ArticleLiterature Review

Sport injuries of the elbow

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... Normal functional stresses on the anterior MCL are thought to be highest when valgus loading occurs while the forearm is supinated and extended or flexed at an angle between 0° and 90° (7,9,12) single event, but they more commonly occur as an exacerbation of chronic repetitive stress injuries, often due to a repetitive overhand throwing motion. The injury mechanism most commonly involves valgus and pronation stresses, which produce a combination of distraction forces around the medial elbow and concomitant compression of the lateral elbow; this typically occurs during overhead throwing with arm acceleration (13,14) but is also often seen after a fall onto an outstretched hand (FOOSH) (15). Valgus instability is most often clinically diagnosed on the basis of the patient's history and physical examination, but it may be demonstrated at radiography performed during valgus loading. ...
... Valgus instability is most often clinically diagnosed on the basis of the patient's history and physical examination, but it may be demonstrated at radiography performed during valgus loading. Ligament damage is best depicted at computed tomographic (CT) arthrography, magnetic resonance (MR) arthrography, or MR imaging (13,16,17). ...
... CT can be used for further evaluation when the presence of an occult fracture is suspected in the setting of postreduction instability or for a more detailed evaluation of comminuted fractures. As mentioned earlier, MR imaging and MR arthrography are best for evaluating the MCL and lateral collateral ligament complex (13,16,17). Urgent MR imaging should be considered in cases in which the extent of postreduction instability prohibits protected early mobilization with use of a hinged brace; injuries of this kind may require immediate surgery to repair ligaments or other soft tissues (53). ...
Article
Traumatic elbow injuries are commonly encountered in the emergency department setting, but their complexity and clinical significance often go unrecognized at the initial evaluation. Initial imaging in patients with elbow trauma should not only help identify major injuries that require immediate intervention but also allow detection of other, often more subtle injuries that may lead to instability or poor functional outcomes if appropriate treatment is delayed. Awareness and detection of these injuries may be improved by a better-developed and more intuitive understanding of the mechanisms that underlie the most common injury patterns. Ideally, such understanding should prompt appropriate early use of advanced imaging techniques. Traumatic elbow injuries should be described in the radiology report within the context of their clinical significance and their implications for management, information that is often best captured by the injury grading and classification systems used by the orthopedic surgery community. This article reviews the relevant anatomy and functional stability of the elbow and discusses common traumatic elbow injury patterns, including elbow dislocations as well as fractures of the distal humerus, radial head and neck, coronoid process, and olecranon. Less commonly encountered injury constellations that are clinically significant are also described. Injury patterns are explained in the context of the responsible force mechanism by using three-dimensional modeling and animation, with emphasis on the functional impact of associated secondary bone and soft-tissue injuries. The utility of cross-sectional imaging modalities such as computed tomography and magnetic resonance imaging in the acute care setting is discussed, and specific imaging guidelines are provided. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.333125176/-/DC1. © RSNA, 2013.
... It is believed that elbow injuries are becoming more common as more people participate in throwing and racquet sports [7] . Frostick [7] says that the most usual injuries in racquet sports, such as tennis, include lateral epicondylitis with backhand, medial epicondylitis on downswing with trailing arm and lateral epicondylitis with leading arm. ...
... It is believed that elbow injuries are becoming more common as more people participate in throwing and racquet sports [7] . Frostick [7] says that the most usual injuries in racquet sports, such as tennis, include lateral epicondylitis with backhand, medial epicondylitis on downswing with trailing arm and lateral epicondylitis with leading arm. Elbow tendinopathy prevalence can be as high as 40% of tennis injuries [8] . ...
... Despite the existing elbow injuries in tennis players, we might also take into account other pathologies that produce elbow injuries that are common as well. Some examples of these ones could be valgus extension overload of the posterior compartment, flexorpronator soreness, hyperextension and dislocation, olecranon bursitis, posterior impingement, ulnar collateral ligament sprain and ulnar nerve irritation, among others [7] . These mentioned pathologies are not only common in racquet sports or golf, but also in other sports such as basketball, baseball, volleyball or gymnastics. ...
Article
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AIM: Lateral epicondylitis, also known as tennis elbow, is a common pathology that usually affects tennis players and athletes involved in overhead throwing, especially athletes between 30 and 50 years old.It is a painful condition that starts with swelling of the tendons that attach to the lateral epicondyle of the humerus and continues as a tendinosis. This pathology is related to a repetitive contraction of the extensor carpi radialis and it could also be associated with the condi- tions of the tennis racquet, an improper technique while playing ten- nis or with the frequency of play. The aim of this review is to analyze the different causes of suffering lateral epicondylitis in tennis players and its pathogenesis. METHODS: A bibliographic research has been performed with Medline database. In order to obtain as much as relevant literature possible, the key words used were: tennis elbow AND pathogenesis. Only manuscripts that had been published in the last ve years and only English- written studies were selected, as well as studies that really mentioned pathogenesis of lateral epicondylitis in adult tennis players. RESULTS: 434 results were obtained reducing to 81 manuscripts in the last ve years. Following the selection criteria, four system- atic reviews were obtained referring to tennis elbow in athletes and pathogenesis. These studies mentioned the possible causes of lateral epicondylitis, especially in tennis players due to their constantly ex- ercise over the extensor muscles that have their origin in the humeral epicondyle in order to keep going with the tennis practice. CONCLUSIONS: A repetitive contraction of the extensor carpi radialis seems to cause lateral epicondylitis in tennis players. But, in fact, there are some aspects that differ: the conditions of the racquet could be a cause of this pathology, as well as an incorrect technique while playing tennis and the frequency of play.
... Although the term "golfer's elbow" is associated with medial epicondylitis, lateral epicondylitis in golfers seems to occur at the same rate as medial epicondylitis. 30 In right handed golfers, such as the patient described in this case, lateral epicondylitis often develops in the left elbow. This may be attributed to forceful impact at the hand/wrist and lateral elbow musculature with left elbow extension during the power portion of the downward stroke and increased torque on the left common wrist extensor musculature during swing follow through. ...
