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