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

First Question What sport do you play?

Most sport related elbow injuries are caused by repetitive microtrauma…

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

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

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

Third Question 3. When does it hurt?

1st Critical Instant Andrews

2nd Critical Instant Andrews

Restraint to Valgus Torque at 90 Degrees Flexion UCL Restraint to Valgus Torque at 90 Degrees Flexion UCL 54% RC Articulation 33% Capsule 10%

Healthy Thrower’s Elbow -Physiologic adaptations to imposed demand

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

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

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

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

Kids ME Apophysitis ME Fragmentation ME Avulsion

ME Apophysitis With Fragmentation Without Fragmentation

14 y/o BB Player No prior symptoms “Pop!”

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

Decreased FCR activity in throwers with an UCL injury

FPM / ME Injury

Pronator Muscle Tear 27 y/o RHP Conjoined Tendon

Severe FPM / ME Think UCL Injury!!!

Rarely inject FPM Deep Massage Modalities Rehabilitation Repair ME

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

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

Direct Repair

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

2 Anterior Bands UCL Extension Flexion

Milking Maneuver UCL Tests Static Valgus Stress

Moving VST O’Driscoll Likely best test

Modified UCL Recon

Medial Antebrachial Cutaneous Nerve

6 – 8 Millimeter Bridge

Three Incision Harvest

Docking Procedure

Avulsion Fracture Sublime Tubercle Glajchen AJR 1998

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

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

Avoid Valgus Torque Until 2 Months

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

Sublime Tubercle Fracture

Ulnar Nerve Injury ME

Ulnar Nerve Injury Fibrosis Compression Tension UN subluxation Elbow valgus laxity

UN Subluxation 16% McGowan

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

Decompression 4 3 2 1 ME

Fascia Sling ME

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

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

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

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

Osteochondritis Dissecans Age 9 - 16 Years Old Progressive Remove loose bodies

Loose Body

Lateral Plica Syndrome Humerus RH Ulna

VEO Syndrome 2nd Critical Instant

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

Examination Local Tenderness Motion Loss Extension Painful Extension Plus Valgus Painful

Extension Test

Posterior & Medial Andrews

Olecranon Tip Resection

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

Olecranon Tip Osteophytes

Kids Olecranon Apophysis Injury

Olecranon Apophysis NU 16 y/o RHP Left Right

10 Days Post-Op 3 Months Post-Op

Tip Stress Fracture

X-ray MRI

The treatment plan is based on the player’s history, examination and response to conservative care.

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

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)

HAWKINS THROWING ACADEMY TEAM APPROACH TO THROWING INJURIES SHCC, Proaxis therapy, ASI One of a kind in the Southeast Focused on performance and prevention Email: baseball@proaxistherapy.com

THANK YOU