... This may be attributed to forceful impact at the hand/wrist and lateral elbow musculature with left elbow extension during the power portion of the downward stroke and increased torque on the left common wrist extensor musculature during swing follow through. [30][31][32] Although the pronator teres muscle does not attach to the lateral epicondyle of the humerus, the presence of pronator teres involvement in lateral epicondylitis is not uncommon. This may be due to increased muscle coactivation at the time of ball impact. ...
Article
Objective The purpose of this report is to describe the chiropractic management of a case of lateral epicondylitis with active release techniques (ART). Clinical features A 48-year-old white man presented to a chiropractic clinic with a complaint of left lateral elbow pain that began 2 years previous with insidious onset. The patient reported an inability to play 18 consecutive holes of golf due to the pain. Intervention and outcome Treatment consisted of 5 sessions of ART (a soft tissue technique that is applied to muscles, fascia, tendons, ligaments, and nerves) applied to the left elbow soft tissue over a duration of 3 weeks. The patient reported an absence of pain and ability to consistently play 18 consecutive holes of golf up to 3 times per week at 4 and 8 weeks post-treatment. Conclusion This patient with lateral epicondylitis responded favorably to chiropractic treatment using the application of ART, as demonstrated by reduced pain and increased functional outcomes.
... Trauma to the distal biceps tendon usually involves forced extension when the elbow flexed at 90 [24]. A fullthickness tear of the distal biceps tendon presents as a hypoechoic gap between the proximal retracted tendon fragment and the radial tuberosity; in some instances, hematoma can be distally observed. ...
Article
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Elbow pain and injuries are commonly observed in athletes and those who perform repeated forearm movements. Inflammatory disorders, soft tissue injuries, neoplasms, and nerve entrapment syndromes are also observed within the elbow joint. Ultrasound has the advantages of providing high-resolution images of the soft tissues, the absence of radiation exposure, easy accessibility, low cost, and it provides relatively easy dynamic examinations in comparison with other radiologic modalities. Because of these advantages, diagnostic ultrasound and ultrasound-guided interventions for evaluating the elbow joint have increased in importance. This article reviews the applications of ultrasound for the diagnosis of common elbow pathologies, including medial epicondylopathy, lateral epicondylopathy, ulnar collateral ligament injury, distal biceps tendon rupture, triceps tendon rupture, joint effusion, olecranon bursitis, occult fracture, soft tissue mass, and nerve entrapment. In addition, this article discusses ultrasound-guided intervention, including aspiration, the injection of medications, and minimally invasive surgical procedures.
... It is associated with repetitive and excessive use of the wrist extensors and is commonly seen in people partaking in sports with overhead arm motion. 59 Lateral epicondylitis is a common condition, developing in over 50% of tennis players at some time or another. 60 It is however, more common in non athletes, mostly presenting between ages 40 and 60 years, and is often seen in workers whose job involves repetitive rotatory forearm movements such as carpenters and cleaners. ...
Article
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MR imaging is a useful modality for evaluating athletes presenting with elbow pain. Osteochondral injuries and ligamentous injuries are well seen on MR imaging. Ligamentous injuries may be associated with clinical instability syndromes, the secondary signs of which may be evident on MR images. Enthesopathies and distal biceps tendon injuries are common clinical problems that may be seen in both professional and recreational athletes. Nerve compression syndromes may be investigated using MR imaging; however, the usual aim of imaging is to exclude an underlying space-occupying lesion. This article reviews the basic anatomy of the elbow joint and discusses the common osteochondral injuries, ligamentous injuries, instability syndromes, and tendinous pathologies at the elbow joint. The role of imaging in compressive neuropathies is briefly discussed.
... Athletes may initially show no changes in active range of motion, but over time, elbow movements may become limited because of the onset of a flexion contracture. Throwing athletes typically experience flexion contractures of the elbow because of the chronic repetitive motions that have been shown to lead to an extension deficit of about 5°and are evidenced in about 50% of all professional baseball pitchers (7,11,14,18,25,32). It is important to consider other conditions, such as ulnar collateral ligament instability, pronator teres syndrome, and medial nerve entrapment, when working with athletes with medial epicondylalgia. ...
Article
ELBOW INJURIES INVOLVING THE MEDIAL EPICONDYLE, SUCH AS EPICONDYLALGIA, ARE COMMONLY SEEN IN ATHLETES AND INDUSTRIAL WORKERS. THIS IS BECAUSE OF THE HIGH DEMAND OF THE ACTIVITIES AND REPETITIVE STRESSES PLACED ON THE MEDIAL STRUCTURES OF THE ELBOW IN UPPER EXTREMITY SPORTS, SUCH AS BASEBALL, SOFTBALL, AND GOLF, AND IN CONSTRUCTION AND ASSEMBLY LINE WORKERS TO NAME A FEW. BECAUSE THESE STRUCTURES ARE SUSCEPTIBLE TO HIGH STRESS, A COMPREHENSIVE INJURY PREVENTION AND REHABILITATION PROGRAM THAT INVOLVES RIGOROUS STRETCHING AND STRENGTHENING SHOULD BE DEVELOPED FOR THESE ATHLETES/WORKERS.
... Bellow is a table of common elbow injuries for different sports, according to Frostick et al (1999). Weight training in general is associated to ulnar nerve disorders. ...
... Harrelson and Newman indicated compression of the ulnar nerve occurred as a result of hypertrophy of the volar carpal ligament and/or accessory muscles caused by extreme valgus stress at the elbow. 2 A separate study identified compression from muscle hypertrophy in racquet sports and strength training as the cause of median nerve entrapment. 3 Given the high stress placed on the grip arm of rodeo athletes, significant anatomic changes in the bone and soft tissue are occurring that should be taken into account when evaluating these athletes and making clinical decisions. ...
