CHAPTER 7
Arm and Elbow Injuries
Andrew L. Sherman, MD, MS, and Jesse N. Charnoff, MD
Arm and elbow injuries are common in athletes and even more prominent in those who participate in sports that require overhead throwing. Young throwing athletes have a high rate of such injuries due to the repetitive stress on their immature skeletons. For example, the overhead throwing motion of most baseball pitchers exposes the medial, lateral, and posterior elbow to forces of tension, compression, shear, and torsion. Poor mechanics and fatigue exaggerate the forces generated by overhead throwing. One survey of 476 pitchers found an incidence of shoulder or elbow pain to be 50 percent in 9- to 14-year-old pitchers who were followed for one season (Lyman et al. 2002).
Additionally, athletes who play golf, tennis, squash, racquetball, and volleyball expose their elbows to repetitive strain and consequent injuries. Other sports, such as American football, skiing, hockey, and soccer, are associated with traumatic elbow injuries. Most elbow injuries are minor and respond well to a short period of rest and rehabilitation. However, other elbow injuries progress over time, threaten the growth plate in young athletes, and may lead to permanent loss of function and athletic opportunity if not identified and treated appropriately.
ARM AND ELBOW INJURIES
Injury | Page |
Tennis Elbow | |
Golfer’s Elbow | |
Radial Tunnel Syndrome | |
Posterior Interosseous Nerve Syndrome | |
Pronator Syndrome | |
Ulnar Collateral Ligament Tear | |
Little League Elbow | |
Osteochondritis Dissecans | |
Cubital Tunnel Syndrome | |
Humeral Stress Fracture | |
Elbow Dislocation | |
Olecranon Bursitis |
TENNIS ELBOW
Common Causes
Lateral elbow tendinopathy (LET) or lateral epicondylitis, also termed “tennis elbow” (TE), is a common sport syndrome that affects more than just tennis pros and the weekend tennis warrior. Tendinitis by definition implies that tendon injury is accompanied by an inflammatory response. Available histopathology studies that compare healthy tendons and those injured secondary to overuse show that injured tendons appear to be in a degenerative state with few or no inflammatory cells. Tendinosis more appropriately defines this process (Charnoff and Naqvi 2018). However, in TE, a tear may be the primary insult and the chronic degeneration a secondary process. For this reason, we prefer the term tendinopathy. Epidemiologic studies have estimated LET occurrence rates from 1 to 3 percent, with the highest incidence among male and female patients 40 to 49 years old, and the second highest incidence from 50 to 59 years old (Allander 1974, Verhaar 1994, Sanders et al. 2015). Historically, it has been stated that the rate of LET was greater than 2:1 (more common in females). More recent data show only a slight increase in rates among females (Sanders et al. 2015). Nirschl and Pettrone described the mechanism of injury at the origin of the extensor carpi radialis brevis, where overuse has resulted in microscopic rupture and subsequent tendinous nonrepair with immature reparative tissue (Nirschl and Pettrone 1979). These muscles originate at a common point at the lateral epicondyle of the elbow. While the overuse injury can occur from many activities, it is the backhand motion of the tennis swing that has the most direct impact on tennis players.
It is clear that certain risk factors come into play when one is investigating the cause of this injury. Epidemiologic studies find that the risk for developing the condition increases in those playing more than two hours per day and in individuals who are under 40 years of age (Gruchow and Pelletier 1979, Pluim et al. 2006). Poor swing mechanics seem to be a common culprit, particularly in one-handed backhands and novice players. Improper equipment also seems to play a role in causing the condition to occur with increased frequency. Often the tennis grip may be too small or too large; the proper grip size is 4-1/2 inches (11.4 cm) from the bottom of the lateral wrist crease to the tip of the ring finger (Adelsberg 1986). Equipment issues including wet, heavy balls, a racket strung too tight, a stiff racket head, a heavy racket, or even playing on faster surfaces like hard courts can increase the load on the extensor muscles and can add to the problem (Adelsberg 1986, Rossi et al. 2014, Giangarra et al. 1993). Finally, weekend warriors who are improperly conditioned are at most risk for injury, because the muscles are not strong and limber enough to account for the stress of infrequent competition.
Identification
A patient who develops LET will most often complain of pinpoint, knifelike pain over the lateral surface of the elbow. The pain usually occurs with wrist extensor and supination activity, such as that seen with a tennis backhand. A physical exam will often confirm the pinpoint tenderness and even swelling on the outside of the elbow. Pain is reproduced by forcibly resisting wrist or finger (especially the long finger) extension. These tests are called the Cozen test and the Maudsley test, respectively. Radiographic studies usually show no abnormality but might reveal a bone spur or calcium deposit outside the elbow joint. Sonographic detection of LET is similar to evaluation of other tendon injuries. Tendinosis appears as areas of hypoechogenicity and thickening of the tendon. It is also important to evaluate the tendon for a tear, which will typically appear hypoechoic or anechoic and is associated with tendon volume loss (Obuchowicz and Bonczar 2016).
If the athlete complains of pain radiating down the forearm, this pain must be distinguished from radial nerve entrapment, which can be mistaken for LET or occur conjointly with it.
Treatment
Treatment of LET is multifaceted and the injury is often very responsive to a conservative approach (Smidt et al. 2006). Over 90 percent of patients will respond to medical treatment. Given the high rate of improvement with medical management, surgery is contemplated only after 12 to 18 months of failed conservative treatment or if there is a frank, complete tear. The first step of treatment is relative rest in order to give the tendon the opportunity to repair itself. Many patients also use bracing in the early stages of recovery. The bracing options include a forearm counterforce brace, often called an elbow clasp or epicondylar brace, that can be coupled with a wrist extensor splint at a 20-degree angle. The clasp reduces stress on the lateral epicondyle by two mechanisms. Firstly, it decreases the expansion and contraction of the muscle via direct compression; secondly, it creates a new area of origin for the extensor tendons, taking the load off of the epicondyle. Data have been unclear as to which treatment is superior. One study showed no difference in total clinical outcome scores between the forearm counterforce strap and the extension wrist splint groups for the treatment of lateral elbow tendinosis at six weeks. However, the extension splint group had significantly better pain relief than the forearm strap brace group (Garg et al. 2010). Manual therapy and taping are also used on occasion.
Rehabilitation should focus on strengthening and coordination. Initially, full pain-free range of motion is achieved with stretching; then strengthening can occur. When strengthening, it is important to monitor pain levels. Exercises that focus on isometric movements may be tolerated better with a progression to concentric (muscle shortening) and eccentric (muscle lengthening) exercises. It is also important to incorporate proximal muscles that can stabilize the upper body and reduce the strain on the elbow. For example, strengthening the latissimus dorsi, muscles of the rotator cuff, and upper scapula stabilizing muscles will allow the athlete to have a more balanced upper body, support the weight of the racket better, and reduce the focused stress on the lateral elbow. As symptoms improve, focused wrist and forearm strengthening exercises with increasing load can be added. Lastly, sport (or task or job)-specific training is initiated to complete the program. Only when the athlete has pain-free range of motion at the elbow, has normal wrist extensor strength, and can apply this strength to a normal swing should the athlete return to competitive play.
