7]. When pain limits a thorough examination, a subacromial injection of lidocaine may help reveal a significant rotator cuff tear if the athlete is still weak or unable to abduct the arm after pain is removed by the injection. Imaging studies can be helpful in diagnosing rotator cuff tears. Plain radiographs may show calcific tendinitis if the injury is longstanding. Also type II or III acromions may be seen. MRI, especially direct arthrography, is very helpful in revealing rotator cuff tears [10 ]. The initial treatment of rotator cuff tears is similar to rotator cuff tendinitis. NSAIDs and icing are used to control pain and inflammation. Partial tears can be responsive to relative rest, physical therapy, and a progressive throwing program. If needed, subacromial steroid injections can be used to control pain and inflammation. Orthopedic referral is warranted for full thickness tears or those unresponsive to conservative treatments. Return to play after rotator cuff repair largely depends on the size of the tear, with larger tears requiring more time for healing.

Shoulder Injuries and Biceps Groove Tendinitis Pain and inflammation of the long head of the biceps in the region of the biceps groove of the humerus is an injury experienced by throwing athletes. Much like rotator cuff injuries, biceps groove tendinitis is often the result of chronic overuse with repetitive throwing. During evaluation, the athlete will describe pain to the anterior shoulder with throwing. Point tenderness will be in the anterior shoulder at the biceps groove and a Speed's test (resisted forward flexion of the arm with elbow slightly flexed) result will typically be positive. Pain to the biceps groove may be encountered with resisted supination of the wrist or when stretching the long head of the biceps by extending the arm posteriorly with the elbow flexed. With isolated biceps groove tendinitis, there should be no pain with abduction or external rotation of the shoulder and there should be a negative drop arm test. Treatment measures follow a similar theme for other injuries, including relative rest, NSAIDs, and icing, and introducing physical therapy with a progressive throwing program.

Baseball and Softball Injuries

Shoulder and Glenoid Labrum Injuries Glenoid labrum tears, specifically the superior labrum anterior to posterior (SLAP) tears, are a common but difficult diagnosis to make in the throwing athlete. The superior labrum is the site for attachment of the long head of the biceps tendon. Chronic repetitive traction of the long head of the biceps during overhead throwing is the most common cause of a SLAP tear. Another source of injury is from direct compression of the glenoid labrum or acute traction to the biceps tendon such as from impact of an outstretched arm during a head-first slide. Dislocation of the glenohumeral joint will also lead to glenoid labrum injury. Evaluation and diagnosis of a glenoid labrum tear is extremely difficult as both history and physical examination findings often overlap with other sources of shoulder pathology. Typically the athlete will report painful throwing with decreased velocity, even after prolonged rest. Athletes may report a repetitive "click" with throwing or specific shoulder motions. Examination will often reveal pain during resisted external rotation with the shoulder abducted as during a throwing motion. However, physical examination findings can be far from accurate as there is no one maneuver to diagnose glenoid labrum injury. Imaging studies can be used to correlate physical findings. Plain radiographs are not helpful in diagnosing glenoid labrum tears, but can help rule out other pathology. MRI with saline or contrast injection is very helpful if positive findings are seen; however, false negative readings are common. If a combination of findings creates a serious suspicion for a glenoid labrum tear, consider an orthopedic referral as definitive diagnosis and treatment may require surgical intervention. For those athletes with more ambiguous findings, a trial of conservative treatment with rest, medication, physical therapy, and a progressive throwing program may be tried first before orthopedic referral [8].

Elbow Injuries and Medial Epicondylitis Medial elbow pain from medial epicondylitis is a common overuse injury from repetitive throwing. It results from repeated valgus stress applied to the medial epicondyle by the attached ulnar collateral ligament and the tendons of the wrist and finger flexors, which are under high tension during the acceleration phase of throwing [11, 12,13 •, 14]. On examination, the history will consist of sharp pain to the medial elbow when throwing, with decreased throwing distance and velocity. By the time the athlete seeks medical attention, often pain will continue as an ache after practices and games. Constant pain or numbness, even at rest, may be symptoms of a more severe injury. Pain typically can be reproduced with palpation of the medial epicondyle, resisted wrist and finger flexion, and valgus stress of the elbow with the arm abducted mimicking a throwing motion. Elbow laxity during val-

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gus stress and a positive Tinel's sign at the cubital tunnel are signs of a more severe injury [15]. Three-view radiographs are helpful, especially in the skeletally immature athlete, as avulsion fractures of the medial epicondyle may be present. Bilateral views are helpful for comparison. Medial epicondyle fractures displaced more than 5 mm warrant orthopedic referral [11]. Rest, NSAIDs, and icing are the mainstays of treatment. Rest of the elbow must be complete, with no other throwing or activities that produce valgus stress for generally 2 to 4 weeks. Once the elbow is pain free during regular daily activities and provocative testing produces no pain, wrist and forearm strengthening exercises as well as a progressive throwing program can begin [16]. For the skeletally immature thrower with an avulsion fracture less than 5 mm, complete rest in a posterior splint or long-arm cast and sling for 2 to 3 weeks until pain free with provocative testing. Progressive throwing can begin if pain free with daily activity and radiographs reveal a healed fracture, generally 4 to 6 weeks.