Poster
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Clinical photograph showing visible changes in soft tissue, with a clear size discrepancy. Activities that necessitate increased load bearing are known to cause bony hypertrophy. In keeping with Wolf's Law, bones increase in size and density in response to activities causing increased stress. While there has been evaluation of unilateral hypertrophy in sports such as tennis, baseball, and field hockey, the current literature investigating this phenomenon in rodeo athletes is limited. Due to the dangerous nature of rodeo competitions, much of the research surrounding these athletes is directed at management of more acute injuries rather than chronic injuries. As part of the sports medicine team serving the rodeo circuit, the authors are not only evaluating these patients for acute injuries, but also monitoring chronic injuries. The patients evaluated had complaints of chronic arm pain and radiographs taken as part of their initial evaluation showed no signs of injury. We hypothesized that the grip arm in these athletes would demonstrate bony hypertrophy and osseous changes compared to the non-grip arm as they had been demonstrated in previous studies in athletes of other sports.
... Furthermore, the abduction angle of the elbow produces abduction loading and probably contributes to some of the overuse injury patterns such as valgus extension overload (Magra, Caine, & Maffulli, 2007). Common elbow injuries in gymnasts are traction injuries to the medial elbow structures such as medial collateral ligament strains, and medial epicondyle traction injuries, and compressive injuries to the posterior and lateral structures such as osteochondritis dissecans of the capitellum (Frostick, Mohammad, & Ritchie, 1999). ...
Article
The aim of the present study was to conduct within-gymnast analyses of biological movement variability in impact forces, elbow joint kinematics and kinetics of expert gymnasts in the execution of the round-off with different hand positions. Six international level female gymnasts performed 10 trials of the round-off from a hurdle step to a back-handspring using two hand potions: parallel and T-shape. Two force plates were used to determine ground reaction forces. Eight infrared cameras were employed to collect the kinematic data automatically. Within gymnast variability was calculated using biological coefficient of variation (BCV) discretely for ground reaction force, kinematic and kinetic measures. Variability of the continuous data was quantified using coefficient of multiple correlations (CMC). Group BCV and CMC were calculated and T-test with effect size statistics determined differences between the variability of the two techniques examined in this study. The major observation was a higher level of biological variability in the elbow joint abduction angle and adduction moment of force in the T-shaped hand position. This finding may lead to a reduced repetitive abduction stress and thus protect the elbow joint from overload. Knowledge of the differences in biological variability can inform clinicians and practitioners with effective skill selection. Copyright © 2014 Elsevier B.V. All rights reserved.
... Entrapment of the median nerve was identified in a separate study to be a result of compression from muscle hypertrophy in racquet sports and strength training. 16 This study is limited by the inclusion of only symptomatic patients. We were unable to account for previous injuries that may have influenced the bone composition of either arm. ...
Article
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Objective Activities that require increased load bearing are known to cause bony hypertrophy. This phenomenon has been documented in the dominant arm of athletes in sports requiring significant utilization of a single limb. The literature addressing this effect in rodeo athletes, however, is minimal. Studies evaluating rodeo athletes are primarily focused on acute injury management rather than chronic symptoms resulting from changes in bone and soft tissue. We designed a study to evaluate bony hypertrophy in athletes without acute injury. Method Rodeo bareback riders presented with frequent pain in their grip arm, no radiographic evidence of injury, and clinical signs of peripheral nerve compression. Anteroposterior and lateral X-rays taken for initial evaluation in 17 bareback rodeo athletes were retrospectively reviewed. The diameter of bilateral ulnas was measured at its longitudinal midpoint. Ratio of Ulnar Diameters (grip arm/free arm) and Percentage Diameter Difference were calculated. An independent samples t-test was used to assess differences in diameters of grip and non-grip arms. Result The mean ulnar diameter was 18.4 ± 3.5 in the grip arm and 16.6 ± 3.5 in the non-grip arm ( p < 0.001). The mean ratio of grip to free arm ulnar diameter was 1.42 ± 0.21 (range = 1.05–1.92). The mean diameter percent difference measured 42.3% (range = 4.7%–92.0%), and the grip arm was observed to have a greater ulnar diameter compared to the non-grip arm. Conclusion There are significant anatomic differences in the grip arm of bareback rodeo athletes compared to the contralateral arm. In cases of persistent pain in the grip arm and no evidence of acute injury, these differences may be relevant to pain symptoms and should be considered as part of the assessment and treatment algorithm.
... Tennis elbow occurs most commonly in people aged 40 to 50 years with an equal distribution between men and women. 3,8,9 The dominant arm is involved in 75% of patients, and the incidence most directly relates to playing time in amateur players. 3 It has been reported that nearly 50% of all tennis players over 35 years old and 60% of players over 50 years old suffer from tennis elbow at some point in their career. ...
Article
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To present the diagnostic features of lateral epicondylosis and response to treatment by Active Release Technique (ART), a promising treatment for lateral epicondylosis. The most important feature is pain at the lateral epicondyle of the humerus, most notably in actively extending or passively flexing the wrist. Treatment involves eliminating any inflammation, reducing muscular pain and hypertonicity, correcting biomechanical dysfunction, and restricting/modifying the offending activity. ART was successfully utilized in an attempt to remove adhesions and promote restoration of normal tissue texture. A sports specific rehabilitation protocol was employed to re-establish wrist extensor strength and interferential current and ice were used to control pain and residual inflammation. A combination of soft tissue therapy, rehabilitation, and therapeutic modalities is a protocol that may be used by both allopathic and chiropractic practitioners alike, and allow for the athletic patient to return to play as quickly as possible.
... 19 However, medial epicondyle fractures are rare in skeletally mature athletes, as the UCL commonly tears before the bone breaks. 14,21 Unfortunately, the number of UCLRs performed in professional as well as youth baseball players has been increasing over the past 10 years. 8,10,15 While the results after UCLR have been encouraging, the procedure is not without complications. ...