If the athlete fails to improve with these conservative measures, other treatment options exist. Corticosteroid (CS) injections administered to the lateral elbow have been used historically, but recently have come under scrutiny. A recent placebo-controlled study comparing CS injection versus placebo injection found that CS injections do help relieve pain in the short term (less than four weeks), but it was noted that these results reversed at 26 weeks, with CS injection displaying worse outcome in regard to pain control and functional measures. At one year the patients who had the CS injection noted significantly worse pain scores and had a 2.4:1 rate of reinjury as compared to the control group (Coombes et al. 2013). These findings along with other clinical trials that show deleterious effects steroids have on intraarticular cartilage have changed the treatment paradigm (McAlindon et al. 2017). Corticosteroid is still a potential treatment option if short-term pain relief is the main goal of treatment, but the long-term risks must be discussed and considered prior to treatment.
Over the last decade, many new treatments have been developed and show promising results. One noninvasive treatment that has been shown to be beneficial in clinical trials is nitric oxide. This medication is delivered via a transdermal patch. It is theorized to work in tendinosis by regulating local blood flow and host defense (Kahlenberg, Knesek, and Terry 2015). It is also believed to have a positive effect on collagen synthesis (Xia et al. 2006). In randomized clinical trials it has shown a significant reduction in both pain and tenderness at three months after treatment, as well as increased wrist extensor force at six months after treatment (Paoloni et al. 2009, McCallum, Paoloni, and Murrell 2011, Paoloni et al. 2003). That being said, longitudinal studies have failed to reveal any significant difference at five years when compared to a standard tendon rehabilitation program (McCallum, Paoloni, and Murrell 2011, Kahlenberg, Knesek, and Terry 2015).
Another noninvasive treatment that has recently gained popularity is extracorporeal shockwave therapy (ESWT). The idea behind shockwave therapy is to use sound waves to induce microtrauma to pathologic tissue. This microtrauma initiates a new healing response that ultimately leads to new collagen formation and a healthier tendon. A recent systematic review that looked at over 100 randomized clinical trials (RCTs) found ESWT both safe and significantly effective when compared to placebo or other treatments for tendinosis in more than 80 percent of RCTs (Schmitz et al. 2015). Current recommendations are that ESWT be done weekly for a total of three sessions with 2,000 impulses per session and with no local anesthetic.
Orthobiologic treatments have garnered significant attention in recent years due to their potential benefits. Platelet-rich plasma (PRP) has generated some of its most compelling data in treating LET. Studies ranging from case series, RCTs, and meta-analysis have shown PRP to be superior to CS injection for TE, particularly at one- and two-year follow-ups (Ahmad et al. 2013, Arirachakaran et al. 2016, Gosens et al. 2011). There are other studies that have shown no difference in outcomes between PRP and CS. Protocols have been called into question regarding standardization of preparation and administration, including platelet count injected and the optimal number of injections over what period of time. Initially it was thought that three injections were required, but now research has shown that one injection generates comparable results (Glanzmann and Audige 2015). The variation in protocols is a large reason why there are such differences in results seen in some studies.
Other minimally invasive treatments considered “experimental” by many clinicians include botulinum toxin A (Botox) injections and prolotherapy. The proposed mechanism of prolotherapy injections is that an injected irritant (hypertonic dextrose, phenol-glycerine-glucose, or sodium morrhuate) either causes a cell rupture through osmosis or attracts inflammatory mediators, thus improving blood supply to the diseased tendon. Data including those from one RCT showed positive short-term decrease in pain up to 16 weeks; however, there does not appear to be supportive evidence for long-term benefits (Scarpone et al. 2008). Botox is not a commonly used treatment of LET, even though there are some promising data that show significant pain decreases at 4, 8, and 12 weeks (Placzek et al. 2007). The theorized mechanism is that the paralysis Botox causes of extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL) prevents further microtrauma to the origin and allows the pathologic tissue to heal (Kahlenberg, Knesek, and Terry 2015, Lin et al. 2010, Placzek et al. 2007). A more recent study has shown significantly improved pain scores in patients treated with CS versus Botox in short-term follow-up. The current data regarding this treatment are not clear, so we suggest using the treatment with caution. It is also important to keep in mind that the inherent extensor weakness that results secondary to treatment must be considered prior to administering to athletes who require this type of strength in their sport.
When all conservative treatments fail to improve the condition, surgery is considered. A less invasive form of tendon debridement has been gaining popularity and shows promise as a treatment for recalcitrant LET. This procedure is called percutaneous ultrasonic tenotomy (PUT). The procedure can be completed in an outpatient setting. After superficial and deep local anesthetic is injected, a small incision is made and a probe is placed over the diseased tissue. Ultrasound is used to guide the procedure. Percutaneous ultrasonic tenotomy uses technology based on the principles of phacoemulsification used in cataract surgery (Paul and Braga-Mele 2005, Kelman 1994). An ultrasonic vibrating tip is directed at the pathological tissue seen in tendinopathy. The tissue becomes emulsified and requires debridement, which is done by the device (Koh et al. 2013, Peck, Jelsing, and Onishi 2016). It is theorized that the pain evoked by the necrotic tendon is mediated by cytokines, which resolves upon removal of the pathologic tissue. In addition, it is hypothesized that the space created by the ultrasonic tenotomy allows a more normal environment leading to a rapid healing response (Barnes, Beckley, and Smith 2015). To date, all of the studies are case series. They show immediate and prolonged patient satisfaction as well as sonographic improvement for up to three years (Seng et al. 2016, Barnes, Beckley, and Smith 2015, Elattrache and Morrey 2013, Patel 2015).
Other surgical procedures include either open or arthroscopic, depending on the underlying condition and the experience of the surgeon. Surgeons can remove a portion of the damaged tendon or release the attachment of the affected tendon. A repair of the healthy portion of tendon is sometimes carried out as well. Postoperatively, the patient usually is placed in a 90-degree brace. Early motion in a brace may be initiated at three to five days, with strengthening exercises usually starting by three weeks postoperatively. Return to tennis and racket sports can be expected by four to six months. Depending on the specific job requirements, patients can return to work in 6 to 12 weeks, although job modification or persistent use of a counterforce brace during work activities may be necessary. Approximately 85 percent of patients who fail conservative treatment and undergo the surgery ultimately report some degree of pain relief.
