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Elbow injuries and the throwing athlete

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Presentation on theme: "Elbow injuries and the throwing athlete"— 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 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 FPM
ME 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)

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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