Article
Background: Ulnar collateral ligament reconstruction (UCLR) is a common procedure among professional baseball pitchers. An uncommon complication after UCLR is a fracture of the medial epicondyle at the level of the humeral tunnel, which requires open reduction internal fixation (ORIF). Purpose/Hypothesis: The purpose of this study was to determine the performance upon and rate of return to sport (RTS) in professional baseball pitchers after ORIF of the medial epicondyle and examine whether there is a difference in the RTS rate and performance between players who underwent ORIF and matched controls. It was hypothesized that there would be a high rate of RTS in professional baseball pitchers after ORIF of the medial epicondyle, with no difference between the ORIF and control groups in the rate of RTS or performance, specifically related to the primary performance outcome variables of win-loss percentage, walks plus hits per inning pitched, fielding independent pitching, and wins above replacement. Methods: All professional baseball pitchers who underwent ORIF of the medial epicondyle between 2010 and 2016 were included in this study. Demographic and performance data (preoperative and postoperative) were recorded for each player. Performance metrics were then compared between the ORIF and control (no history of UCLR or ORIF) groups. Results: Overall, 15 pitchers (80.0% starters, 73.3% right-handed) underwent ORIF of a medial epicondyle fracture. All had undergone prior UCLR using either the American Sports Medicine Institute (n = 9; 60.0%) or docking (n = 6; 40.0%) technique. ORIF techniques included fixation with 1 screw (n = 13; 86.7%) and fixation with suture anchors (n = 2; 13.3%). Eleven (73.3%) pitchers were able to return to sport (did not differ from controls; P = .537); 55% returned to the same level or higher. No significant differences existed in the primary performance outcome variables when comparing preoperative with postoperative performance. No significant differences in the primary performance outcome variables were seen between the ORIF and control groups after surgery, although players in the ORIF group pitched fewer innings than controls after surgery (P = .003). Conclusion: After ORIF of the medial epicondyle in professional pitchers with a history of UCLR, 73.3% were able to return to sport (only 55% of those who returned pitched at the same level or higher) without a significant decline in most performance variables when compared with their preoperative performance or matched controls. The number of innings pitched declined after surgery.
... Upper limb movements often involve coordinated and harmonized engagements of the core as well as the joints of the shoulder, elbow, and wrist (Escamilla, Fleisig, Barrentine, Zheng, & Andrews, 1998;Fleisig et al., 1996;Noguchi, Demura S, Takahashi, Demura G, & Mori, 2014). Because the upper limb is overworked in numerous contact and non-contact sports, injuries are relatively prevalent, and some may develop into serious problems that threaten the athlete's future (Noguchi, Demura S, Takahashi, Demura G, & Mori, 2014;Frostick, Mohammad, & Ritchie, 1999;Page, 2011). The lengthy healing time, the lost playing time, and the residual effects are all reasons why upper limb injuries are considered an immense threat to both the amateur and the professional athlete (Bedi, 2011). ...
Article
Objectives To explore the patterns and trends of upper limb injuries in Major League Baseball(MLB). Design Descriptive Epidemiological Study. Setting The MLB website was screened for injuries between 2010 and 2016, inclusive. Participants Players that were placed on the Injured Lists(IL) due to upper limb injuries. Main Outcome Measures The players’ position, injury location, injury information, date of injury, and time spent on the IL were collected. Results A total of 3512 injuries were documented; 1609 injuries(49%) affected the upper limb(n=1609). On average, players were placed on the IL for 71 days (std dev=57 days) due to these injuries. The shoulder was the anatomic location most prone to injury(35%). The elbow had the highest average days on IL (94 days;std dev=63 days), significantly higher than all other anatomic locations(P<0.001). Strain was the most cited cause for upper limb injuries. Pitchers had a significantly higher mean incidence rate (MIR) than fielders and catchers for shoulder, elbow, arm, and forearm injuries. Pitchers had significantly lower wrist and hand injury MIRs when compared to fielders and catchers. April had the highest burden of injuries with 380 injuries(24%). Surgery was performed on 225 injuries(14%). Conclusion Upper limb injuries are prevalent in the MLB, especially among pitchers. The shoulder is the anatomic location most prone to injury. Better understanding of the trends and patterns of these injuries will help in establishing better prevention policies.
... Furthermore, Magra et al. (2007) demonstrated that the abduction position and corresponding internal adduction moment of the elbow produced abduction loading and probably contributed to some of the overuse injury patterns such as valgus extension overloading. These repetitive loads cause lesions to the elbow, including medial collateral ligament strains, medial epicondyle traction injuries and osteochondritis dissecans of the capitellum (Frostick et al., 1999;Koh et al., 1992). Chronic injuries resulting from skills that are well learned, basic or moderately difficult have been shown to be most common, and these occur with highest frequency on the floor exercise (Lindner and Caine, 1990). ...
Article
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The importance of technique selection on elbow injury risk has been identified for the key round off skill in female gymnastics, with a focus on the second contact limb. The aim of this study was to shift the focus to the first contact limb and investigate the biomechanical injury risk during parallel and T-shape round-off (RO) techniques. Seven international-level female gymnasts performed 10 trials of the RO to back-handspring with parallel and T-shape hand positions. Synchronized kinematic (3D motion analysis system; 247 Hz) and kinetic (two force plates; 1235 Hz) data were collected for each trial. The t-test with effect size statistics determined differences between the two techniques. No significant differences were found for vertical, anterior posterior and resultant ground reaction force, elbow joint kinematics and kinetics. Specifically, the results highlighted that change in technique in RO skills did not influence first contact limb elbow joint mechanics and therefore, injury risk. The findings of the present study suggest the injury potential of this skill is focused on the second limb during the parallel technique of this fundamental gymnastic skill.
... Lateral epicondylitis is a painful condition of the elbow which is common in racquet sports players and also occurs in non-athletes. This is mainly due to repetitive stress and thus causes significant -down time‖ for the patients limiting their day to day activities [9,10,11]. ...
... 19 However, medial epicondyle fractures are rare in skeletally mature athletes, as the UCL commonly tears before the bone breaks. 14,21 Unfortunately, the number of UCLRs performed in professional as well as youth baseball players has been increasing over the past 10 years. 8,10,15 While the results after UCLR have been encouraging, the procedure is not without complications. ...