Return to Action
The criteria for return to play after treatment for lateral epicondylitis elbow injury are similar to those for other musculoskeletal injuries. The goal of treatment and benchmarks for clearance include the restoration of normal strength, endurance, and flexibility. Returning too early puts the athlete at risk of reinjury and the inability to perform at a satisfactory level. Lateral elbow tendinopathy reinjury does not usually result in fracture or severe disability; therefore, some flexibility may be granted for the recreational athlete. Thus, some athletes may gradually return to sport with less than normal physical capacity. For full competitive play, grip and wrist extensor strength in the dominant arm should exceed that in the nondominant by approximately 10 percent. Accelerating the return would include steps to change swing technique, training habits, and equipment and obtaining an elbow counterforce brace. Ultimately, 95 percent of those who receive treatment for LET should achieve excellent functional recovery with conservative treatment.
GOLFER’S ELBOW
Common Causes
Medial elbow tendinopathy (MET) or medial epicondylitis, also termed “golfer’s elbow” (GE), is a malady that occurs less commonly than the lateral form of tendinopathy but can be just as painful. Similar to that in TE, in GE the injury occurs as a result of overuse stress placed on the musculotendinous junction. In this case, the muscle–tendon interface is in the flexor forearm tendons and the medial epicondyle. Like TE, this injury often presents secondary to chronic overuse and degeneration in the form of tendinosis, or failure to fully heal microtears of the tendon, which leads to chronic pain and dysfunction (Charnoff and Naqvi 2018). Golfer’s elbow has been found most commonly in people aged 45 to 64 years and slightly more often in women as compared with men (Shiri et al. 2006).
Similar to TE, GE can progress due to poor swing mechanics and equipment issues. The medial elbow pain occurs most commonly in the trailing arm in golf or the dominant elbow in throwing sports. It can be seen in baseball pitchers who open the body up too quickly while throwing. Sports or occupations that require a strong grip can cause increased stress on the wrist flexor muscles, increasing stress on the tendon at the medial elbow. Incorrect plane in the backswing and downswing can cause abnormal stress on the elbows and wrists. In tennis, late ball strike has been implicated as a cause for MET.
Identification
The patient who develops medial epicondylitis most often complains of pain on the medial elbow. The pain is worse with wrist flexion (palm bent down) and pronation (the motion used to turn a dial counterclockwise starting with your palm up and ending with it facing down). Some patients also complain of tingling or numbness in the fourth or fifth fingers. This suggests either irritation or even frank entrapment of the ulnar nerve as it travels through the ulnar groove in the elbow. This injury is called cubital tunnel syndrome and must be suspected when patients’ hand or grip strength has decreased to the point that they are dropping the ball or even simple household objects. Ulnar nerve entrapment in cubital tunnel syndrome is important to identify, because surgical treatment may be required for severe neurological impairment.
On physical examination, the health care professional can usually reproduce the pain of MET by palpating at the medial epicondyle itself or just distal, in the area of the flexor musculotendinous junction. The range of motion of the elbow is usually normal, and it is unusual to have any discoloration or swelling in the joint. However, if an acute tear of the musculotendinous junction is present, there may be some swelling and warmth.
Imaging studies do not usually reveal helpful details. An X-ray is performed to rule out any loose bodies or bone spurs. Magnetic resonance imaging scanning can investigate the condition of the ligaments, especially the ulnar collateral ligament, for tearing or inflammation. Sonographic detection of MET is similar to evaluation of other tendon injuries. In tendinosis, the tendon appears hypoechoic (dark) and thickened. It is also important to evaluate the tendon for a tear, which will typically appear hypoechoic or anechoic and is associated with tendon volume loss (Obuchowicz and Bonczar 2016). A nerve condition velocity study (NCV) and needle electromyographic (EMG) study are performed when neurological abnormalities are present, to investigate the function of the ulnar nerve as it courses through the elbow, arm, and wrist.
Treatment
Initial treatment of acute GE focuses initially on the PRICE principles (protection, rest, ice, compression, elevation) and then on relative rest, medial counterforce bracing, icing, and anti-inflammatory medications. Early mobilization in musculoskeletal injuries has been shown to hasten return to play and improve patient satisfaction. Once the acute phase has passed or the pain is reduced, more attention can be given to rehabilitation. Many athletes, particularly baseball pitchers and golfers who develop medial epicondylitis, have weak upper-back, neck, and thoracic muscles. Coupled with a tight latissimus dorsi (back) and pectoralis (chest), this muscular imbalance often leads to poor posture and altered sport mechanics that ultimately produce abnormal stress on the inadequately supported elbow, shoulder, and wrist joints. Therefore, the preliminary rehabilitation program must incorporate proper body posture, improving upper body muscular strength to better support the distal extremities and the weight they bear, and teaching better sport mechanics to prevent future symptoms. As the athlete progresses, sport-specific and eccentric exercises are introduced.
The golf swing, in particular, varies so much from individual to individual that flaws can often be spotted and corrected in affected individuals. The swing itself has four phases: backswing, downswing, acceleration and ball strike, and follow-through. Each phase is fairly self-explanatory, and each uses a different set of muscles and stress points on the body. In particular, golfers with elbow pain often have problems with the backswing and downswing. With too steep a swing plane (club shaft too perpendicular to the ground), the hands and wrists overcompensate to position the head for ball impact, increasing the risk of hitting a “fat” shot, which transmits forces to the hands, wrists, and elbows. Too flat a swing plane (club shaft too parallel to the ground), and the elbows will also undergo undue stress as the forearms try to provide lift at the end of the swing by contracting the wrist flexor muscles too strongly. Videotaping the swing can often provide the golfer with further insight into swing mechanics.
Looking at the equipment may also make a difference. Using cavity-backed irons with larger “sweet spots” can dampen vibrations that are transmitted to the wrists, forearms, and elbows. Although researchers who performed EMG studies could not prove a correlation between grip size and forearm muscle firing, a larger grip size still is often advocated as a way to relieve elbow pain.
All of the injections discussed in the TE section are also options for GE. These are less studied with regard to GE, but are based on the same premise. Historically, steroids have been used but are now employed far less due to the known deleterious effects (Coombes et al. 2013, McAlindon et al. 2017). Orthobiologics show promise, but their cost can be a limiting factor for many patients. Few studies have been performed assessing orthobiologic efficacy for GE, mainly consisting of case studies.
Up to 90 percent of people who suffer from MET are successfully treated with conservative management (Ciccotti, Schwartz, and Ciccotti 2004). Conservative treatment achieves the highest success in the athlete when such treatment encompasses all aspects of the problem by providing for initial pain, holistic rehabilitation, correcting any abnormal posture and sport mechanics, and attending to equipment errors that had contributed to the problem. Similar to TE, when conservative treatment fails, surgery has been shown to produce good and safe results (Han et al. 2016). The procedures available are the same as those for TE, ranging from PUT and release to open or an arthroscopic debridement (Sahu 2017, Barnes, Beckley, and Smith 2015).
Return to Action
Athletes may return to action when they have full pain-free range of motion of the elbow. Grip strength should be nearly symmetric. The rehabilitation program must focus on re-creating proper body posture, improving upper body muscular strength to better support the distal extremities and the weight they bear, and teaching improved sport mechanics to prevent future symptoms. Once that program is complete, the athlete can focus on strengthening the hand, wrist, and forearm.
