Saturday, September 13, 2008

More on Stress Fractures in the Shoulder

From the Abstract of "Stress Fracture of the humerous in college baseball pitchers: A case report" by Polu, et. al.:

As the number of young people participating in sports at the professional and amateur level grows, so does the incidence of stress fractures in the athletic population.13 Stress fractures usually result from a sudden change in volume or intensity in the athlete's regimen.5 Several theories have been proposed to explain stress fractures. One theory suggests that, over time, repetitive, nonviolent loads applied to bone overwhelm its ability to compensate. As a result, reabsorption exceeds formation and predisposes the weakened bone to a stress fracture.1,5 A second theory considers that stress fractures occur when muscular fatigue leads to alterations in movement patterns, with a redistribution of force to the underlying bone.5 In effect, the shock or energy absorption capabilities of muscle are overpowered, and the bone is subjected to abnormal forces and predisposed to development of a fracture. Devas7 first described stress fractures in the athletic population in 1958. Since then, stress fractures have been documented in various athletic activities, most notably in the tibia or tarsus bones of runners.16 In contrast, stress fractures of the upper extremity have not been as widely reported. Although upper extremity injuries account for 20% of all athletic injuries,15 most are soft tissue injuries of the shoulder.15,22 The number of reported humeral stress fractures is particularly low, and these fractures are usually not recognized until later in the course of injury, when a spiral fracture occurs secondary to muscular violence.1,4,10,12,22 The patient who develops a humeral stress fracture usually experiences a period of arm fatigue and aching after cessation of the sporting activity. Gradually, the pain occurs during the activity itself and can be referred to the shoulder or elbow. Physical examination will reveal tenderness at the site of the stress fracture, but the range of motion of the elbow and shoulder are not affected.76 Stress fractures usually appear as localized periosteal reaction, endosteal thickening, a radiolucent cortical line, or a combination of these three.216 Bone scan and MRI are both sensitive imaging tools in detecting occult fractures. Scintigraphy detects minimal changes in blood flow and metabolism occurring during the abnormal bone remodeling process and is usually positive within 12 to 15 days after the onset of symptoms.5,17,20 Roub et al.20 demonstrated that tibial stress fractures in young athletes could be detected on radionuclide imaging before changes were seen on plain radiographs. Imaging modalities have played a valuable role in the diagnosis of stress fractures. Although plain radiographs are the first modality used in evaluation of bone injury, evidence of stress fracture on radiographs depends on the interval between injury and evaluation. It may take several weeks for stress fractures to become visible on plain radiographs. However, many patients with stress fractures do not have any radiographic findings.
So a stress fracture is either the result of a sudden change of activity (check) or alterations of movement patterns (compensating for injuries?). Obviously, Joel Zumaya's injury was so unique that the recovery process should not have been expected to go smoothly. It just seemed curious to me that he was allowed to continue pitching even though he complained of shoulder pain. Let's just be patient with him, let him get as close to 100 % as possible before letting him pitch again.

Now, what worries me is that something had to have caused this. It could be adjusted mechanics, or it could be something as serious as decreased stability in the shoulder. It just seems like he is at risk of this repeating.

Either way, he shouldn't be expected to contribute to the 2009 Tigers.

3 comments:

NPJ said...

Come on -- this is practicing medicine without a license!

You read an *abstract*, draw a conclusion, and then take the position of knowing better than Zumaya, the team, and their doctors what should be done?

Time to take a break and recover some perspective

Eddie B said...

If this was the first occurrence of a player playing through and later aggravating an injury, I'd settle down and gain some perspective. The simple fact is that it has been an all to common happening for this team over the past two seasons.

All I was doing was pointing out some information on a stress fracture in the shoulder, since it is such a rare baseball injury. What, exactly, is so wrong with suggesting that the Tigers not count on Joel Zumaya. No, I'm not a doctor, but I hardly feel I'm practicing medicine.

Art said...

Found this pdf on trapshooter's shoulder: http://www.ejbjs.org/cgi/reprint/57/6/862.pdf

While shooting a shotgun is radically different from pitching, the injury itself sounds pretty similar. And on the positive side, the patient in the case report seemed to be making a pretty quick and full recovery.

At the very least, the Tigers should be able to track Zumaya's progress over the next couple of months and be able to approach the offseason with a plan adjusted accordingly.

Also have to agree, though, that the Tigers should consider looking at their training/medical staff.