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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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Presentation on theme: "Elbow injuries and the throwing athlete Michael J. Kissenberth MD Orthopaedic Surgery, Sports Medicine SHCC, Greenville Hospital System."— Presentation transcript:

1 Elbow injuries and the throwing athlete Michael J. Kissenberth MD Orthopaedic Surgery, Sports Medicine SHCC, Greenville Hospital System

2 First Question What sport do you play?

3 Most sport related elbow injuries are caused by repetitive microtrauma…

4 And the underlying pathology is directly related to the biomechanics of the sport.

5 The rest of sport related elbow injuries are caused by acute macrotrauma…like an elbow dislocation.

6 Second Question 2.Where does it hurt? Anterior Medial Posteromedial Posterior Lateral

7 Third Question 3. When does it hurt?

8 1 st Critical Instant Andrews

9 2 nd Critical Instant Andrews

10 Restraint to Valgus Torque at 90 Degrees Flexion UCL54% RC Articulation33% Capsule10%

11 Healthy Throwers Elbow -Physiologic adaptations to imposed demand

12 Effects of Valgus Torque Medial Tension –ME injury –Sigmoid rim fx –FP mass injury –UCL lesions –UN neuritis Lateral Compression –RC joint injury –Synovitis

13 History Medial Pain Late Cocking, Early Acceleration Recurrent Symptoms Pop on Single Throw Swelling, Stiffness Lost Performance!!!

14 Previous Treatment Lost Playing Time Rehabilitation Injections Diagnostic Studies Surgery (VEO)

15 Examination Medial Swelling Motion Loss UCL Tender Valgus Stress Painful Valgus Laxity Associated Findings

16 Kids ME Apophysitis ME Fragmentation ME Avulsion

17 ME Apophysitis With Fragmentation Without Fragmentation

18 14 y/o BB Player No prior symptoms Pop!

19 The flexor pronator muscles provide varus torque MEUlna FPM UCL Flesig AJSM 95, Werner JOPST 93 FP Muscles - UCL

20 Decreased FCR activity in throwers with an UCL injury

21 FPM / ME Injury

22 Pronator Muscle Tear 27 y/o RHP Conjoined Tendon

23 Severe FPM / ME ThinkUCLInjury!!!

24 ME FPM Rarely inject Deep Massage ModalitiesRehabilitationRepair

25 Treatment Relative / Active Rest Ice, NSAID Local Modalities Prevent Atrophy Treat Associated Conditions NO Steroid Injections!!!

26 Treatment Strengthen FCU, FDS Trunk, Scapula, Cuff Stab. PNF, Plyometrics Sport Specific Exercise Review Throwing Mechanics Interval Throwing Program

27 Direct Repair

28 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

29 2 Anterior Bands UCL Extension Flexion

30 Milking Maneuver UCL Tests Static Valgus Stress

31 Moving VST ODriscoll Likely best test


33 Modified UCL Recon

34 Medial Antebrachial Cutaneous Nerve

35 6 – 8 Millimeter Bridge



38 Three Incision Harvest

39 Docking Procedure

40 Glajchen AJR 1998 Avulsion Fracture Sublime Tubercle

41 Sublime Tubercle Fracture Rest Bone Growth Stimulator Direct Repair Suture Anchors ORIF with Screw Ligament Reconstruction

42 Rehabilitation Initial Immobilization Relieve Pain Resolve Arm Swelling Recover Range of Motion Prevent Muscle Atrophy Restore Aerobic Condition Maintain/develop core stability

43 Avoid Valgus Torque Until 2 Months

44 Toss4 - 5 Months Mound6 - 8 Months Game Months Prevent Shoulder Injury

45 Sublime Tubercle Fracture


47 Ulnar Nerve Injury ME

48 Fibrosis Compression Tension UN subluxation Elbow valgus laxity Ulnar Nerve Injury

49 UN Subluxation 16% McGowan

50 Non-operative Care Night Splint NSAIDs Oral Steroids Activity Modification Desensitization / Soft tissue release

51 Decompression ME 1324

52 Fascia Sling ME

53 Lateral Compression Injuries Rad-Cap arthrosis Stress fracture OCD Lateral synovium

54 Kids – Lateral Elbow 1.Panners Disease <10 yo, self limited 2.OCD Capitellum Progressive!!!

55 OCD capitellum 5-10yo Self limited Tx conservatively –Rest, ice, nsaids –Gradual RTP. Must be able to throw without sx Panners Disease

56 Posterior blood supply peds lateral elbow Repetitive injury to epiphysis may alter blood flow = osteochondrosis

57 Osteochondritis Dissecans Age Years Old Progressive Remove loose bodies

58 Loose Body

59 Lateral Plica Syndrome RH Ulna Humerus

60 VEO Syndrome 2nd Critical Instant

61 History Pain- posteromedial at ball release and in follow through Past history pain Past history UCL injury Stiffness Performance, warm-up

62 Examination Local Tenderness Motion Loss Extension Painful Extension Plus Valgus Painful

63 ExtensionTest

64 Posterior & Medial Andrews

65 Olecranon Tip Resection

66 KJOC / Mayo - Ostectomy …removal of > 3 mm of bone and cartilage places the UCL at risk for injury. ElAttrache, Rosen, Morrey ElAttrache, Rosen, Morrey

67 Olecranon Tip Osteophytes

68 Kids Olecranon Apophysis Injury

69 Olecranon Apophysis NU LeftRight 16 y/o RHP

70 10 Days Post-Op 3 Months Post-Op

71 Tip Stress Fracture

72 MRIX-ray

73 The treatment plan is based on the players history, examination and response to conservative care.

74 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

75 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)

76 HAWKINS THROWING ACADEMY TEAM APPROACH TO THROWING INJURIES SHCC, Proaxis therapy, ASI One of a kind in the Southeast Focused on performance and prevention


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