RADIAL TUNNEL SYNDROME
Common Causes
Radial tunnel syndrome (RTS) is most often caused by repetitive twisting and torqueing of the elbow, especially the repetitive motion of the throwing arm. Repeated pronation and supination of the elbow, seen often in pitchers, can aggravate the radial nerve. Eventually, scarring or an extra ligament traps the radial nerve in the proximal elbow. The most common sports in which the injury occurs are tennis, racquetball, golf, baseball, and other throwing sports.
Identification
In RTS, the motor branch (the part of the nerve that causes the muscle to contract) of the radial nerve becomes entrapped. Symptoms of pain and numbness in the back of the hand and forearm occur with weakness in extending of the wrist and fingers.
The athlete might at first appear to have TE, but the injury does not improve with usual conservative treatment. Further examination reveals neurological deficits in the forearm and back of the hand. X-rays or magnetic resonance imaging (MRI) typically cannot identify the nerve injury itself or entrapment but can reveal other injuries to the bone or tendons, such as stress fracture or bone avulsion. Magnetic resonance imaging findings in RTS are most commonly denervation edema (swelling in the muscle due to poor nerve supply) or atrophy within muscles innervated by the posterior interosseous nerve (Ferdinand et al. 2006). Electrodiagnostic testing initially may be normal in patients with RTS if the severity of nerve compression is mild or transient. However, in more severe cases, nerve conduction studies can identify the site of nerve entrapment and often the severity of nerve damage. Neuromuscular ultrasound can be used to identify injuries to the radial nerve and overlying tendons. Dynamic ultrasound scanning can show nerve subluxation and points of entrapment where static images like X-ray and MRI cannot.
Treatment
In the short term, alternating ice and heat to the elbow, along with anti-inflammatory medications, can reduce inflammation and pain. Initially, stretching can increase the flexibility of the overlying tendons and improve the symptoms. For a more severe or chronic problem, the athlete should see a professional, who will prescribe rehab specific to the athlete’s needs and goals. An injection of local anesthetic and steroid can be administered under ultrasound guidance to help decrease inflammation around the injured nerve. If conservative management fails and pain or neurological symptoms become even more severe, surgery to decompress the nerve may be an option.
Return to Action
The throwing athlete can return to action when the pain has improved to the point at which a full pain-free throwing range of motion is achieved. Most athletes can achieve this through exercise, stretching, and rehabilitation. Rehabilitation should be guided by an experienced clinician. A gradually progressing throwing program can prevent reoccurrence of the injury. If, however, surgery is performed, there is a longer road to recovery. Some markers such as equal grip strength, wrist extensor strength, and finger extensor strength should be achieved before returning to throwing, golf, or racket sports.
POSTERIOR INTEROSSEOUS NERVE SYNDROME
Common Causes
Posterior interosseous nerve (PIN) syndrome, in which a branch of the radial nerve is impinged or irritated, occurs most often in tennis players and results in weakness of the muscles used in finger extension. Symptoms of PIN syndrome mimic RTS in that the finger extensors are weak but they differ in that PIN does not produce wrist extension weakness. The most common cause for this condition is compression of the nerve. One mechanism of compression is repetitive rotation or pronation of the forearm, which has been shown in cadaveric studies to increase the pressure inside the radial tunnel (Erak, Day, and Wang 2004). In the literature the proximal aponeurotic edge of the supinator (also known as the arcade of Frohse) is mentioned as the most frequent site of entrapment of the PIN (Naam and Nemani 2012). This condition is commonly found in tennis players, likely secondary to the high degree of pronation and supination (Lorei and Hershman 1993).
Identification
Athletes with PIN often complain of pain in the lateral elbow. They notice difficulty extending their fingers. Numbness is unusual. Examination typically reveals local tenderness over the lateral aspect of the elbow. Tapping on the lateral aspect of the elbow or just distal to the elbow may cause “electrical” pain to radiate down the outside of the elbow. Sonography can be used to identify points of entrapment and injury. Electrodiagnostic testing is often necessary to identify the severity of the injury.
Treatment
Initially, control the inflammation at the elbow. Rest, ice, anti-inflammatory medication, and sometimes splinting should reduce pain and inflammation. Severe cases that include weakness or numbness likely require physician input. Local injection under ultrasound guidance with anesthetic and CS has shown promise as a treatment if minimally invasive procedures are required. Although conservative treatment usually resolves PIN, surgery might be necessary to free the nerve in the elbow and forearm areas.
Return to Action
Athletes may return to sports when they have a normal grip and when strength is restored to the upper limb and finger extensors. The elbow must be pain free throughout the throwing motion. A period of rehabilitation supervised by a trainer or physical therapist will be needed to restore that strength.
PRONATOR SYNDROME
Common Causes
Pronator syndrome (PS), often termed anterior interosseous syndrome, occurs when the median nerve (one of the two main nerves that supply function to the hand and sensation to the thumb and the first two fingers) is compressed near the crease of the bent elbow. Pronator syndrome has traditionally been described as compression of the median nerve between the two heads of the pronator teres or by the flexor digitorum superficialis (FDS) (Lee and LaStayo 2004). More recent cadaveric studies have revealed that this nerve can be compressed due to several structures including the ligament of Struthers, lacertus fibrosis (bicipital aponeurosis), flexor superficialis tendon, or, most commonly, between the two heads of the pronator teres in the proximal volar forearm (Tetro and Pichora 1996). When the compression occurs between the two heads of the pronator teres, only the motor branch, the anterior interosseous nerve, is affected, resulting in motor but not sensory deficits.
Pronator syndrome has been seen in athletes and employees who play sports or have jobs that require repetitive exertional grasping activities (Lee and LaStayo 2004). This group includes assembly line workers, carpenters, weightlifters, and tennis players. The most common cause of the condition in athletes is hypertrophy (increase in mass) of the volar (front) forearm muscles due to weightlifting or similar activities. The injury is usually transient and benign. Most susceptible to PS are weightlifters, who are often told they have “Popeye arms,” meaning thick forearms. Baseball pitchers with overdeveloped forearms can also acquire PS. If the injury is left untreated, or in the case of severe ligament entrapment, PS can result in permanent injury to a motor branch of the median nerve and result in forearm muscle atrophy and weakness of muscles in the lower forearm and hand.
Identification
The compression of the median nerve most often occurs in the arm or forearm, commonly between the two heads of the pronator teres in the area of the elbow crease. Usually, only the motor branch of the nerve is affected, resulting in motor but not sensory deficits (identify patients with weakness but not loss of touch in their palm or over the first three fingers).
Avid weightlifters with this injury might experience symptoms of performance decline in the affected extremity caused by painless muscular weakness. Alternatively, athletes will complain of pain described as a dull ache. The pain is localized to the flexor forearm (often the belly of the pronator teres muscle) and is worsened with pronation movements (turning the palm down when the upper arm is straight out in front of you) or prolonged activity. In contrast to carpal tunnel syndrome, nocturnal pain is uncommon. A physical exam will reveal significant weakness in the finger flexor muscles, and especially in the thumb flexor muscles. Pronator strength is often preserved because the pronator teres muscle is innervated by the nerve prior to compression.
