sat sprts elbow 2013cme.uthscsa.edu/presentations/sports13/011913/6...mcl deficiency at the elbow...

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COMMON SPORTS INJURIES of the ELBOWInjuries to the Throwing Athlete

B F Morrey, MDProfessor of Orthopedic Surgery, UTHSCSA


Financial Disclosure

Dr. Bernard Morrey has disclosed that he is the Medical director of Tenex Health.


• Muscles/tendons• Ligaments• Articulation

OUTLINE


• Biceps• Triceps• Epicondylitis

Muscles/Tendons


DISTAL BICEPS TENDON RUPTURE

• Diagnosis – how hard is it• Does it have to be fixed • Does technique matter • How long to protect/ rehab • If fixed, what can pt expect

QUESTIONS

F lectionAB ductionS upination



• Diagnosis – how hard is it• Does it have to be fixed

– Lose ~ 10 -15% flexion strength– Lose > 50% supination strength

QUESTIONS

Comparable clinical results


• Diagnosis – how hard is it• Does it have to be fixed • Does technique matter • How long to protect/ rehab

– Depends on security of repair• Immobilize: 3-4 days • Active assisted motion: 5-10 days• Against gravity: 10 -21 days• Progress to full activity 1-4 months

QUESTIONS



• Diagnosis – how hard is it• Does it have to be fixed • Does technique matter • How long to protect/ rehab• If fixed, what can pt expect

QUESTIONS

> 90% are >90% normal

TRICEPS TENDON RUPTURE

• Diagnosis – Central attachment:MRI QUESTIONS


• Diagnosis – Central attachment:MRI• Does it have to be fixed - Yes• How should it be fixed – Bone tunnels

QUESTIONS



• Diagnosis – Central attachment:MRI • Does it have to be fixed - Yes• How should it be fixed – Bone tunnels• How long is the rehab period - 1 year!!!• What can pt expect - >90/90, if acute

QUESTIONS

•Biceps•Triceps•Epicondylitis

Muscles/Tendons


Epicondylitis: Where are we, really?

• What is the pathology • Does everything work• Does anything work • Anything new?

QUESTIONS


• Non inflammatory• Degenerative• ECRB

Patho/anatomy

Well accepted


• Less invasive/ percutaneous• Scope?– Acupuncture– Botox– Shock Wave– PRP– Ultrasound

Treatment TrendsToday

TENNIS ELBOWWhat Works: Anything – Everything?

• Current Concepts in Sports MedPopularity based on safety and attractivenessNot on the scientific evidence of effectiveness

Platelet Rich Plasma (PRP)

Hall, et et; JAAOS, 2010



• PRP– Appears to be effective– Safe– Improves with time– Alters natural history?– Unpredictable– Painful/expensive

CONCLUSION


• Effective: 80 – 90%- Added value?- Cost effective?

Arthroscopy


Safety characteristics• Visualize/localize the pathology• Energy only effective with diseased tissue

Ultrasound: Dx / Rx



• Local anesthetic• Prep = cortisone

• 4mm stab wound

• Insert probe (#16)

Technique - Treatment


Channel of debris clearance by US Probe

5.5

1.0

Visual Analogue Scale (VAS)

Clinical Experience


Subjective satisfaction - 19/20 AJSM, March 2013


Time to intervention3 months 1 year

Site of intervention

Office ASC


•MCL• LCL

Ligaments


MCL Deficiency at the Elbow

• Etiology? Spectrum • Single event; trauma• Repetitive; throwing

QUESTIONS


• Diagnosis – how hard is it

QUESTIONS


• Does it have to be fixed– Only one study

–45% heal without surgeryRettig, A; Am J Sp M: 2001

QUESTIONS


Technique:MUCL Docking concept preferred


Ulnar nerve



• When to operate• How to fix it• Has the rehabilitation program changed?

– No, still 12 months (10 -12)• Expected outcome

– Athlete: 70%– Non – athlete: 90%

• CONCERN: being done frequently in the young

QUESTIONS

• Plica• Osteophyte• Articular - OCD

Articular


• Snapping easy– Rolls over the head in flexion (60 deg)– Snaps back when going into extension

BUT•May mimic epicondylitis !!!

Plica




Plica


Plica

•Plica•Osteophyte

Articular



Impingement at the Elbow

• How much should be removed

QUESTIONS

FEATURES

Valgus

Compression

Tension

3 mm resection med corner increases lig strain!!

Kamineni,ElAttrache et al:JBJS, Am, 2005

• Valgus– Olecranon– MCL

Med

Rationale

Collateral Ligaments & Elbow Instability

Sensitivity

•Plica•Osteophyte•Articular - OCD

Articular



Osteochondritis of the Elbow

• When to treat• How to treat• When can pt return to sport

QUESTIONS

TREATMENTLOGIC

OCDLesion

Stable

CanReattach

StableRim

Leave/Drill Reattach Remove

CatrlgeTrnsplnt

YES

YESYES

NoNoNo



• Intact cartilage – drill

• Flap – sew back down

• Detached – graft/ micro fx

How to Rx



• Do NOT allow mechanical sx to persist

Beware!


• When to treat• How to treat• When can pt return to sport

– When healed– When asymptomatic with progressive

sports related activity

QUESTIONS

• Spectrum of pathology• Reliable rx options• Requires expertise• Recognize the time

critical conditiions

Summary



Thank You

Elbow Bend Ranch, La Grange, Texas

Thank You

ARTHROSCOPY of the ELBOWOsterchondritis Dissecans

SUMMARY


FEATURES

• Repair vs reconstruction:– If tissue adequate – repair

• Use #5 non-absorbable suture

Considerations

Collateral Ligaments and Elbow Instability

FEATURES

THANK YOU

ARTHROSCOPY of the ELBOWOsterchondritis Dissecans

• Type I: stable = Rest• Type II -

– Loose body, smooth bed: excise– Detached, rough bed: debride

TREATMENT


• Accurate diagnosis, localization– Improves with experience

• Intervention - Indications– Alternate to steroid injection– Alternate to surgical intervention

• Unique attribute – Removal of diseased tissue

Ultra soundDx/Rx

TENDONOPATHY at the ELBOWRationale for this Treatment/Study

Major advance – if safe and cost effective

sat sprts elbow 2013cme.uthscsa.edu/presentations/sports13/011913/6...mcl deficiency at the elbow...

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