Effectiveness Of Overuse Injury Prevention Programs On Upper Extremity Performance In Overhead Youth Athletes: A Systematic Review

Background Youth athletes in single hand overhead sport are at risk of upper extremity overuse injuries due to musculoskeletal immaturity, repetitive actions and stress overload. While several upper extremity injury prevention programs have been developed, the effectiveness of upper extremity injury prevention programs on performance outcome measures in overhead youth athletes has not been investigated. This study critically evaluated the effectiveness of existing upper extremity injury prevention programs on performance outcome measures in overhead youth athletes and identified and categorized the training components of these programs.Methods A systematic search was conducted in PubMed, Physiotherapy Evidence Database (PEDro), SPORTDiscus (via EBSCOhost), ScienceDirect, and Web of Science. The inclusion criteria were youth athletes with full participation in throwing or striking sports; the intervention utilized training programs or exercises; control group performed usual training or sham exercises; reported at least one performance outcome measure; and utilized either randomized controlled trials, cluster-randomized controlled trials, or non-randomized controlled trials. Studies had to be published in the English language and within the last two decades. Methodological quality was assessed based on the PEDro Scale. Results Five studies, with a total of 456 youth athletes (age range 10.2-17.1 years) were included. The average PEDro score was 6.6. The effectiveness of the injury prevention programs on the identified performance outcome measures of strength, mobility, and sport-specific measures (ball speed and serve accuracy) were 30.4%, 28.6%, and 22.2%, respectively. The training components targeted were categorized as strength, mobility, and plyometrics. Strength was the most common training component and the most widely investigated performance outcome measure among existing upper extremity injury prevention programs. ConclusionCurrent injury prevention programs have a modest effect on sport performance outcome measures. Future upper extremity injury prevention programs should include training components of strength, mobility and plyometrics in their design given their moderate effects on strength, mobility, and sport-specific outcome measures. Standardized protocols are required for injury prevention program characteristics, and measurement and reporting of performance outcomes measures.

VARIATION IN TREATMENT APPROACHES TO ADOLESCENT MIDSHAFT CLAVICLE FRACTURES IN PEDIATRIC VERSUS ADULT HOSPITALS

Background: Optimal treatment of midshaft clavicle fractures in adolescents remains a topic of controversy. While adolescent midshaft clavicle fractures have historically been treated nonoperatively, recent randomized controlled trials of displaced midshaft clavicle fractures in the adult literature have raised the question of decreased symptomatic nonunion and malunion and improved functional outcomes with surgery. Consequently, the rates of surgical treatment of adolescent midshaft clavicle fractures, particularly in the older adolescent age group, has increased, despite a paucity of high-level evidence to justify this trend. Hypothesis/Purpose: To identify differences in treatment approach for isolated, displaced midshaft clavicle fractures in ‘older’ adolescent patients at adult versus pediatric hospitals. The secondary objective was to identify factors associated with surgery. Methods: Adolescents aged 15 to 18 years with isolated, displaced midshaft clavicle fractures treated at one of two adult tertiary care hospitals or one pediatric tertiary care hospital. Exclusion criteria included open fractures, skin tenting, nondisplaced fractures, medial third or distal third clavicle fractures, non-isolated injuries, and delay from injury to presentation of more than 2 weeks. Bivariate analysis and multivariable logistic regression analysis were used to identify factors associated with surgical treatment. Results: Two hundred and fourteen patients (median age: 16 years, mean BMI: 22.5, 85% male) were included. The cohort from the pediatric hospital was significantly younger, had lower BMI, had fewer comminuted fractures, and a higher proportion of angulated fractures (Table 1). One hundred six (50%) patients underwent surgical treatment. Bivariate analysis showed that older age (p = 0.004), higher BMI (p = 0.002), dominant upper extremity injury (p = 0.001), and treatment at an adult hospital (p < 0.0001) were associated with surgery. The fracture characteristics of comminution (p < 0.0001), greater displacement (p < 0.0001), and greater shortening (p < 0.0001) were associated with surgery. Multivariable logistic regression analysis showed superior-inferior fracture displacement (OR 1.13, 95% CI 1.06 to 1.20), dominant upper extremity injury (OR 2.60, 95% CI 1.19 to 5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28 to 12.2) to be independently associated with surgery. Conclusions: After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high quality prospective outcomes studies. [Table: see text]

