Download - Elbow injuries and the throwing athlete
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Elbow injuries and the throwing athlete
Michael J. Kissenberth MD
Orthopaedic Surgery, Sports Medicine
SHCC, Greenville Hospital System
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First Question
What sport do you play?
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Most sport related elbow injuries are caused by repetitive microtrauma…
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And the underlying pathology is directly related to the biomechanics
of the sport.
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Second Question
2. Where does it hurt?• Anterior• Medial• Posteromedial• Posterior• Lateral
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Third Question
3. When does it hurt?
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1st Critical Instant
AndrewAndrewss
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2nd Critical Instant
AndrewAndrewss
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Restraint to Valgus Torqueat 90 Degrees Flexion
UCL 54%RC Articulation 33%Capsule 10%
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Effects of Valgus Torque
• Medial Tension– ME injury– Sigmoid rim fx– FP mass injury– UCL lesions– UN neuritis
• Lateral Compression– RC joint injury– Synovitis
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History• Medial Pain• Late Cocking, Early
Acceleration• Recurrent Symptoms• Pop on Single Throw• Swelling, Stiffness• Lost Performance!!!
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Previous Treatment
• Lost Playing Time
• Rehabilitation
• Injections
• Diagnostic Studies
• Surgery (VEO)
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Examination
• Medial Swelling• Motion Loss• UCL Tender• Valgus Stress Painful• Valgus Laxity• Associated Findings
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Kids
• ME Apophysitis
• ME Fragmentation
• ME Avulsion
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ME Apophysitis
With With FragmentationFragmentation
Without Without FragmentationFragmentation
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14 y/o BB Player14 y/o BB Player
No prior No prior symptomssymptoms
““Pop!”Pop!”
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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
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Decreased FCR activity in throwers with an UCL injury
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FPM / ME Injury
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Pronator Muscle Tear
27 y/o 27 y/o RHPRHP
Conjoined Conjoined TendonTendon
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Severe
FPM / ME
ThinkThinkUCL UCL
Injury!!!Injury!!!
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MMEE
FPFPMM
RarelRarely y injectinjectDeep Deep MassageMassage
ModalitiesModalities
RehabilitatioRehabilitationn
RepairRepair
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Treatment
Relative / Active RestIce, NSAIDLocal ModalitiesPrevent AtrophyTreat Associated ConditionsNO Steroid Injections!!!
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Treatment
Strengthen FCU, FDSTrunk, Scapula, Cuff Stab.PNF, PlyometricsSport Specific ExerciseReview Throwing MechanicsInterval Throwing Program
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Direct Direct RepairRepair
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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
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Milking Milking ManeuverManeuver
UCL UCL TestsTests
Static Valgus StressStatic Valgus Stress
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Moving VSTMoving VSTO’DriscollO’Driscoll
Likely best Likely best testtest
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Modified UCL ReconModified UCL Recon
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6 – 8 Millimeter 6 – 8 Millimeter BridgeBridge
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Three Incision Three Incision HarvestHarvest
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Docking Procedure
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Glajchen AJR Glajchen AJR 19981998
Avulsion Fracture Avulsion Fracture Sublime TubercleSublime Tubercle
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Rehabilitation
Initial Immobilization Relieve PainResolve Arm SwellingRecover Range of MotionPrevent Muscle AtrophyRestore Aerobic ConditionMaintain/develop core stability
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Toss 4 - 5 Months
Mound 6 - 8 Months
Game 11 - 12 Months
Prevent Shoulder Prevent Shoulder InjuryInjury
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Ulnar Nerve Injury
MMEE
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FibrosisCompressionTension
UN subluxationElbow valgus laxity
Ulnar Nerve InjuryUlnar Nerve Injury
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Non-operative Care
• Night Splint• NSAIDs• Oral Steroids• Activity Modification• Desensitization / Soft tissue
release
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DecompressioDecompressionn
MEME1133 2244
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Fascia SlingFascia Sling
MMEE
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Lateral CompressionInjuries
Rad-Cap Rad-Cap arthrosisarthrosis
Stress fractureStress fracture
OCDOCD
Lateral Lateral synoviumsynovium
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Kids – Lateral Elbow
1. Panner’s Disease• <10 yo, self limited
2. OCD Capitellum• Progressive!!!
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• OCD capitellum
• 5-10yo
• Self limited
• Tx conservatively– Rest, ice, nsaids– Gradual RTP. Must be able to
throw without sx
Panner’s Disease
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Posterior blood supply peds lateral elbow
Repetitive injury to epiphysis may alter blood flow = osteochondrosis
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Osteochondritis Dissecans
• Age 9 - 16 Years Old
• Progressive• Remove loose
bodies
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Loose BodyLoose Body
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Lateral Plica Syndrome
RHRHUlnUlnaa
HumerusHumerus
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VEO Syndrome
2nd Critical Instant2nd Critical Instant
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History
Pain- posteromedial at ball release and in follow through
Past history painPast history UCL injuryStiffnessPerformance, warm-up
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Examination
Local Tenderness
Motion Loss
Extension Painful
Extension Plus Valgus Painful
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ExtensioExtension n
TestTest
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Posterior & Medial
AndrewAndrewss
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Olecranon Tip Resection
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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
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Olecranon Tip Osteophytes
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Kids
Olecranon Apophysis Injury
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Olecranon Apophysis NU
LefLeftt
RighRightt
16 y/o RHP16 y/o RHP
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10 Days 10 Days Post-OpPost-Op
3 3 Months Months Post-OpPost-Op
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Tip Stress Fracture
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MRIMRIX-X-rayray
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The treatment plan is based on the player’s history,
examination and response to conservative care.
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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
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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)
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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:
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THANK YOU