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 Where does it hurt? Anterior Medial Posteromedial
Posterior
Lateral

7. Third Question
3. When does it hurt?

8. 1st Critical Instant
Andrews

9. 2nd Critical Instant
Andrews

10. Restraint to Valgus Torque at 90 Degrees Flexion UCL
Restraint to Valgus Torque at 90 Degrees Flexion UCL % RC Articulation 33% Capsule %

11. Healthy Thrower’s 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. FP Muscles - UCL The flexor pronator muscles provide varus torque FPMME
Ulna
Flesig AJSM 95, Werner JOPST 93

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
Think
UCL
Injury!!!

24. Rarely inject
FPM
Deep Massage
Modalities
Rehabilitation
Repair ME

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
O’Driscoll
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. Avulsion Fracture Sublime Tubercle
Glajchen AJR 1998

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. Toss 4 - 5 Months Mound 6 - 8 Months Game 11 - 12 Months
Prevent Shoulder Injury

45. Sublime Tubercle Fracture

47. Ulnar Nerve Injury ME

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

49. UN Subluxation
16%
McGowan

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

51. Decompression 4 3 2 1 ME

52. Fascia Sling ME

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

54. Kids – Lateral Elbow Panner’s Disease OCD Capitellum
<10 yo, self limited
OCD Capitellum
Progressive!!!

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

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
Humerus RH
Ulna

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. Extension
Test

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

67. Olecranon Tip Osteophytes

68. Kids
Olecranon Apophysis Injury

69. Olecranon Apophysis NU
16 y/o RHP
Left
Right

70. 10 Days Post-Op
3 Months Post-Op

71. Tip Stress Fracture

72. X-ray
MRI

73. The treatment plan is based on the player’s 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

77. THANK YOU