Article
Full-text available
Background: Ulnar collateral ligament reconstruction (UCLR) is a common procedure among professional baseball pitchers. An uncommon complication after UCLR is a fracture of the medial epicondyle at the level of the humeral tunnel, which requires open reduction internal fixation (ORIF). Purpose/hypothesis: The purpose of this study was to determine the performance upon and rate of return to sport (RTS) in professional baseball pitchers after ORIF of the medial epicondyle and examine whether there is a difference in the RTS rate and performance between players who underwent ORIF and matched controls. It was hypothesized that there would be a high rate of RTS in professional baseball pitchers after ORIF of the medial epicondyle, with no difference between the ORIF and control groups in the rate of RTS or performance, specifically related to the primary performance outcome variables of win-loss percentage, walks plus hits per inning pitched, fielding independent pitching, and wins above replacement. Methods: All professional baseball pitchers who underwent ORIF of the medial epicondyle between 2010 and 2016 were included in this study. Demographic and performance data (preoperative and postoperative) were recorded for each player. Performance metrics were then compared between the ORIF and control (no history of UCLR or ORIF) groups. Results: Overall, 15 pitchers (80.0% starters, 73.3% right-handed) underwent ORIF of a medial epicondyle fracture. All had undergone prior UCLR using either the American Sports Medicine Institute (n = 9; 60.0%) or docking (n = 6; 40.0%) technique. ORIF techniques included fixation with 1 screw (n = 13; 86.7%) and fixation with suture anchors (n = 2; 13.3%). Eleven (73.3%) pitchers were able to return to sport (did not differ from controls; P = .537); 55% returned to the same level or higher. No significant differences existed in the primary performance outcome variables when comparing preoperative with postoperative performance. No significant differences in the primary performance outcome variables were seen between the ORIF and control groups after surgery, although players in the ORIF group pitched fewer innings than controls after surgery (P = .003). Conclusion: After ORIF of the medial epicondyle in professional pitchers with a history of UCLR, 73.3% were able to return to sport (only 55% of those who returned pitched at the same level or higher) without a significant decline in most performance variables when compared with their preoperative performance or matched controls. The number of innings pitched declined after surgery.
Article
MRI is a valuable tool for evaluating the athlete with elbow pain, particularly in those with nonlocalizable pain. MRI also is helpful in sorting out the cause of pain in athletes who may have acute trauma superimposed on tendinopathy or other chronic injuries from repetitive microtrauma. Even in athletes in whom the cause of pain confidently can be diagnosed clinically, MRI can document the injury severity, which can be helpful for estimating recovery time or in preoperative planning. By contributing to an accurate early diagnosis, MRI also can help minimize the time that athletes are away from their sports. The authors describe their approach to the MRI interpretation of elbow injuries in athletes, including osteochondral lesions, epicondylitis, and tears of the medial collateral ligament.
Article
To develop a schematic segmentation of the proximal ulna in order to detect, assess the frequency, and characterize the bony outgrowths arising from the trochlea and from the radial notch of the ulna, to enable differentiation of osteophytes from enthesophytes. Eighty well-preserved ulna specimens from the collection of the San Diego Museum of Man were analyzed by two musculoskeletal radiologists. The trochlea and the radial notch of the ulna simulate the shape of a clock quadrant. The proximal ulna was divided into 24 anatomic areas. The relationships of the joint capsule and insertions of tendons and ligaments onto these area were assessed by the two readers, and the resulting appearances of bony outgrowths were compared at visual inspection and on Radiographs. The interobserver visual comparison was good in 17 areas out of 24, but poor correlation was found in 7 areas. In one case, difficulties in differentiating osteophytes originating from the brachialis muscle/ tendon (area 9) from an enthesophyte originating from the capsule insertion on the coronoid process (areas 2 or 3) occurredand between two different enthesophytes in a further case. Five cases had difficulties in defining differences in the grading system of the outgrowths. The percentage of outgrowths observed in each of the areas was globally high, especially in areas 9 and 10. On radiographs it was possible to observe irregularities in ten areas; in eight at a threshold of height of 2 mm (areas 1-4, 9, 10, 11, 14) and in two at a threshold of height of 3 mm (areas 5, 6). The two readers had the same difficulties in differentiating enthesophytes from osteophytes at radiographic and visual examination. Our segmentation scheme is reproducible and objective, and permitted the differentiation of the bony outgrowths arising from the proximal ulna into osteophytes and enthesophytes, which may be particularly useful for the in vivo assessment of abnormalities seen in elbow overuse syndromes.
There is a wide spectrum of pathology that affects the elbow in the athlete. This is further complicated by the complex anatomy of this articulation and the numerous normal anatomic variations that can serve as pitfalls in imaging diagnosis. A detailed knowledge of the anatomy and pathology that commonly affect this articulation can facilitate the ease and accuracy of imaging diagnosis.
Article
Because of the often complex system of static stabilizers and surrounding tendons of the elbow joint, as well as the inherent obliquity of the joint alignment, imaging beyond conventional radiographs is often necessary. Because of its superior soft tissue contrast and direct multiplanar capabilities, magnetic resonance imaging is well suited for assessment of sports-related injuries, which may involve the articular cartilage, supporting ligaments, and tendons. Although not as comprehensively used in the United States, sonography can also be of use, especially when there is a targeted clinical question, such as the presence of epicondylitis, or to provide guidance for diagnostic or therapeutic injections.
Article
Elbow injuries, both acute and chronic, continue to rise as both the young and elderly increase their participation in athletic activities. The role of imaging is to provide supportive data as to the cause of the patient's symptoms and to guide treatment options for the referring physician. Understanding the anatomy and biomechanics of this sophisticated joint, various injury patterns, and the implication of injury to the static and dynamic stabilizers will result in improvement in diagnostic accuracy. Each of these topics are discussed to provide a foundation and overview of key concepts necessary to understand common elbow injuries.