Ultrasound-Guided Alcohol Neurolysis For Treatment of Refractory Radial Neuralgia

Background: The radial nerve is especially vulnerable to injury due to its location near the humerus. When acute pain becomes chronic and surgical repair is no longer an option, it is necessary to have non-opioid, nonpharmacological methods of pain relief. Case Report: A 63-year-old man presented with severe radial nerve neuralgia secondary to traumatic left upper extremity injury 40 years ago. After several unsuccessful surgical interventions and failing medication management, he was sent to pain management as a last resort prior to elective amputation of the left upper limb. After initial evaluation, the patient underwent a diagnostic ultrasound-guided radial nerve block at the midhumeral level with complete but short-lasting relief of his pain. Shortly after, we performed ultrasoundguided alcohol neurolysis of the radial nerve at the same level. This treatment resulted in 100% pain relief for 10 months with gradual resumption of pain to previous levels at 12 months post neurolysis. Conclusion: Alcohol neurolysis is an effective and viable option for the treatment of neuralgia resistant to other therapeutic modalities. To our knowledge, this is the first case report that describes the use of ultrasound to perform chemical neurolysis of the radial nerve. Key words: Alcohol neurolysis, chronic pain, nerve ablation, neuralgia, neurolysis, opioids, radial nerve, traumatic injury, ultrasound

Lumbopelvic Control and the Development of Upper Extremity Injury in Professional Baseball Pitchers

Background: The baseball-throwing motion requires a sequential order of motions and forces initiating in the lower limbs and transferring through the trunk and ultimately to the upper extremity. Any disruption in this sequence can increase the forces placed on subsequent segments. No research has examined if baseball pitchers with less lumbopelvic control are more likely to develop upper extremity injury than pitchers with more control. Purpose: To determine if baseball pitchers who sustain a chronic upper extremity injury have less lumbopelvic control before their injury compared with a group of pitchers who do not sustain an injury. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 49 asymptomatic, professional baseball pitchers from a single Major League Baseball organization participated. Lumbopelvic control was measured using an iPod-based digital level secured to a Velcro belt around each player’s waist to measure anteroposterior (AP) and mediolateral (ML) deviations (degrees) during single-leg balance with movement and static bridge maneuvers. During a competitive season, 22 of these pitchers developed upper extremity injuries, while the remaining 27 sustained no injuries. Separate 2-tailed t-tests were run to determine if there were significant differences in lumbopelvic control between groups ( P < .05). Results: There were no significant between-group differences for the stride leg (nondominant) during the bridge test in either the AP ( P = .79) or the ML ( P = .42) directions, or either direction during the drive leg bridge test ( P > .68). However, the injured group had significantly less lumbopelvic control than the noninjured group during stride leg balance in both the AP ( P = .03) and the ML ( P = .001) directions and for drive leg balance in both the AP ( P = .01) and the ML ( P = .04) directions. Conclusion: These results demonstrate that baseball pitchers with diminished lumbopelvic control, particularly during stride leg and drive leg single-leg balance with movement, had more upper extremity injuries than those with more control. Clinicians should consider evaluating lumbopelvic control in injury prevention protocols and provide appropriate exercises for restoring lumbopelvic control before returning athletes to competition after injury. Specific attention should be given to testing and exercises that mimic a single-limb balance task.

