Proper imaging should supplement the history and physical examination when diagnosing injuries to the elbow. Radiographs, including AP, lateral, and oblique views with the elbow in flexion can be used to identify osteophytes. Imaging of the contralateral arm is useful in skeletally immature athletes and may help to identify stress and avulsion fractures. Wilson et al. found that posterior osteophytes were easily found in a standard lateral radiograph in all their presurgical patients, but noted that identification of the problematic posteromedial osteophyte using radiographic imaging was difficult [43]. They found that with the elbow in 110° of flexion and the beam angled at 45° to the ulna, the symptomatic osteophyte was most easily seen [43]. Conway recommended an AP view with the elbow in full flexion with 40° of external rotation for complete visualization of the posteromedial olecranon and osteophytes [44] [Fig. 11.3]. CT scans and/or MRI can be utilized to identify stress fractures or avulsion fractures in the elbow [37, 45]. MRI remains the best option when evaluating soft tissue damage to muscles, tendons, ligaments, and articular cartilage [Figs. 11.4 and 11.5] [37, 38]. Intra-articular contrast medium improves the yield of detecting tears in the UCL, especially undersurface tears [45–47]. Ultrasonography and dynamic ultrasonography can be used to evaluate the UCL and can detect increased laxity with valgus instability [32, 48].

Instability of the UCL represents a wide spectrum of injuries. The treatment of these injuries is guided by a complex interplay of the patient age, level of participation, concomitant injuries, degree of instability and dysfunction, patient and family expectations, and response to rest and therapeutic exercise.

Age is useful parameter to help guide treatment. Youth baseball players, 16 years old and younger, frequently present with overuse symptoms in the medial elbow. The overwhelming majority of youth injuries, especially those seen in younger side of this cohort, are treated with rest, player and family education, and rehabilitation concluding with a graduated return to sport. Stress fractures are seen in both youth and elite players. These can be uniformly treated with rest and nonoperative management. In contrast, rest and therapy may not be the ideal for the acute displaced sublime or medial epicondyle fracture [Fig. 11.6]. Open reduction and internal fixation of medial epicondyle fractures with displacement of 5–10 mm of the fragment has been suggested in the competitive youth athlete [49]. There is a lack of defined parameters for sublime tubercle fractures, but 2 mm displacement may be an indication for surgery. Prior to surgical intervention some youth athletes may be encouraged to change positions, away from pitching, or even consider switching sports if the youth athlete is not committed to the requisite rehabilitation and the desire for participation at the university level.

VEO is an important part of medial elbow instability. VEO is characterized by posteromedial elbow pain with osteophytes that form in the posteromedial joint as a result of ligament attenuation and abutment of the ulna against the olecranon fossa [Fig. 11.7]. It is sometimes useful to think of VEO as a prodromal syndrome to frank UCL insufficiency. Importantly, this prodrome may last for many years or may never manifest into overt UCL incompetence, even in the setting of a complete tear of the UCL. The pathological osteophytes may actually be protective against UCL incompetence. While seen in young athletes, VEO is seen more often in an older athlete. Acute pain and loss of extension may lead to alteration in throwing mechanics and a subsequent earlier release of the ball, perpetuating the stress seen on the elbow. Treatment for this entity involves cessation of throwing until the inflammatory phase is resolved, regaining pain-free pre-injury motion along with guided therapy followed by a gradual resumption of sports. As a rough guideline, the period of shutdown is doubled to estimate the ease back into sports. So if a player needs 2 weeks of shutdown to regain pain-free range motion, that player will need 4 additional weeks of a graduated throwing program. The MRI appearance of the ligament should not guide the treatment in the absence of clinically overt symptoms, especially in the older elite player who may recover and return to play with an overtly abnormal ligament. Judicious use of intra articular corticosteroid injection may also be helpful in the early phase of treatment of VEO .

Isolated partial and complete soft tissue tears of the UCL in the youth population should be considered for nonoperative management , particularly in the 11–15 year old age group. The diagnosis of a partial tear may be facilitated by MRI arthrogram; CT arthrogram is also an option. Once again, player age, chronicity and degrees of dysfunction help to guide treatment and period of shutdown, ranging from a few weeks to 3 months. The majority of acute tears are from the ulnar insertion of the UCL; recent biomechanical data suggests that tears just proximal to the sublime tubercle, as opposed to just distal, may be associated with greater degrees of instability [50]. Hassan et al. conducted a study where 13 specimens had their UCL detached at 50 % and then 100 % from the ulna in a proximal-to-distal fashion and 12 specimens followed the converse tear pattern, distal-to-proximal [50]. There was a significant change in contact area and movement of the center of pressure in partial proximal versus partial distal simulated rupture, suggesting that the proximal half of the distal UCL has a primary role in maintaining posteromedial stability of the elbow [50]. Earlier data had suggested that partial tears in elite athletes should be considered for early surgical reconstruction [51–53]. In contrast, Podesta et al. conducted a study involving 34 athletes with partial UCL tears, who failed at least 2 months of nonoperative treatment as well as an interval throwing program [54]. Each patient was injected with platelet-rich plasma and asked not to take any NSAIDs after the procedure [54]. After injection, each patient underwent a progressive course of physical therapy designed for eventual return to play [54]. The results of this study showed an 88 % return to play without complaints, with an average return to play at 12 weeks [54]. There is promise to this technique in soft tissue injuries. The rehabilitation program is not to be understated in this study.

While some may advocate for operative treatment of acute traumatic tears of the UCL, the extremes of age of the throwing athlete, the very young, ages 11–15, and the older elite athletes, ages 35–40, may undergo a trial of nonsurgical treatment. The patient may be placed in hinged elbow brace, locking out the terminal 30° of extension for 4–6 weeks, followed by a therapy and guided throwing program with a goal for return to sports at 3–4 months.

Acute traumatic avulsions in contact athletes such as football and lacrosse may also be braced with an extension block. Return to sport may be faster than the 3–4 month program for throwing. Return to contact sports is more guided by symptoms and function, with players returning to play in just a few weeks.