Ulnar Collateral Ligament Injury The ulnar collateral ligament is one of the most important stabilizing structures of the elbow for a throwing athlete. Pain and instability at the medial elbow due to sprain, attenuation, or rupture of the ulnar collateral ligament is a precursor to ineffective throwing. For a throwing athlete, injury to the ulnar collateral ligament is a career-altering, if not a career-ending, injury. The ulnar collateral ligament is made up of anterior, posterior, and transverse bands. Injury to the anterior band, specifically the posterior bundle of the anterior band, leads to medial elbow laxity [17•]. This injury is seen in the active thrower, usually between 16 and 40 years of age. On evaluation, the main history that should draw attention to the ulnar collateral ligament is the report of medial elbow pain with throwing plus decreased velocity and distance of throws. Some may report a sensation of the medial elbow "opening" during the late cocking and/ or acceleration phase of throwing. The elbow "pop" during a throw is the classic initiating event, but low-grade medial elbow pain that worsens over time with throwing is the more common history [17•]. Paresthesia in the ulnar nerve distribution and lateral, and/ or posterior elbow pain are signs of secondary complications from medial elbow laxity [17•]. On examination, there may be pain on palpation about 2 em distal to the medial epicondyle at the insertion of the ulnar collateral ligament on the ulna [17•]. A positive valgus stress test indicating medial elbow laxity is the desired finding for making a diagnosis of ulnar collateral ligament injury. Lock the athlete's hand and wrist between the examiner's elbow and trunk. Bend the elbow about 30° to free the olecranon from the olecranon fossa. Gently apply valgus stress to the elbow

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with the heel of the examiner's hand, looking for laxity at the medial joint line of the elbow. Compare with the opposite side. Increased laxity or no firm endpoint indicates incompetence of the ulnar collateral ligament due to rupture or attenuation [17•). However, performing a valgus stress test is very difficult as the positive finding of laxity is subtle and easily missed even by a highly experienced examiner. There are several variations to the general method described above, such as the "milking maneuver" and "moving valgus stress test" [13•,17•,18). Valgus stress radiographs can be helpful to show medial elbow laxity. If the distance of the medial joint space of the elbow is larger than the unaffected elbow under stress, ulnar collateral ligament injury is suspected. MRI can be helpful if found to be positive. False negative readings may be encountered with attenuation of the ulnar collateral ligament. Surgery is indicated for athletes with complete rupture of the ulnar collateral ligament who wishes to return to high-level throwing activities [17•,19]. Surgery is also indicated for persistent medial elbow pain and instability failing nonsurgical treatment for 3 months or more. If an evaluation reveals no complete tear of the ulnar collateral ligament, a trial of nonsurgical treatment is warranted. Complete rest for 4 weeks followed by a wrist and elbow strengthening program should be initiated. At about 3 months, a progressive throwing program can begin. If pain and instability return, surgical intervention is indicated. With current surgical techniques and rehabilitation protocols, return to competitive throwing can be reached by 8 to 9 months (20]. Return to an athlete's previous level of competition is almost 70% after ulnar collateral ligament reconstruction (19]. Whether or not the athlete throws with the same level of effectiveness is controversial and determination is made on an individual basis.

Complete rest for 2 to 3 months is the initial treatment. There should be no throwing and other physical stress of daily activity to the elbow should be minimized. Physical therapy can then begin in 3 months if daily activities are pain free. A progressive throwing program can begin once evidence of healing is seen via repeat MRI or bone scan. Surgical treatment is warranted for failed nonsurgical treatment, formation of loose bodies, or if the osteochondral defect is large.

Conclusions Baseball and softball InJuries are common and occur from impact from the ball, other equipment or the field, and from repetitive overuse. Soft tissue injuries are most common and include contusions, abrasions, and lacerations. Protective equipment is available to lessen the risk of and to protect after these injuries. Return to play for simple abrasions and lacerations is allowed if there is low risk of further tissue injury or the contamination of others. Repetitive throwing can lead to shoulder injuries to the rotator cuff, biceps tendon, and the glenoid labrum. History and physical examination can help differentiate the type of injury. Most injuries will respond to conservative therapies that includes relative rest, medications, and rehabilitation exercises. Elbow injuries include medial epicondylitis, ulnar collateral ligament injury, and osteochondritis dissecans. Medial epicondylitis and osteochondritis dissecans of the elbow can be responsive to conservative measures. However, significant ulnar collateral ligament injury will require surgical reconstruction if return to high-level throwing is desired.