Article
Elbow injuries, both acute and chronic sports-related cases, have increased over the last decade. With one in every four members of a household participating in sports, both clinics and radiology departments are seeing more patients with elbow pain. High-resolution ultrasound is well suited for evaluating the elbow. Ultrasound is growing in popularity and fast becoming another modality that the radiologist can use to help diagnose elbow pathology. With advancing transducer technology and accessibility, ultrasound offers focused and real-time high-resolution imaging of tendons, ligaments, and nerve structures. Its advantages include the use of safe nonionizing radiation, accessibility, and cost effectiveness. Another unique advantage is its ability for dynamic assessment of tendon and ligament structures such as in cases of partial tears of the medial ulnar collateral ligament or ulnar nerve dislocation. It is also easy to assess the contralateral side as a control. Ultrasound is also useful in therapeutic guided injections for its multiplanar capability and clear visualization of major vessels and nerves. We discuss the unique application of ultrasound in evaluating common elbow pathology and in advanced ultrasound-guided treatments such as dextrose prolotherapy and platelet-rich plasma.
Chapter
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Elbow injuries are common, especially in the athlete, and can be basically classified into acute or chronic injuries. The following discussion of magnetic resonance imaging (MRI) of the elbow will address variations in normal anatomy that represent pitfalls in imaging diagnosis, and commonly encountered osseous and soft-tissue pathology.
Chapter
Sports-related elbow injuries have increased over the last decade. With one in every four members of a household participating in sports, both clinics and radiology departments are seeing more patients with elbow injuries. The most common clinical presentation is lateral elbow pain. Familiar terms such as “tennis elbow,” “golfer’s elbow,” and “little leaguer’s elbow,” are mostly due to the popularity of overhead throwing and racquet sports such as baseball, football, and tennis. It is important to understand the anatomy of the elbow joint, its supporting structures, and its complex biomechanics to allow for a quick and accurate diagnosis. Injuries to the bone, tendon, ligaments, and nerves are related to the biomechanics of the elbow joint as each structure fails due to chronic overuse, repetitive microtrauma, or acute events. Additionally, different injury patterns occur in children than in adults. Risk factors include suboptimal mechanics, improper equipment, or deconditioned state. We will discuss how MR imaging, CT, and ultrasound can help to diagnose elbow injuries seen in sports, and how together with a firm understanding of the biomechanics of the various injuries will lead to a diagnose for proper rehabilitation and quick return to the sport. KeywordsElbow-Epicondylosis-Epicondylitis-Collateral ligament-Magnetic resonance imaging-Ultrasound
Article
Recent advances in imaging techniques shed light on anatomical variants considered normal historically in medical literature. We present an 11-year-old gymnast with unilateral left elbow pain and unusual symmetrical radiographic findings of both elbows that initially raised the question of normal variant cleft epiphysis of the proximal radius. Further imaging with MRI demonstrated bilateral elbow injury that is likely repetitive and chronic rather than an anatomical variant. Post-treatment MRI showed improved changes with rest and non-steroidal anti-inflammatory medications. These findings emphasize the need for vigilance and further investigation when diagnosing a normal variant, particularly in an athlete.
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Objective: The purpose of this review is to describe the upper extremity injuries that frequently accompany aging, the typical clinical presentations, and the differential diagnoses with an emphasis on the injury most likely encountered with each presentation. Conclusion: Expectation of continued participation in exercise and sports activities by the baby boomer population has presented new challenges to the medical field. The concepts behind factors that predispose older athletes to certain pathologic conditions that affect the muscles, tendons, and bones of the upper extremity must be understood.
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Imaging in golf and racquet sports is becoming increasingly important as the popularity of the sports flourishes among all ages and levels of experience. Because amateurs and professionals show different patterns of injuries, the importance of understanding and applying the biomechanics of the sport to specific injuries and their imaging is paramount. This chapter will detail the biomechanics, types of injuries, and the imaging of golf and racquet sports injuries.
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Imaging of the elbow can demonstrate a wide range of elbow abnormalities that involve osseous structures, articular surfaces, ligaments, muscles, tendons, bursae, and nerves. In the following discussion, the elbow anatomy — with variants and pitfalls as well as commonly encountered osseous and soft-tissue pathology — will be addressed. The emphasis will be on their magnetic resonance imaging (MRI) appearances.
Article
To assess the number and anatomical location of fractures associated with elbow dislocation, to study the correlation between the direction of dislocation and the trauma energy, and to assess radiographs' diagnostic performance characteristics for fractures using MDCT as a reference standard. A retrospective study was performed at a level 1 trauma center, finding a total of 140 patients who had sustained an elbow dislocation and who had undergone a subsequent MDCT examination. The CT and radiographs of the patient were reviewed by two musculoskeletal radiologists. CT images were analyzed for the site and size of the fracture fragments. In addition, the primary direction of the dislocation, patients' age, and gender were recorded. Trauma energy was also assessed. One hundred and thirty-four out of 140 patients (96 %) had a fracture that was seen on the correlative CT examination. The most common anatomical fracture locations were the coronoid process of the ulna 84 out of 140 (60 %), the radial head 75 out of 140 (54 %), and the humeral capitellum 57 out of 140 (41 %). Multiple fractures were seen in 71 out of 134 (53 %) patients with fractures. The left elbow was more commonly dislocated than the right one. The overall sensitivity of the radiographs was 62 % and the specificity 96 %. Small fractures and impaction fractures are almost invariably present in elbow dislocations, and half of the patients have more than one fracture. Radiographs have a sensitivity of only 62 %. MDCT is an invaluable method for determining the extent of bony injury and revealing occult fractures.
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IntroductionWho Is Affected by Injury?Where Does Injury Occur?When Does Injury Occur?What Is the Outcome?What Are the Risk Factors?What Are the Inciting Events?Injury PreventionFurther ResearchReferences
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The elbow is a complex joint made up of three separate articulations within a common capsule. The proximal ulna articulates with the trochlea and functions as a hinge joint, while the proximal radioulnar joint provides for rotational movement of the forearm. The radiocapitellar joint allows for both hinge and rotational movement. Together, these allow for flexion and extension of the arm and, in conjunction with the distal radioulnar joint at the wrist, pronation and supination.