Physical exam maneuvers can help identify the site of entrapment. The pronator teres is considered the site of compression if symptoms are reproduced with resisted pronation, with the forearm in neutral as the elbow is gradually extended. The lacertus fibrosus is suspected if symptoms are reproduced with resisted elbow flexion at 120 and 130 degrees of flexion with the forearm maximally supinated (Tetro and Pichora 1996, Lee and LaStayo 2004). The FDS is suspected as the source of compression by reduction of symptoms with resisted flexion of the proximal interphalangeal joint of the long finger (Rehak 2001). In addition to the physical exam, more invasive testing, including electromyography, may be indicated for precise diagnosis and determining area of compression.
Pronator syndrome is less common than other upper-limb entrapments, so other conditions that cause pain, weakness, or numbness such as carpal tunnel syndrome must be evaluated for. Electrodiagnostic studies are required to distinguish these often overlapping and sometimes coexisting problems. Magnetic resonance imaging or ultrasound of the elbow can sometimes show ligament entrapments or abnormal signal within the median nerve but is more likely to be of value when performed in the cervical spine to rule out a herniated disc with nerve root compression that might mimic PS symptoms.
Treatment
Treatment consists of initial rest to the affected upper limb and avoiding athletic activity. Although there is no clear evidence for its efficacy, one can try applying a wrist immobilization splint in 15 degrees of flexion for the athlete to wear for four to six weeks. The athlete is taught to perform friction massage at the site of entrapment or muscular restriction. Quite often, the rest, forearm stretching, and possible antagonist strengthening of the wrist extensors resolve the symptoms. Modalities including ultrasound, electrical stimulation of the nerve, and nerve gliding maneuvers may be used (Lee and LaStayo 2004). If symptoms persist and a physician suspects the nerve is entrapped by a tendon, muscle, or ligament, surgical exploration might be necessary.
Return to Action
Weightlifters with this injury may return to exercises that stress the front of the forearm and wrist only when they feel no pain when performing the exercise. Gradually, they will need to strengthen the area again to attain symmetry with the uninvolved side. Throwing athletes with this problem on the dominant side should return to their sport only when the injured side is at least 80 percent back to normal and no pain occurs during the throwing motion.
ULNAR COLLATERAL LIGAMENT TEAR
Common Causes
Injuries to the ulnar collateral ligament (UCL), the ligament on the medial (inner) side of the elbow, can be seen in all athletes but most commonly occur in baseball pitchers. The UCL, which sits three-quarters of an inch (1.9 cm) away from the medial epicondyle (bone on the inside of the elbow), is a tremendously important structure in terms of the medial elbow stabilization mechanism. When the elbow is flexed 90 degrees and undergoes stress, which regularly occurs in wrestling and American football, the UCL distributes over 50 percent of the medial support of the elbow. After the initial windup during a baseball throw, and then during the transition between bringing the arm back and then forward, the UCL is maximally stressed. During the throwing motion, the UCL pulls the forearm forward with the rotating upper arm. The tremendous tension produced in the relatively small UCL during a properly executed throw is close to its limit. When an athlete uses improper mechanics or if arm muscles become fatigued, the load might be more than the UCL can withstand and may cause microtears. If such microtears are not addressed with rest, change in improper mechanics, and therapy, a devastatingly large tear or sprain can occur.
Initial epidemiology studies implicated breaking-ball pitches as increasing the risk for arm pain in youth pitchers by 52 percent with curveball and up to 86 percent with sliders in pitchers 9 to 14 (Lyman et al. 2002). More recent studies, including biomechanical as well as clinical studies, have been unable to link an increase of torque or increase in arm pain with throwing breaking balls (Chalmers et al. 2016). A significant relationship has been found between peak velocity of fastball and pitchers who have undergone UCL reconstruction in Major League Baseball. Other secondary risk factors have been identified as high body mass index and young age (Chalmers et al. 2016).
Identification
Pitchers with UCL injuries often describe feeling or hearing a pop in the elbow during a particular pitch. Many experts believe that the one pitch was just “the straw that broke the camel’s back” and produced a final microtear that led to a large tear. A pitcher who tears the UCL loses a significant amount of support and strength in the elbow, thus limiting the ability to perform. Acute and then chronic pain in the medial side of the elbow will persist if the athlete tries to pitch through the injury. Magnetic resonance imaging scans are necessary to confirm and then determine the extent of the injury. Sometimes dynamic imaging is required to visualize a tear. This can be done sonographically. While visualizing the UCL if stress is applied to the ligament, a gap will become evident if there is a tear present. Alternative injuries such as elbow stress fractures must be ruled out.
Treatment
Although nonoperative management of the tear may reduce pain and swelling in a noncompetitive athlete, it will not enable a competitive athlete to recover completely. In most cases, the forces that high-level athletes place on the elbow are too strong for them to compete with a UCL tear. Surgery, in which a tendon is woven back and forth between the bones of the elbow (ulna and humerus) to fabricate a new ligament, is almost always recommended. This procedure has been coined “Tommy John” surgery because one of its first applications was on then-famed major league pitcher Tommy John.
Ligament reconstruction has been found to be more successful, with return to previous level of performance ranging from 92 to 93 percent, as compared to repair of the ligament, with 50 percent returning to play (Gregory and Nyland 2013). Many misconceptions regarding this procedure exist among both the general population and physicians. It has been found that 25 to 50 percent of players, coaches, and parents believe that this procedure allows pitchers to throw harder after the surgery than before they were injured (Ahmad, Grantham, and Greiwe 2012). Pitchers may improve after surgery secondary to their injury being healed and rigorous strengthening performed as part of their rehabilitation. Improved speed cannot be attributed to the actual procedure.
Recovery is a long process if the athlete wishes to regain lost skills. During the first three weeks after surgery, the goal of rehabilitation is to brace the elbow for support and restore lost elbow flexion, pronation, and supination motions. When athletes can touch their shoulder with their fingers, they may begin strengthening the wrist, flexor, and pronator muscles. Once full extension is achieved, the athlete can begin to strengthen the shoulder, elbow, and grip. Stressing the elbow should be avoided for four months.
After three months, the athlete can begin a throwing program with a foam ball for two weeks, a tennis ball for two more weeks, and then a hardball. Many physical therapists and sports medicine specialists recommend that no throwing take place until the athlete achieves what they consider to be a normal strength ratio of the external and internal rotator muscle groups. The ratio that they consider normal is when the external rotator strength is 65 percent of that of the internal rotators.
