Elbow injuries and the throwing athlete

Michael J. Kissenberth MD

Orthopaedic Surgery, Sports Medicine

SHCC, Greenville Hospital System

First Question

What sport do you play?

Most sport related elbow injuries are caused by repetitive microtrauma…

And the underlying pathology is directly related to the biomechanics

of the sport.

Second Question

2. Where does it hurt?• Anterior• Medial• Posteromedial• Posterior• Lateral

Third Question

3. When does it hurt?

1st Critical Instant

AndrewAndrewss

2nd Critical Instant

AndrewAndrewss

Restraint to Valgus Torqueat 90 Degrees Flexion

UCL 54%RC Articulation 33%Capsule 10%

Effects of Valgus Torque

• Medial Tension– ME injury– Sigmoid rim fx– FP mass injury– UCL lesions– UN neuritis

• Lateral Compression– RC joint injury– Synovitis

History• Medial Pain• Late Cocking, Early

Acceleration• Recurrent Symptoms• Pop on Single Throw• Swelling, Stiffness• Lost Performance!!!

Previous Treatment

• Lost Playing Time

• Rehabilitation

• Injections

• Diagnostic Studies

• Surgery (VEO)

Examination

• Medial Swelling• Motion Loss• UCL Tender• Valgus Stress Painful• Valgus Laxity• Associated Findings

Kids

• ME Apophysitis

• ME Fragmentation

• ME Avulsion

ME Apophysitis

With With FragmentationFragmentation

Without Without FragmentationFragmentation

14 y/o BB Player14 y/o BB Player

No prior No prior symptomssymptoms

““Pop!”Pop!”

The flexor pronator muscles provide varus torque

MMEE

UlnaUlna

FPFPMM

UCLUCL

Flesig AJSM 95, Werner Flesig AJSM 95, Werner JOPST 93JOPST 93

FP Muscles - UCLFP Muscles - UCL

Decreased FCR activity in throwers with an UCL injury

FPM / ME Injury

Pronator Muscle Tear

27 y/o 27 y/o RHPRHP

Conjoined Conjoined TendonTendon

Severe

FPM / ME

ThinkThinkUCL UCL

Injury!!!Injury!!!

MMEE

FPFPMM

RarelRarely y injectinjectDeep Deep MassageMassage

ModalitiesModalities

RehabilitatioRehabilitationn

RepairRepair

Treatment

Relative / Active RestIce, NSAIDLocal ModalitiesPrevent AtrophyTreat Associated ConditionsNO Steroid Injections!!!

Treatment

Strengthen FCU, FDSTrunk, Scapula, Cuff Stab.PNF, PlyometricsSport Specific ExerciseReview Throwing MechanicsInterval Throwing Program

Direct Direct RepairRepair

UCL Complex

• Anterior Bundle– Strongest portion– Insertion on

sublime tubercle• 18 mm posterior

to coronoid tip

– Origin is inferior and posterior to rotation axis

• Tighter in flexion

Milking Milking ManeuverManeuver

UCL UCL TestsTests

Static Valgus StressStatic Valgus Stress

Moving VSTMoving VSTO’DriscollO’Driscoll

Likely best Likely best testtest

Modified UCL ReconModified UCL Recon

6 – 8 Millimeter 6 – 8 Millimeter BridgeBridge

Three Incision Three Incision HarvestHarvest

Docking Procedure

Glajchen AJR Glajchen AJR 19981998

Avulsion Fracture Avulsion Fracture Sublime TubercleSublime Tubercle

Rehabilitation

Initial Immobilization Relieve PainResolve Arm SwellingRecover Range of MotionPrevent Muscle AtrophyRestore Aerobic ConditionMaintain/develop core stability

Toss 4 - 5 Months

Mound 6 - 8 Months

Game 11 - 12 Months

Prevent Shoulder Prevent Shoulder InjuryInjury

Ulnar Nerve Injury

MMEE

FibrosisCompressionTension

UN subluxationElbow valgus laxity

Ulnar Nerve InjuryUlnar Nerve Injury

Non-operative Care

• Night Splint• NSAIDs• Oral Steroids• Activity Modification• Desensitization / Soft tissue

release

DecompressioDecompressionn

MEME1133 2244

Fascia SlingFascia Sling

MMEE

Lateral CompressionInjuries

Rad-Cap Rad-Cap arthrosisarthrosis

Stress fractureStress fracture

OCDOCD

Lateral Lateral synoviumsynovium

Kids – Lateral Elbow

1. Panner’s Disease• <10 yo, self limited

2. OCD Capitellum• Progressive!!!

• OCD capitellum

• 5-10yo

• Self limited

• Tx conservatively– Rest, ice, nsaids– Gradual RTP. Must be able to

throw without sx

Panner’s Disease

Posterior blood supply peds lateral elbow

Repetitive injury to epiphysis may alter blood flow = osteochondrosis

Osteochondritis Dissecans

• Age 9 - 16 Years Old

• Progressive• Remove loose

bodies

Loose BodyLoose Body

Lateral Plica Syndrome

RHRHUlnUlnaa

HumerusHumerus

VEO Syndrome

2nd Critical Instant2nd Critical Instant

History

Pain- posteromedial at ball release and in follow through

Past history painPast history UCL injuryStiffnessPerformance, warm-up

Examination

Local Tenderness

Motion Loss

Extension Painful

Extension Plus Valgus Painful

ExtensioExtension n

TestTest

Posterior & Medial

AndrewAndrewss

Olecranon Tip Resection

KJOC / Mayo - Ostectomy

“…“…removal of > 3 mm removal of > 3 mm of bone and cartilage of bone and cartilage places the UCL at risk places the UCL at risk for injury.”for injury.”

ElAttrache, Rosen, ElAttrache, Rosen, MorreyMorrey

Olecranon Tip Osteophytes

Kids

Olecranon Apophysis Injury

Olecranon Apophysis NU

LefLeftt

RighRightt

16 y/o RHP16 y/o RHP

10 Days 10 Days Post-OpPost-Op

3 3 Months Months Post-OpPost-Op

Tip Stress Fracture

MRIMRIX-X-rayray

The treatment plan is based on the player’s history,

examination and response to conservative care.

SUMMARY

• When evaluating elbow injuries pay attention to age of athlete and location of pain.

• Acute injuries with “pop” require full evaluation.

• Most respond to conservative treatment

Our Goals

• Not to operate on elbows

• If we have to – results pretty good at getting pitchers back to play

• Use the down time to fully evaluate the rest of the body (shoulder / hips / core)

HAWKINS THROWING ACADEMY

• TEAM APPROACH TO THROWING INJURIES

• SHCC, Proaxis therapy, ASI• One of a kind in the Southeast• Focused on performance and

prevention• Email:

baseball@proaxistherapy.com

THANK YOU