Elbow Injuries in the Adult Athlete Tamara A. Scerpella, MD Professor, Orthopedic Surgery University of Wisconsin
Elbow Injuries in the Adult Athlete Tamara A. Scerpella, MD Professor, Orthopedic Surgery University of Wisconsin
Acute
• Elbow Dislocation • Fracture
– Distal humerus – Olecranon – Radial head
• Distal Biceps Rupture • Ulnar Collateral Ligament Tear
Acute
• Elbow Dislocation • Fracture
– Distal humerus – Olecranon – Radial head
• Distal Biceps Rupture • Ulnar Collateral Ligament Tear
Chronic (Throwing)
• Lateral Epicondylitis • Valgus Extension Overload
– Ulnar neuritis – UCL laxity – Flexor pronator mass injury – Posteromedial impingement – Olecranon stress fracture
• Osteochondral Lesions (capitellum)
Elbow Dislocation
• 10-25% of all elbow injuries • 6-8 cases / 100,000 (2nd to shoulder)
Elbow Anatomy – Bony Stability
• Primary Bony Stabilizers (~50%) – Ulnohumeral joint – Coronoid and olecranon
• Secondary stabilizers – Radial head (static)
Elbow Anatomy – Soft Tissue Stabilizers
• Primary Ligamentous Stabilizers – Radial Collateral Lig – UCL, anterior band
• Secondary stabilizers – flexor-pronator, common
extensors (dynamic)
Elbow Dislocation - Mechanism Direction = ulna displacement
• 80-90% posterior or posterolateral
• Fall on outstretched arm è posterior or posterolateral
• Fall on flexed elbow è anterior
• Hyperlaxity predisposes (gymnasts)
Elbow Dislocation - Posterior
Elbow Dislocation -Posterior
Elbow Dislocation - Diagnosis
Elbow Dislocation - Treatment • Immediate / On-Field –
one reduction attempt – Splint / X-ray if
unsuccessful (possible fracture)
• Sedation / Anesthesia – prolonged or complex (with fracture)
Elbow Dislocation - Reduction Anterior
Elbow Dislocation - Treatment • Post-reduction:
– NV exam; Xray to r/o fracture; assess stability
Immobilize THEN Mobilize • Soft tissue rest • Early mobilization
to restore ROM
Mehlhoff et al 1988
Surgical Indications • Unstable after reduction
– Even if flexed, pronated • Significant soft-tissue
damage • Repair:
– LCL complex first – UCL if still unstable – common extensor, flexor-
pronator avulsions
Associated Fractures • Coronoid • Radial Head • Distal
Humerus • Olecranon • Terrible Triad:
Radial Head, Coronoid & Elbow Dislocation
Associated Fracture - Coronoid
• Anterior dislocation • Type 1: avulsion fx • Type 2: < 50% • Type 3: > 50%
– Elbow stability significantly compromised
– Valgus instability (UCL insertion)
– Treatment: ORIF
Acute
• Elbow Dislocation • Fracture
– Distal humerus – Olecranon – Radial head
• Distal Biceps Rupture • Ulnar Collateral Ligament Tear
Radial Head Fracture • FOOSH • Diagnosis:
tenderness, effusion • X-ray: fat pad sign • Treatment based
upon displacement: >2mm = ORIF
• Non-op: immobilize 3-5 days only
• Rapid mobilization to prevent extension loss
Distal Biceps Rupture • Rare in young athlete • Forcible extension
while actively flexing • FB, weight-lifting • Diagnosis:
– Ecchymosis – Deformity -retraction
• Treatment: – Surgical repair
Ulnar Collateral Ligament Rupture - Acute
• Painful pop while throwing
• Localized swelling • Laxity to valgus
stress • MR-arthrogram is
diagnostic
Case
• 20 y.o. M LHD collegiate pitcher • Acute onset medial elbow pain in left arm • Felt a “pop” during a pitch
– Immediate pain – Decreased velocity and control
• Swelling medial elbow X 2 weeks • tingling in ring and small finger
– Resolved when swelling subsided
Case
• Physical Exam – Mild swelling medial elbow – TTP just distal to medial epicondyle – 1+ laxity on valgus stress at 30 and 90