Return to Action
Only the athlete’s physician, with input from the trainer and physical therapist, should give the athlete clearance to return to competitive play after a ULC tear. On return, the athlete must still adhere to a strict, slowly progressive throwing program to avoid a second injury or relapse. In all cases, progress depends on such factors as age, experience, injury status, and healing patterns. Address soreness with care, allowing for an extra day of rest between workouts.
Before full return to competition, the athlete should be tested in a simulated game situation. For example, for a baseball pitcher, the simulation should be off a regulation mound with the same type of throwing that the pitcher would do during a game—same number and mix of pitches. If the stimulation is successful, the athlete may return to actual games. After surgery and proper rehabilitation, roughly 90 percent of athletes can expect to return to preinjury level (Thompson et al. 2001).
LITTLE LEAGUE ELBOW
Common Causes
Little League elbow (LLE) is an overload injury that occurs as a result of repetitive stress on the elbow in the immature throwing athlete. Injuries can occur to both the medial and lateral side of the elbow. However, it most commonly occurs medially in overhead throwers. During the throwing motion, the valgus stress on the elbow creates stretch tension on the elbow’s medial structures and compression of its lateral structures.
The throwing motion includes the windup, early cocking, late cocking, early acceleration, late acceleration, deceleration, and follow-through. A majority of injuries occur during the cocking and acceleration phases (Benjamin and Briner 2005). The acceleration phase of a throw subjects the elbow to valgus stress on the ULC, medial epicondyle (the bone on the inside of the elbow), and the ulnar nerve. The proximal end of the UCL in skeletally immature athletes is attached outside the elbow joint itself to the unfused medial humeral apophysis (the area of a bone where tendons attach, near the area where bone growth occurs). In one type of LLE disorder, excessive overhand throwing can cause a subclinical medial elbow stress fracture and eventually a partial separation of the medial apophysis (growth plate) from the humerus. Such microtrauma can add up and cause the partial separation to become a complete avulsion (tearing away) of the growth plate off the humerus, a much more devastating injury.
The elbows of skeletally immature overhead throwing athletes have secondary ossification centers at the radial head and olecranon (prominent bone on the upper end of the ulna behind the elbow joint). When subjected to the repetitive stress of overhead throwing, the growth plates of these unfused centers are more vulnerable to injury than the adjacent muscle–tendon units are.
The risk factor with the strongest correlation has been found to be the amount of pitching the athlete does (Olsen et al. 2006). This has become an issue as more and more athletes specialize in one sport at an earlier age and play in competitive leagues year-round. This exposes young pitchers to more innings at a high level with less time to rest (Fleisig and Andrews 2012). This has caused significant changes in the recommendations and rules in youth baseball leagues over the last 15 years. Coaches should consider monitoring total pitch count, including warm-up pitches before the game and between innings. These pitches are currently going uncounted and may negatively affect pitchers. It is also recommended that pitchers not also play catcher, because there has been a trend toward increased risk for serious injury due to more “throws” (Fleisig et al. 2011).
There is some debate as to whether throwing curve balls and sliders exposes pitchers to increased risk for elbow pathology. Previous recommendations were to avoid these pitches. More recent biomechanical and clinical studies have shown no increase in torque at the elbow when adolescents throw a curveball compared to throwing a fastball (Nissen et al. 2009). Studies have not found any evidence that throwing breaking pitches at early ages increases risk for injury (Fleisig et al. 2011, Fleisig and Andrews 2012, Olsen et al. 2006). In fact, many now believe that LLE is more related to pitch volume than pitch type. Although research has not been able to prove a link between curveballs and injuries, most clinicians still recommend that younger athletes avoid these pitches (Fleisig and Andrews 2012).
Identification
With LLE, the athlete will most often complain of medial elbow pain, although the pain can also be lateral or posterior. Often the pain is associated with one of the following factors:
- Throwing too hard, too often
- Increasing the number of pitches thrown per week too quickly
- Using poor pitching mechanics
- Changing to a league in which the pitcher’s mound is farther from home plate or the mound is elevated
Most adolescent pitchers who experience severe disabling pain are still at a reversible stage. However, when elbow weakness is evident, a single hard throw might partially or completely tear the medial apophysis from the epicondyle.
Proper diagnosis is important in achieving a good outcome. Diagnosis will often be a clinical one. Up to 85 percent of radiographs have been found to be normal in athletes with LLE (Hang, Chao, and Hang 2004). In most cases in which medial elbow pain does not improve quickly, X-rays or MRI is required. Valgus stress imaging should be considered to look for instability in skeletally immature athletes (Benjamin and Briner 2005). The clinician should be able to identify stress fractures if they are present.
Treatment
Initial treatment is usually conservative and requires complete rest from pitching for four to six weeks. Ice and nonsteroidal anti-inflammatory drugs (NSAIDs) may be useful and are often used in the initial phase of healing. Corticosteroid injections are generally avoided in the adolescent patient population, because they have known long-term deleterious effects (McAlindon et al. 2017, Gregory and Nyland 2013). After three to six months of treatment, if pain has resolved and the athlete has full range of motion, throwing programs may begin (Gregory and Nyland 2013). If pain persists or injury is catastrophic, surgery is considered.
Return to Action
After an athlete returns to pitching, preventing reinjury takes on primary importance. Proper stretching exercises and warm-up throws are essential. The American Physical Therapy Association publishes a set of stretching exercises recommended for Little League pitchers. A therapist or trainer can also provide the team with exercises. After the game, applying ice to the elbow for 10 to 15 minutes should reduce inflammation and prevent the kind of soreness that can lead to further injury.
Not all arm injuries can be prevented, but they can be minimized by limiting the number of pitches as well as having appropriate rest between pitching outings. Limiting pitch counts is better than limiting innings because one never knows how many pitches will be thrown in an inning. New guidelines should be referenced before the start of each season via the national Little League or Major League Baseball websites or both. If a more invasive procedure was performed the athlete may miss significant time, and should not return until completely pain free.
OSTEOCHONDRITIS DISSECANS
Common Causes
Osteochondritis dissecans (OCD) is a musculoskeletal condition that often affects adolescents and young adult athletes while they have a maturing skeleton. It is most commonly seen in the knee, but OCD in the elbow is increasing in incidence at a rapid rate (Jones et al. 2010). The area of the elbow most frequently affected is the anterolateral surface of the humeral capitellum (the outside of the elbow). The cause of the injury is repetitive throwing that causes microtrauma to the elbow. As a consequence of repetitive strain, the medial or lateral elbow suffers a localized separation of a segment of articular cartilage and subchondral bone. The capitellum is noted to have limited healing once a pathologic process has started, due to a limited blood supply (Nissen 2014).
