Medial Elbow Problems in Overhead Athletes

Outline Anatomy Biomechanics Valgus Instability Valgus Extension Overload Medial Epicondylitis

Anatomy Normal carrying angle deg of valgus 50% elbow stability due to boney configuration ( 90 deg) 3 main soft tissue component Anterior capsule Radial Collateral complex Ulnar Collateral Complex

Anatomy Ligament Biomechanics AMCL & RCL taught throughout ROM Axis of elbow rotation occurs thru RCL Humeral insertion PMCL taught at >65 deg AMCL strongest and stiffest Failure load 260 N Palmaris Longus 357 N Regan, Morrey CORE ‘91

Anatomy Ulna Collateral Ligament Complex Anterior Bundle: inserst on medial coronoid process (sublime tubercule) eccentrically located Consists of Ant and Post bands Ant band 1 0 restraint to valgus 0-90 deg. Post band increases restraint from 60-max flexion Post band more important in Overhead athlete ElAttrache, F. Jobe

Anatomy Ulnar Collateral Complex Anterior Bundle Ant. band Post. band

Anatomy Ant. Medial collateral: Length 27.1mm Width 4.7mm

Anatomy Ulnar Collateral Complex Posterior Bundle: inserst on medial margin of Semilunar notch Fan shaped Thinner and weaker 2 0 restraint at >90 deg Vulnerable to stress only if ant bundle disrupted Callaway, Field JBJS ‘97

Anatomy Ulnar Collateral Complex Posterior Bundle

Anatomy Ulnar Collateral Complex Oblique/Transverse Bundle: Deepens sigmoid notch Flexor Pronator muscle mass PT, FCR, PL, FDS, FCU Dynamic contribution to valgus stability

Biomechanics: Stages of Pitching Motion I Windup II Early cocking, from ball leaving glove until forward foot contacts ground

Biomechanics: Stages of Pitching Motion III Late cocking, maximal shoulder Ext rotation and Abduction, deg elbow flexion w/ increasing pronation

Biomechanics: Stages of Pitching Motion IV Rapid acceleration, ends w/ ball release occurs over only msec angular acceleration of 600K deg/ sec Maximal valgus stress Load on MCL approaches tensile strength

Biomechanics: Stages of Pitching Motion IV Rapid acceleration, ends w/ ball release

Biomechanics: Stages of Pitching Motion V Follow-through, dissipation of stress rapidly, large decelerating forces No greater adverse effects on elbow w/ Curveball Sisto, Jobe Am J Sp Med ‘87

Biomechanics: Stages of Pitching Motion

JAVELIN THROW Unlike the other throws the javelin begins with an approach run and is relatively light. The javelin thrower is unique amongst the throwers needing a "quick arm" as well as speed and strength. Correct javelin technique is essential. Poor technique will result in elbow injuries which are difficult to treat and which may end an athlete’s career. The javelin must be thrown from above the shoulder

JAVELIN THROW Unlike the other throws the javelin begins with an approach run and is relatively light. The javelin thrower is unique amongst the throwers needing a "quick arm" as well as speed and strength.

Valgus Instability Traumatic not subtle, hear/feel pop Repetitive micro-trauma more common, chronic subtle exam

Valgus Instability Pitchers w/ UCL deficiency have dec.activity of Flex/pronator muscles during pitch sequence by EMG Glousman, Jobe Am J Sports Med ‘92 Leads to cycle of injury Inc. instability inc. force 2 0 stabilizers radial/capitellar jt chondromalcia

Valgus Instability: Diagnosis History: Medial elbow pain w/ throwing >60-75% suggestive of ligament attenuation Mechanical c/o Sensation of instability Check for Ulna nerve symptoms- 40% incidence

Valgus Instability: Diagnosis PE: ROM - limited terminal extension Tenderness w/ palpation Pain w/ resisted wrist flexion, pronation Valgus stress test and Milking Maneuver

Valgus Instability: Diagnosis PE: Valgus stress test position b/w stabilize against body, apply stress compare side-side difference Only 3-4mm of opening w/ complete rupture

Valgus Instability: Diagnosis PE: Milking Maneuver Pullng on pt’s thumb w/ forearm supination, shoulder extension, elbow flexed > 90 deg Tests posterior band of anterior bundle

Valgus Instability: Diagnosis Imaging: Xray- loose bodies, osteophytes, calcifications Gravity stress: >3mm diagnostic *may be neg w/ known UCL lig rupture MRI- Study of choice, perform w/elbow in extension, 3mm coronal sections, +/- gad

Valgus Instability:Treatment Nonoperative Understand Pt’s goals Rx of choice for acute injury in non-throwers PT, technique changes, relative rest 3-6 months 50% success at returning athlete to pre-injury level