degrees – Pain with moving valgus stress test – 2 pt discrimination normal in ulnar nerve
distribution
Case
• UCL reconstruction using palmaris longus
Case
Chronic Injury (Throwing) • UCL Chronic Tear - attenuation • Valgus Extension Overload
– UCL laxity – Flexor pronator mass injury – Posteromedial impingement – Olecranon stress fracture – Ulnar neuritis
• Lateral Epicondylitis • Osteochondritis Dissecans (capitellum)
Ulnar (Medial) Elbow Overuse
• Overhead throwing: – tremendous valgus stress – concentrates on medial side
• Medial elbow problems predominate – 97% of elbow c/o in baseball pitchers
• Also football, volleyball, tennis, javelin, gymnastics
• Chronic, overuse most common • Acute UCL tears may occur
Valgus Extension Overload • Medial tensile forces • Lateral compressive
forces • Posterior shear stresses • Result:
– UCL laxity – flexor–pronator mass
injuries – neuritis of the ulnar nerve – posterior impingement – olecranon stress fractures
Chronic UCL Laxity - Pathogenesis
• 3 bundles: anterior, posterior, transverse – Anterior: strongest, primary valgus restraint at <90 – Posterior: restraint at >60
• Valgus forces > Intrinsic Tensile force of UCL = microtearing of UCL
• Additional stress: – bad mechanics – poor flexibility – inadequate conditioning
• Result: attenuation and… ultimate rupture of UCL
Chronic UCL Laxity - Presentation
• Symptoms – medial pain in late-cocking, early acceleration – +/- ulnar n sxs – Can throw only 50-75% of normal level
• Exam: • valgus force at 20-30 degrees flexion (ant band) • “milking maneuver” at > 90 deg (post band) • Flexion contracture: result of repeated attempts
at healing and stabilization, don’t need full extension to throw
• Pain with wrist flexion or tenderness over flexor mass origin suggests flexor/pronator mass injury.
Valgus Instability - Exam
• Milking maneuver
• Valgus stress test ~15o and full pronation
Valgus Instabilty - Exam • Moving valgus stress
test – 90 degrees abduction,
full ER – Full flexion to extension
maintaining a constant valgus stress
• pain/apprehension • Usually @ 70-120o
– 100% sensitive and 75% specific for UCL attenuation/tear (O’Driscoll AJSM ’05)
UCL Tear - Imaging • XRAY: changes c/w chronic instability:
calcification/ossification of ligament • MRI: ligamentous avulsions, partial injuries,
midsubstance tears, surrounding soft tissues • CT Arthrography: undersurface tears
– Similar to MRI with gadolinium • Timmerman, Andrews (1994) – MRI, CT
arthrography with arthroscopy correlation – Equivalent ability to detect full-thickness tears
Chronic UCL Tear – Nonoperative Treatment
• 2-4 weeks rest, NSAIDS, PT • Corticosteroid injections NOT recommended • After acute inflammation gone - supervised
flexibility, strengthening program – target FCU, pronator teres, FDS
• After full ROM / strength regained - begin throwing, conditioning program (~ 3 mos)
• Early treatment can stop progression of instability
• ~50% athletes returning to preinjury level
Chronic UCL Injury – Surgery • Indications:
– competitive athletes with acute, complete UCL rupture – chronic sxs with failure of 3-6 mos nonoperative tx
• Surgery - repair or reconstruct UCL • Direct repair - acute ligamentous avulsions • Reconstruction - chronic instability with
attenuation, midsubstance tears – palmaris longus, plantaris, Achilles, hamstrings – PL – avg load to failure 357N (Ant UCL – 260N)
• Morrey et al.
UCL Reconstruction
Ulnar nerve transposition ONLY if nerve symptoms!