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The elbow joint has a complex “trochoginglymoid “architecture which allows for the wide range of motion, including hinged (elbow flexion and extension) and rotational (forearm supination and pronation) motion. Stability is dependent on the congruity of this articulation with major support of the medial and lateral ligament complex but with only a minor contribution of the muscles. Acute varus, valgus, anterior, and posterolateral overload may result in a variety of fractures and lead to recurrent instability and overuse injury. Although lower limb injuries are the most common and comprise 74 % of all sports injuries (Alonso et al. 2012), upper limb injuries are an important cause of reduced performance and loss of playing time for athletes. Upper limb injuries are most common in throwing sports but frequently occur in weight-lifting sports as well. Imaging of acute injuries in most cases involves conventional radiographs to visualise osseous anatomy and pathology but offers only limited soft tissue evaluation. US provides high-resolution images of the muscle, tendons, and ligaments, including dynamic assessment of the joint movement and (sub)luxation of the tendons and nerves. Hypervascularisation and angiogenesis are easily assessed with Doppler ultrasound. The ultrasound examination is typically focused on the area of tenderness and discomfort. MRI and MR arthrography are the best imaging techniques in complex pathology with involvement of bone, joint, and soft tissues. The 2D and 3D multiplanar reconstruction capacity of CT depicts the complex osseous anatomy and pathology in fracture dislocation and fracture healing and in soft tissue calcification and ossification. Good knowledge of the (functional) anatomy and its variants is mandatory.
Article
The elbow is a complex synovial hinge joint that is frequently involved in both athletic and nonathletic injuries. A thorough understanding of the normal anatomy and various injury patterns is essential when utilizing diagnostic imaging to identify damaged structures and to assist in surgical planning. In this review, the elbow anatomy will be scrutinized in a systematic approach. This will be followed by a comprehensive presentation of elbow injuries that are commonly seen in the emergency department accompanied by multimodality imaging findings. A short discussion regarding pitfalls in elbow imaging is also included.
Article
There is no consensus about the main aetiology of Lateral Epicondylitis (LE) or Tennis Elbow. While electromyographic assessment of alterations in neuromuscular control and activation patterns of forearm muscles has received increasing interest as potential intrinsic factors in non-tennis players, there has been insufficient attention in tennis players. The purpose of present review was to search the literature for the electromyographic studies of forearm muscles in tennis players in order to 1) identify related implications for LE, 2) highlight key technical and methodological shortcomings, and 3) suggest potential pathways for future research. An electronic search of PubMed, Scopus, Web of Science, and Google Scholars (1980 to October 2014) was conducted. Titles, abstracts, and full-text articles were screened to identify “peer-reviewed” studies specifically looking into “electromyographic assessment of forearm muscles” in “tennis players”. After screening 104 articles, 13 original articles were considered in the main review involving a total of 216 participants (78% male, 22% female). There were indications of increased extensor activity in all tennis strokes and less experiences single-handed players, however with insufficient evidence to support their relationship with the development of LE. Studies varied widely in study population, sample size, gender, level of tennis skills, electrode type, forearm muscles studied, EMG recording protocol, EMG normalisation, and reported parameters. As a result, it was not possible to present combined results of existing studies and draw concrete conclusions in terms of clinical implications of findings. There is a need for establishment of specific guidelines and recommendations for EMG assessment of forearm musculature in terms of electrode and muscle selection. Further studies of both healthy controls and tennis players suffering from TE with adequate sample sizes and well-defined demographics are warranted.
Article
Women participation in sports increased dramatically in the last century, especially in the last quarter. Women are now involved more in competitive athletics and other vigorous exercise programs, and women of all ages are exercising earlier in life and with greater intensity. This mass participation in sports resulted in dramatic increase in certain sports-related musculoskeletal injuries among women which their incidences and locations differ according to the type of sports.
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Elbow injuries in athletes are becoming more frequent, especially in those involved in racket and throwing sports. Correct diagnosis of a painful elbow requires a thoughtful understanding of the anatomy and complex kinetics of this joint. Although elbow problems may present acutely, they are more commonly seen as chronic overuse syndromes. Elbow tendinopathy is caused by tendinous microtearing followed by an incomplete reparative response. Lateral and medial epicondylitis are more common in the amateur athlete and usually respond to conservative measures. Participants in overhead sports are subjected to tremendous valgus and extension overload, generating medial tensile forces with compression on the lateral compartment and shear stresses posteriorly. This may lead to chronic injury to the elbow, the so-called valgus extension overload syndrome. This spectrum of pathology includes insufficiency of the medial collateral ligament, osteochondritis dissecans of the capitellum (in young athletes), and posterior olecranon impingement syndrome. In patients who fail to respond to conservative measures, surgical reconstruction of the medial ligament, or arthroscopic debridement of capitellar or olecranon lesions may be required. Lateral elbow pain may be due to posterolateral instability, usually found in the context of previous trauma or surgical treatment of radial head fractures or epicondylitis. Radiohumeral synovial plicae must be also considered in the differential diagnosis of pain on the lateral aspect of the elbow. Tendon ruptures, affecting the biceps and triceps, occur more often in weight lifters and should be treated surgically by re-attaching the torn tendon to bone.
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We examined differences in muscle power between the dominant and non-dominant upper limbs of 33 healthy right-handed university baseball players (mean age, 20.4 ± 1.1 years) with an average baseball experience >11 years. After measuring maximal voluntary contraction (MVC) of hand grip, elbow flexion, and shoulder internal rotation in both upper limbs, the muscle power of each joint was measured at 40%, 50%, and 60% MVC. No significant differences were observed in the main factors affecting MVC and elbow flexion power loads between dominant and non-dominant upper limbs. For hand grip power, load factors at 40% MVC in the dominant hand were lower than those at 60% MVC in the same hand and those at 50% and 60% MVC in the non-dominant hand. Significant differences were observed in shoulder internal rotation power between dominant and non-dominant upper limbs, with the dominant limb having greater power at all loads. Correlations between muscle power of both upper limbs for hand grip and elbow flexion were significant and moderately high at all loads. For shoulder internal rotation power, the degree of correlation was significant and moderately high at 40% MVC but low to moderate at 50% and 60% MVC. Baseball players therefore have marked lateral dominance in shoulder internal rotation power unlike hand grip and elbow flexion power, although the relationship between shoulder internal rotation muscle powers of both upper limbs becomes lower with increasing load. The dominance of muscle power of each joint varied even in the same upper limb. It is thus beneficial for baseball players to train with even loads on both arms or adopt simultaneous workout of both arms after adjusting for strength differences.