Early Sport Specialization Linked to Throwing Arm Function and Upper Extremity Injury History in College Baseball Players

Background: Evidence suggests that shoulder and elbow injuries account for 31% to 37% of all National Collegiate Athletic Association (NCAA) baseball injuries, and up to 69% of NCAA baseball injuries are the result of noncontact and overuse mechanisms. Early sport specialization may contribute to the high rates of upper extremity injuries in college baseball players. Hypothesis: Higher specialization by age 13 years would be associated with worse subjective throwing arm function and a greater history of shoulder and elbow injury. Study Design: Cohort study. Level of Evidence: Level 2. Methods: Survey data were collected from college baseball players (N = 129) during midseason of the spring 2019 baseball season. Participants were stratified in low, moderate, and high specialization groups based on a 3-criteria sports specialization questionnaire. Participants’ throwing arm function was measured using the Functional Arm Scale for Throwers and the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow questionnaires. Participants’ history of a shoulder or elbow injury that resulted in missing ≥2 weeks of baseball activity at any point in their baseball career was also collected. Results: The high specialization group reported worse subjective throwing arm function on the Functional Arm Scale for Throwers questionnaire than the low ( P = 0.03) and moderate ( P = 0.01) specialization groups. The high specialization group was over 5 times more likely to report a history of shoulder injury than the moderate (odds ratio [OR] = 5.42; 95% CI [1.71, 17.2]; P = 0.004) and low (OR = 5.20; 95% CI [1.87, 14.5]; P = 0.002) specialization groups, and over 3 times more likely to report a history of elbow injury than the moderate specialization group (OR = 3.77; 95% CI [1.05, 13.6]; P = 0.04). Conclusion: College baseball players that were highly specialized by age 13 years reported worse subjective throwing arm function and were more likely to have a history of upper extremity injury than players that were moderate or low specialization. Clinical Relevance: Early specialization in baseball may be detrimental to long-term upper extremity health in college baseball players.

Preseason Upper Extremity Range of Motion and Strength in Relation to In-Season Injuries in NCAA Division I Gymnasts

Background: Gymnastics is a demanding sport that places unique forces on the upper extremity. The repetitive nature of the sport and the high-impact forces involved may predispose the gymnast to overuse injuries. Risk factors for injuries in gymnastics are not well understood. Purpose/Hypothesis: The purpose of this study was to ascertain whether preseason upper extremity range of motion (ROM) and strength differ between National Collegiate Athletic Association (NCAA) Division I collegiate gymnasts who sustain an in-season upper extremity injury and those who do not. We hypothesized that gymnasts who sustain an upper extremity injury would demonstrate reduced ROM and strength compared with noninjured gymnasts. Study Design: Cohort study; Level of evidence, 3. Methods: Over 4 seasons, from 2014 to 2018, a total of 15 female NCAA Division I collegiate gymnasts underwent preseason upper extremity ROM (shoulder: flexion, internal and external rotation; elbow: extension; wrist: extension) and strength (shoulder: internal and external rotation, and middle and lower trapezius) testing. Overuse upper extremity injuries were tracked in each subsequent season. Gymnasts were dichotomized into injured and noninjured groups, and a 2 × 2 analysis of variance was used to measure differences in preseason measures between the groups as well as within arms (injured vs noninjured arm for the injured group; dominant vs nondominant arm for the noninjured group). Results: A total of 12 overuse upper extremity injuries (10 shoulders; 2 wrist/forearm) occurred during 31 gymnast-seasons. There were no significant interactions for preseason ROM and strength measurements between groups (injured vs noninjured) or within arms (injured and noninjured arm for the injured group; dominant and nondominant arm for the noninjured group; P = .07). Conclusion: Preseason upper extremity ROM and strength were not different between gymnasts who sustained an in-season upper extremity overuse injury and those who did not. It is possible that ROM and strength measures used to screen other overhead athletes may not capture the unique features and requirements of gymnastics. Further, it may be challenging to discern differences in clinical measures of ROM and strength in gymnastics populations owing to the bilateral nature of the sport.