Post-op Rehabilitation • Brief immobilization (7-10 d) - then active shoulder,
elbow, wrist ROM • 4-6 weeks: PREs wrist/forearm • 6 weeks: PREs elbow • Valgus stress avoided until 4 months • 2-3 months: RTC strengthening emphasized • 3-4 months: throwing program - light tossing • 6 months: lobbing ball 60 ft with easy windup • 7 months: 50% max velocity • 8-9 months: pitchers 70% max • 12-18 months: full activity
Results- Surgical Reconstruction
• Jobe et al: reconstruction with ulnar transposition – 10/16 (63%) preinjury function (11-19 months) – 1 to lower level, 5 retired – High incidence of ulnar n complications – 5/16
• 2 reoperated – 1 transposition, 1 neurolysis • 3 paresthesias that resolved
• Conway et al: 14 direct repair, 56 reconstruction – direct: 71% G/E, 50% return to play by 9 mos – recon: 80% G/E, 68% to preinjury by 12 mos – 40% preop ulnar sx, 22% postop - 8 req transposition
• Jobe et al (1997): reconstruction without transposition – 83 athletes (54 pro, 18 college, 11 rec) – 94% G/E results – avg RTP 13 mos – 3 with ulnar paresthesias, 1 with neuropathy
– all resolved by 6 months
• Chronic UCL laxity • Compressive lateral
forces = synovitis, osteochondral lesions at radiocapitellar joint
• Posterior impingement (olecranon osteophytes)
Valgus Extension Overload
Posterior Impingement • Posteromedial olecranon osteophytes, chondromalacia
• Posterior pain with valgus/extension (late acceleration phase)
• Rest, ice, NSAIDS • Functional strengthening elbow, forearm
– Dynamic stabilizers • Stretching - isotonic, isokinetic, isometric
exercises begun • As strength improves - plyometric
exercises (flexor/pronator mass); interval throwing program
Posterior Impingement Non-operative Treatment
• Indications: – failed non-op tx – symptomatic spurs or loose bodies
• Elbow arthroscopy - good results, low complication rates – undersurface tears of UCL can be seen but
must be addressed open • Reconstruction of UCL reserved for pts
who have failed all above treatment
Posterior Impingement Surgical Treatment
Ulnar Neuritis • Associated with UCL laxity • Pain / numbness / tingling • Later: weakness / atrophy • Treatment: decompression / transposition
Flexor Pronator Injury Medial Epicondylitis = “Golfer’s
Elbow” • repetitive valgus forces = chronic
inflammatory changes • 10-20 X less common than lateral • Pronator teres, FCR, FCU
– PT highest activity in acceleration phase
– FCU overlies UCL at 120o
– Decrease in FCU activity with UCL instability
• Microtears between PT and FCR origins – inflammatory and fibrotic granulation
tissue
• Medial elbow pain, insidious, worse with throwing
• Physical exam – tender flexor-pronator origin – pain with wrist flexion, forearm pronation
• XR - normal / traction spurs, UCL Ca++ • MRI - signal musculotendinous origin • EMG/NCV - evaluate for ulnar neuropathy
– 60% have ulnar neurapraxia
Presentation
• Rest, ice, NSAIDS • Steroid injections (tendon attenuation
with repeat injections) • Splinting or counterforce bracing • PT - wrist flexor/pronator stretching, then
progressive isometrics; PREs • >90% success
Treatment - Nonoperative
• >6 months of non-op PT • Debride inflamed tissue, repair tendon • Postop rehab:
– Brief immobilization (7-10d) – Passive, active elbow ROM – @4-6 weeks - PREs – RTP - 4 months
• 95% success • Ulnar neuropathy=poor prognosis
Treatment - Surgical
Lateral Epicondylitis
Lateral Epicondylitis - Treatment
Summary
• Throwing / racquet athlete = medial-sided problems – Flexor pronator tendinosis / medial
epicondylitis – UCL laxity – Posterior Impingement – Ulnar neuritis
• Many respond to non-operative Rx