Identification
Elbow pain in young throwers is commonly known as Little League elbow (see p. 144); OCD is another, less common elbow problem. Little League elbow typically produces pain along the medial (inner) side of the elbow while OCD usually produces pain along the lateral (outer) side of the elbow. However, the two injuries often occur simultaneously. Nearly 90 percent of those diagnosed with OCD have a history of elbow pain, and almost 55 percent report a loss of range of motion. Initially, elbow pain responds to NSAIDs and rest. Pain will often return when the offending activity begins again. Pain is usually intermittent and occurs with activity, especially hard throwing or increased stress on the elbow. Patients will often not come for evaluation until the condition is starting to affect their level of play (Nissen 2014). Osteochondritis dissecans of the capitellum is more often seen in adolescents ages 13 to 17 and is caused by repetitive lateral compression of the elbow during overhead motions. A radial head stress fracture can occur in similar fashion and might need to be ruled out by a physician.
Many athletes have symptoms similar to those with apophysitis or LLE, and it is impossible to tell the difference between the two conditions without X-rays. X-rays might show loose bodies within the joint or secondary ossification (bone formation) centers within the joint that are abnormal. Magnetic resonance imaging of the elbow can rule out stress fractures and ligament tears. Magnetic resonance imaging should also reveal bone fragments and cartilage damage, if present. Computed tomography (CT) scan may be useful in assessing for bone lesions and loose bodies.
Treatment
Whether surgery is required depends on the size of the bony lesion and its location. The presence of the loose bodies and the condition of the articular cartilage of the capitellum and radial head also help determine the need for surgery. The earlier OCD is detected, and the younger the age of the athlete, the greater the likelihood that no surgery will be needed. Conservative care consists of eliminated or significantly reduced stress on the elbow for at least six weeks (Nissen 2014). This allows the lesion to stabilize and properly heal. The athlete can start limited throwing, using anti-inflammatory medication, and doing forearm strengthening exercises, under the guidance of a skilled therapist or trainer after this time if pain is resolved. If conservative measures fail after 8 to 12 weeks, surgery may be considered. There are many surgical options, including arthroscopic debridement with curettage. In this procedure, a device called an arthroscope is placed through the skin and into the elbow joint. The arthroscope has a camera attached to it so that the surgeon can clearly see the joint space while operating. Once inside the joint, the surgeon many simply remove any loose bodies in the elbow or may opt to drill the OCD lesion, which helps stimulate bone regrowth.
Because OCD occurs primarily as a result of overuse, both the injury and its recurrence can be prevented. As stated on page 146, the number of pitches in both the skeletally immature and mature athlete must be limited appropriately. Coaches, parents, and athletes must become thoroughly educated so they can recognize the injuries early. All baseball players and other at-risk athletes such as javelin throwers, shot-putters, and even tennis players must learn proper technique and conditioning.
Many throwing elbow injuries occur when the throw involves a whipping or snapping motion with the arm in a relatively horizontal position during delivery. Thus, baseball pitchers should avoid opening their lead shoulder and lifting their back foot from the ground too soon. Preventive strengthening of forearm muscles, including flexors and extensors, scapular muscles, and supportive trunk and even pelvic and thigh muscles, should begin long before the season starts and continue throughout the schedule.
Return to Action
As pain in the elbow subsides and full range of motion returns, athletes may start a gradual throwing program to increase endurance. Throwing technique must be evaluated by trainers and coaches familiar with the sport, and corrections must be made immediately. Serial MRI tests might be of some value, but the athlete’s description of symptoms is the best signal of when to return. If the athlete is pain free, the elbow has full range of motion, and proper grip strength is fully returned (equal to that on the nonaffected side), the athlete may be cleared for full throwing activities.
CUBITAL TUNNEL SYNDROME
Common Causes
Cubital tunnel syndrome is caused by repeated throwing motions that result in excessive bending and twisting of the inner elbow. This injury is seen most often in baseball pitchers who throw curveballs, other throwing athletes, and golfers. Racket athletes can also suffer from this problem.
Identification
This injury is the result of irritation or entrapment of the ulnar nerve (the forearm nerve that supplies the fourth and fifth digits of the hand) as it travels through the ulnar groove of the inner elbow. If the ulnar nerve is entrapped such that nerve conduction is blocked or actual nerve fibers (axons) are damaged, the athlete might have numbness in the pinky finger and outside half of the ring finger. The athlete will also have atrophy and weakness of the inner hand muscles. Often athletes with an entrapped ulnar nerve in the cubital tunnel have a valgus deformity to the elbow (a lateral bend of the extended elbow). Athletes with weak intrinsic muscles of the hand cannot make a tight thumb–pinky finger pinch.
Treatment
Short-term treatment involves reducing inflammation, rest, and splinting. Anti- inflammatory medication might be prescribed. The elbow is splinted in a natural 45-degree bend to reduce stress on the nerve. The therapist can provide forearm and wrist stretching to mobilize the nerve and significantly reduce symptoms. Once elbow pain and hand numbness subside, the hand and grip should be strengthened by a professional hand therapist or occupational therapist.
If the symptoms do not improve, or if the hand weakness gets worse, surgery might be required to decompress the nerve. After surgery, a period of immobilization is necessary. Following this period, a professional therapist spends many weeks or even months helping the athlete regain wrist and forearm strength. Many different techniques are employed, using hand weights and resistive straps to regain strength.
Return to Action
Throwing athletes may return to sport only when they can demonstrate pain-free range of motion of the elbow and grip, as well as forearm strength equal to the opposite side or close to preinjury levels (if the dominant hand was injured). Athletes require sport-specific training before being able to safely return to sport.
HUMERAL STRESS FRACTURE
Common Causes
A throwing athlete who develops pain in the arm above the elbow after repetitive throwing might have a stress fracture in the mid-arm or humerus bone. A stress fracture differs from a true fracture in that the bones are not displaced, so no resetting is necessary. However, a stress fracture can destabilize into a full fracture. Also, a thorough medical investigation sometimes reveals that what seemed to be a routine arm fracture is in fact bone cancer; treating this early can prevent its spread throughout the body. Stress fractures can also occur at the radial head, shoulder, wrist, and lower extremities. Wheelchair athletes who use their upper limbs to bear weight are at particular risk for upper-limb and elbow stress fractures.
Identification
The athlete with a stress fracture often has chronic, increasing pain in the arm or elbow with increased activity. The symptoms usually vanish with rest but then recur when activity resumes. Examination by the trainer or physician will often identify areas of local tenderness in the arm or, in the case of radial (arm bone) head fracture, the distal elbow. X-rays might not show the abnormality, which makes MRI or bone scan necessary to reveal the stress fracture.
Stress fractures in a non-weight-bearing bone are rare, so other causes, such as benign lesions, cancer, or infection (osteomyelitis), must be considered. In the unfortunate case of bone cancer, a biopsy will need to be ordered by the treating physician if the MRI is suspicious.
Treatment
The athlete should abstain from activity that stresses the affected area. For stress fractures in the upper extremity, throwing and activities in which the arms bear weight (such as poling in cross-country skiing) should be avoided. Typically, recovery time is about six weeks but will vary depending on the severity of the fracture. Magnetic resonance imaging and bone scan will remain abnormal for a prolonged period of time (a few months for MRI and up to two years for a bone scan) after the fracture has healed, so these are not usually repeated unless symptoms return.
