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:
THANK YOU
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