Valgus Instability:Treatment

Operative Indications: failure of above x 3-6 months, commitment to play at competitive level, (baseball,volleyball, javelin, gymnastics, tennis) Or acute injury in above patients

Valgus Instability:Treatment Operative Techniques: direct repair for acute injury or those w/ limited career Similar recovery time (Jobe) Ligament reconstruction graft choice: palmaris, semitendinosis, allograft, plantaris, strip of achilles or FCR

Valgus Instability:Treatment Operative Technique

Valgus Instability:Treatment Operative Technique Preserve branches of Antebrachial cutaneous N Preserve Common flexor origin at epicondyle Split flexor mass at post 1/3 in line w/ fibers Separate Lig complex, incise and check joint. Drill holes and weave tendon, check isometry Tension at 45deg. Neutral varus/valgus Transpose nerve only if pre-op neuritis, subluxation, or constriction noted at surgery

Valgus Instability:Treatment Operative Technique

Valgus Instability:Treatment Postoperative Immobilize 7-10 days Active ROM x 4-6 weeks Wrist and Forearm strengthening Avoid valgus stress for 4 months After 6 months begin lobbing ball, progressively increasing distance and speed; back to mound at 8-9 months w/ <70% velocity until 1 yr.

Valgus Instability:Treatment Operative Results Conway, Jobe ’92 JBJS 70 pts, F/U 6.3 yrs Direct repairReconstructed Return to7/1438/56 sport G&E10/1445/56 Previous operation led to dec ability to return to sport All w/ ant. Transposition of Ulna N Complications: 15 P-op neuropathy; 6 transient 9 requiring decompression

Valgus Instability:Treatment Operative Results Thompson, Jobe ’01 JSES 83 pts w/o Ulna transposition All reconstructed w/ muscle splitting aproach 23% Pre-op ulna symptoms 5% Transient post-op ulna neuropathy In 33 pts w/ >2 yr f/u : 82% excellent, 12% good results All pts returned to sport, 82% at same level 4 w/ re-op: 1 for re-tear of flexor/pronator muscle 3 w/ arthroscopic posterior debridement

Valgus Instability:Treatment Operative Results Azar, Andrews ’00 Am J Sports Med 59/78 reconstructions and 8/13 repairs, F/U 36mos 81% recon, 63% repairs returned to same level Overall 79% success rate Ave time to competitive throwing 9.8 months 9/10 w/ ulna neuropathy resolved P-op

Valgus Instability:Treatment Operative Results Azar, Andrews ’00 Am J Sports Med Complications: 1 ulna neuropathy months) 1 arthroscopic lysis of adhesion, 1 arthroscopic posterior debridement 2 c/o pain at palmaris harvest site, 2 superficial infections at graft site, 1 at elbow wound

Valgus Extension Overload Secondary to insufficiency of UCL Leads to subluxation in extension, w excessive forces at lateral and posterior aspects of elbow Radiocapitellar chondromalacia => OCD, OC Fx, loose bodies

Valgus Extension Overload Diagnosis Symptoms: catching, locking Tenderness at medial olecranon Pain during late acceleration and follow thru Xray: Spurs post medial olecranon loose bodies

Valgus Extension Overload Treatment RICE Rehab Surgery if failure to respond

Valgus Extension Overload Surgical Treatment Arthroscopy eval for laxity w/ valgus stress test If >1-2mm of medial ulna-humeral opening=> ant bundle insufficiency. If >4mm => complete MCL insufficiency Field Altcheck AJSM ‘96 Avoid resection of >3mm from olecranon

Valgus Extension Overload Surgical Treatment Results Fideler, Kvitne JSES ‘ professional baseball players 100% dec pain and symptoms 74% G&E results w/ return to same level Bradley JSES ’95 6/6 NFL Linemen w/ G&E results 2 yrs post debridement

Medial Epicondylitis Golfer’s elbow Patholigic degenerative changes in Flexor/pronator insertion 7-20x less common than Lat Epi Usually involves humeral origin of Pronator Teres, FCR and less frequently FCU PT most active in overhead athletes

Medial Epicondylitis PE: + TTP, eval stability 60% assoc w/ Ulna neuropathy RX: Rest, Nsaids, good short term relief w/ steroid injection(<6) Change technique, PT 90% success w/ no-op treatment

Medial Epicondylitis Surgery indicated if failed > 6 mos conservative Rx. Frequently find full thickness tears. Debridement, w/ secure tendinous repair

Medial Epicondylitis Surgical Results: Vangsness, Jobe JBJSB’ 91 34/35 pts G&E results 86% no limitations, all returned to sport Isokinetic and grip strength difference not significant

Medial Epicondylitis Surgical Results: Gabel, Morrey JBJS ‘95 26 pts, 30 elbows 96% G&E results Those w/ ulna symptoms only 40% (2/5) G&E

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