Return to Action
After about six weeks, reassess the athlete; if pain free, the athlete can start throwing again and begin to train for a return to play. A gradual return makes it less likely for the fracture to recur, but if it does, the healing process will need to be restarted again. Muscle strengthening around the injured arm might also prevent recurrence and should be supervised by an athletic trainer or physical therapist.
ELBOW DISLOCATION
Common Causes
Elbow dislocation is the most common dislocation in children and the second most common in adults (shoulder dislocation is number one). Sports injuries account for 44.5 percent of dislocations in patients 10 years and older (Stoneback et al. 2012). Adolescent males are most at risk. Males most commonly dislocate elbows when engaging in football, wrestling, and basketball. Females most commonly dislocate their elbows in gymnastics and skating activities (Stoneback et al. 2012). Roughly 90 percent of dislocations occur posteriorly (when the radius and ulna [forearm] are driven posterior relative to the humerus [arm]) and 10 percent anteriorly (when the radius and ulna [forearm] are driven anterior relative to the humerus [arm]) (Cohen and Hastings 1998). Most posterior dislocations occur when athletes fall on an outstretched hand with the elbow only slightly flexed. Anterior dislocations usually occur secondary to a direct blow to the back of the elbow, thrusting the forearm anterior.
The major risk with elbow dislocation is its potential to compromise nerves and blood vessels in the area. While the obvious concern may seem to be the pain and possible fracture(s) associated with a dislocated elbow, the urgent need is to ensure that the athlete has intact sensation, strength, and pulse in the lower forearm and hand. If the skin appears pale (cyanotic) or there is little voluntary wrist–hand motion and a lack of feeling on the skin of the hand, this is a medical emergency, and the athlete must be transported to the local emergency room immediately.
Identification
The athlete will feel immediate pain. If the median or ulnar nerve is injured or stretched, the athlete will feel numbness and tingling in the hand on the injured side. The ulnar nerve is the nerve most commonly injured, and this occurs in up to 14 percent of adult elbow dislocations (Wheeless 1996). If the brachial artery is injured, the hand may become pale or bluish (cyanotic) due to lack of blood supply. In young athletes, elbow subluxations of the radial head (in which the head of the elbow is moved out of position) can occur with a pull on the elbow. The youngster will hold the elbow close to the body and refuse to allow movement of the elbow.
Dislocations are typically diagnosed with X-rays of the elbow, which are also needed to rule out associated fractures. For younger athletes, the clinician should be aware of the six ossification (bone forming) centers of the elbow joint as well as the annular ligament (a strong band of fibers in the arm). Ossification can be mistaken for fractures on X-ray.
Treatment
Immediate treatment is to reduce the dislocation (relocate the elbow), but before that can happen, the athlete needs analgesia and sedation, not only for comfort but also to allow adequate relaxation in the arm. Relocation can be accomplished in the prone or supine position but should occur in a controlled environment in the emergency room or be supervised by trained medical personnel. The prone position with the arm hanging over the bed and application of downward traction is usually preferred for relocation.
A complete examination of surrounding nerves and blood vessels is essential both before and after the reduction. Any vascular (blood flow) compromise requires immediate attention and might even require immediate action to reduce the dislocation. However, avoid on-the-field reduction in most cases because unrecognized fractures might be associated with the dislocation. If there is any question of vascular compromise, the athlete should be admitted to a hospital for 24 hours of observation. Follow-up X-rays will be required to rule out fractures.
After the dislocation is reduced and the elbow stabilized, a period of immobilization is required. How long the elbow remains immobilized depends on the presence or absence of fractures (which occur in up to 15 percent of cases). An injury to the ulnar nerve (the nerve running from the shoulder to the hand) also occurs in up to 14 percent of cases and might need a period of immobilization to heal (Wheeless 1996). As soon as the athlete is cleared by the surgeon, rehabilitation should begin as soon as possible.
During the acute phase of rehabilitation, the therapist will control any excessive accumulation of fluid (edema) and restore the athlete’s elbow range of motion. Once adequate range of motion has been achieved, the athlete may begin strengthening of the forearm and arm muscles. Once adequate muscle strength has been restored, sport-specific training will optimize recovery and help prevent reinjury of the elbow.
Return to Action
Athletes involved in nonthrowing sports, such as soccer or American football, who suffer trauma to the elbow that caused a dislocation may return to sport in six weeks if adequate elbow range of motion and arm strength have returned. Throwing athletes might need to wait as long as three months or more to recover enough to return to sport. The throwing athlete will require full pain-free elbow range of motion, restoration of arm strength, and participation in a gradually increasing throwing program before resuming full participation.
OLECRANON BURSITIS
Common Causes
Mild but repeated trauma to the elbow is probably the most common cause of olecranon (tip of the elbow) bursitis. For example, people who lean on their elbows a lot cause friction and repeated mild injury over the olecranon. Informal names have been given to olecranon bursitis when the cause is obvious, such as “student’s elbow” caused by studying while leaning on elbows placed on a desk. Alternatively, a one-time injury such as a blow to the back of the elbow can also cause this condition. This injury often occurs in American football, hockey, soccer, basketball, and other contact sports. An infection to the olecranon bursa might occur if the skin over a bursa is cut and allows in bacteria; the infection can become dangerous if not treated right away with antibiotics or surgery. In the end, many cases of olecranon bursitis are idiopathic, meaning that no cause is ever found. Some are likely caused by old injuries that have been long forgotten.
Identification
Olecranon bursitis is not an extremely common injury. But once bursitis occurs, the superficial nature of the elbow creates a situation in which repeated trauma leads to a recurrent injury that can be frustrating to treat. Athletes often will present for treatment secondary to significant swelling over the elbow. Symptoms of bursitis can include all the components of an inflammatory problem: pain, redness, heat, and swelling. A large amount of redness and heat along with systemic fever might indicate an infection, so a physician should be consulted immediately. In the acute form of bursitis, the swelling might not be painful but might lead to a reduced range of motion that impairs athletic performance.
Treatment
Treat immediately with anti-inflammatory measures such as ice to the elbow, nonsteroidal anti-inflammatory medications, wrapping of the joint, and rest. The athlete should see a physician to rule out more serious pathology, such as infection or systemic arthritis.
The swelling should subside once the athlete avoids trauma to the tip of the elbow. A padded brace might be helpful in this regard. In cases in which the amount of fluid is extremely large, or when fluid is not receding despite treatment, needle aspiration and fenestration of the bursa along with a cortisone shot might be required. If so, it is crucial to maintain sterile conditions so an infection is not introduced into the bursa and joint.
Return to Action
Athletes with olecranon bursitis may return to sport when the pain subsides and full range of motion to the elbow is restored. If rest was required, rehabilitation of the surrounding arm and forearm muscles might be necessary. Athletes with recurring bursitis should consider wearing an elbow pad. Even after the injury has healed, the athlete may have some residual loose or thickened skin over the elbow.
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