References and Recommended Reading Osteochondritis Dissecans of the Elbow Osteochondritis dissecans of the elbow is a very concerning problem as it involves articular surface degeneration due to repetitive microtrauma. Osteochondral fracture, loose bodies, and avascular necrosis are potential complications. Osteochondritis dissecans of the elbow typically occurs at the radiocapitellar joint due to compressive forces generated across this joint during throwing (16]. On evaluation, there will be reported a gradual onset of pain to the lateral elbow that worsens with throwing. There may be pain to palpation of the lateral aspect of the elbow. Valgus stress of the elbow may produce lateral pain. Typically, there is decreased range of motion with supination and pronation and flexion contractures can also be present. Plain radiographs will be positive for an osteochondral lesion or a loose body of the capitellum. MRI can also reveal the osteochondral lesion, and assist in staging and determining the presence of a loose fragment. Bone scans are useful in helping identifying vascularity of the lesion and serving as a prognostic indicator.

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

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5. 6. 7.

Romeo SJ, Hawley CJ, Romeo MW, Romeo JP: Facial injuries in sports: a team physician's guide to diagnosis and treatment. Physician Sportsmed 2005, 33:45-53. CPSC Releases Study of Protective Equipment for Baseball. Release #96-140. US Consumer Product Safety Commission; June 4, 1996. http:/Jwww.cpsc.gov/CPSCPUB/PREREL/PRHTML96/96140.html Sangwill SO, Strasburger JS: Commotio cordis. Pediatr Clin North Am 2004, 51:1347-1354. Geddes LA, Roeder RA: Evolution of our knowledge of sudden death due to commotio cordis. Am ] Emerg Med 2005, 23:67-75. Maron BJ. Gohman TE, Kyle SB, et al.: Clinical profile and spectrum of commotio cordis. lAMA 2002, 287:1142-1146. Maron BJ, Estes NAM, Link MS: Task force 11: commotio cordis. I Am Coli Cardiol2005, 45:1371-1373. Millstein ES, Snyder SJ: Arthroscopic evaluation and management of rotator cuff tears. Orthop Clin North Am 2003, 34:507-520.

Baseball and Softball Injuries Park HB, Lin SK, Yokata A, McFarland EG: Return to play for rotator cuff injuries and superior labrum anterior to posterior (SLAP) lesions. Clin Sports Med 2004, 23:321-334. Kibler WB: Rehabilitation of rotator cuff tendinopathy. 9. Clin Sports Med 2003, 22:837-847. Jbara M, Chen Q, Marten P, et al.: Shoulder MR arthrography: 10. how, why, when. Radio! Clin North Am 2005, 43:683-692. Rudzki JR. Paletta GA: Juvenile and adolescent elbow 11. injuries in sports. Clin Sports Med 2004, 23:581-608. Hutchinson MR, WynnS: Biomechanics and development 12. of the elbow in the young throwing athlete. Clin Sports Med 2004, 23:531-544. 13.• Cain EL Jr, Dugas JR: History and examination of the thrower's elbow. Clin Sports Med 2004, 23:553-556. Excellent overview of the elbow examination noting key elements of the history and physical examination involved with the throwing athlete. Segment on the adolescent thrower is very helpful differentiating the skeletally immature athlete from the adult. Kibler WB, Sciascia A: Kinetic chain contributions to elbow 14. function and dysfunction in sports. Clin Sports Med 2004, 23:545-552.

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Keefe DT, Lintner DM: Nerve injuries in the throwing elbow. Clin Sports Med 2004, 23:723-742. Wilk KE, Reinold MM, Andrews JR: Rehabilitation ofthe 16. thrower's elbow. Clin Sports Med 2004, 23:765-801. Safran MR: Ulnar collateral ligament injury in the 17.• overhead athlete: diagnosis and treatment. Clin Sports Med 2004, 23:643-663. Very comprehensive overview of the pathophysiology of ulnar collateral ligament injury of the elbow. Diagnosis and treatment options are well explained. O'Driscoll SWM, Lawton RL, Smith AM: The •moving 18. valgus stress test" for medial collateral ligament tears of the elbow. Am J Sports Med 2005, 33:231-239. Conway JE, Jobe FW, Glousman RE, Pink M: Medial insta19. bility of the elbow in throwing athletes: treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg 1992, 74A:67-83. Curl LA: Return to sport following elbow surgery. 20. Clin Sports Med 2004, 23:353-366. 15.