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We have reviewed 185 articles published since 1966 to assess the scientific evidence for methods of treatment for lateral epicondylitis of the elbow. Of the 185 articles, 78 discussed treatment, but since the natural history of the syndrome is uncertain we considered only those series with concurrent control groups. Only 18 of these were randomised and controlled studies. We then graded these papers for scientific validity, using the methods of Chalmers et al (1981). The mean score of the 18 articles was only 33%, with a range from 6% to 73%. A minimum of 70% is required for a valid clinical trial, and we therefore concluded that there was insufficient scientific evidence to support any of the current methods of treatment. There were too many methodological differences to allow a quantitative meta-analysis, but our qualitative review established the importance of the natural evolution of the syndrome and of the placebo effect of all treatments. Properly designed, controlled trials are needed.
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The radiological changes of chronic stress injuries of the elbow in 19 adolescent elite gymnasts are reported. The principal abnormalities were avascular necrosis of the capitellar epiphysis (Panner's disease) (one patient), post-traumatic subarticular necrosis (osteochondritis dissecans) of the capitellum (six patients) and the medial articular eminence of the distal humerus (one patient). Flattening and anterior depression of the radial head epiphysis with an underlying metaphyseal notch associated with an epiphyseal cleft (three patients), which, in one patient who continued training, developed into a chronic Salter Type IV stress fracture. A further patient, post-epiphyseal fusion, showed osteochondritis dissecans of the anterior aspect of the radial head. Seven patients exhibited a spectrum of olecranon changes from fragmentation of the epiphysis to chronic Salter Type I stress fractures of the growth plate. A follow-up survey found that, of those who responded to a questionnaire, nearly all the patients with articular surface damage failed to continue with competitive gymnastics whereas those with olecranon abnormalities were able to continue gymnastics at the same level. The mechanism of injury and the pathological changes are discussed.
Article
The gymnast often places unphysiologic extreme stresses upon her body during the maneuvers characteristic of that sport. These may result in stress fractures to the skeleton, the lumbar spine being at greatest risk. Minor malalignments of the extremities can encourage injury. The extremes of joint position can produce significant symptoms with chrondromalacia.
Article
The diagnosis and treatment of throwing injuries of the elbow rely on a thorough understanding of the complex anatomy of the elbow, including both osseous and soft-tissue attachments. This article discusses the anatomy of the elbow, the biomechanics of throwing relating to the elbow joint, and the diagnosis and treatment of medial- and lateral-sided injuries to the elbow.
Article
Fastball pitches of eight intercollegiate varsity baseball pitchers were filmed using the direct linear transformation (DLT) method of three-dimensional cinematography. Coordinate data were obtained, and the resultant joint forces and torques at the shoulder and elbow joints were calculated. Various kinematic parameters were also calculated to help describe the motions of the shoulder and elbow joints throughout the pitch. At the instant of stride foot contact, a horizontal adduction torque was present at the shoulder joint, and the shoulder was externally rotating. After the onset of the horizontal adduction torque, abduction and internal rotation torques were also present at the shoulder joint and a varus torque was present at the elbow joint. After the instant of maximum external rotation (30 ms prior to ball release), the upper arm started to internally rotate, but it was still in a position of external rotation at the instant of release. This paper discusses the roles of the torques in producing the ...
Article
To determine the types and frequency of injuries among amateurs, open-ended questionnaires were sent to 4,036 golfers; 1,144 responded (942 men and 202 women; average age, 52 years). The respondents played an average of two rounds per week; 708 (62%) had sustained one or more injuries. Among men, the most common injury site was the lower back; among women it was the elbow. Excessive practice and poor swing mechanics were the most common causes. Golf injuries perhaps could be prevented or reduced by proper technique, controlled practice routines, and physical conditioning.
Article
Valgus extension overload syndrome describes the wide spectrum of elbow injuries seen in the high-performance throwing athlete. Upon presentation, age will segregate patients as either adolescent or adult. Adolescent throwers develop valgus extension overload syndrome just like their adult counterparts. However, since their musculoskeletal system is immature, their specific diagnosis will be different. In adult athletes, valgus extension overload syndrome includes five types of injuries: type I, ulnar collateral ligament (UCL); type II, posterior medial impingement: type III. flexor pronator injury; type IV, peripheral nerve entrapment: and type V, radiocapitellar overload. Conditioning, evaluation, and treatment of the throwing athlete is advanced when all of the types of injuries that result from valgus extension overload syndrome are recognized and understood by their caretaker.
Article
Elbow injuries were studied epidemiologically among 2,633 participants in a tennis school. Thirty-one percent had experienced elbow pain at some time in their playing history. In this portion of the study, multiple factors were analyzed to identify differences between players with and without elbow pain. Variables that were not associated with tennis elbow were height, hand dominance, and two-handed strokes. Factors significantly related to elbow pain were age, weight, level of ability, years of play, frequency of play, and other tennis injuries, which were all greater in players who had elbow pain. Overall, the variables with the most significant average differences between groups with and without pain were age and frequency of play (p<.005). The study showed that women had more wrist and forearm injuries, and men had more shoulder and knee injuries. Higher wrist and forearm injury rates among women might be related to the fact that women generally have less upper extremity strength than men. A more vigorous service motion and generally more aggressive play might be associated with the higher rate of shoulder and knee injuries in men. The elbow is the primary area of injury in tennis players. The injury rate in the elbow (31 injuries per 100 players), which is almost four times as great as the next most injured region (ankle, 8%), clearly establishes this.
Article
The gymnast often places unphysiologic extreme stresses upon her body during the maneuvers characteristic of that sport. These may result in stress fractures to the skeleton, the lumbar spine being at greatest risk. Minor malalignments of the extremities can encourage injury. The extremes of joint position can produce significant symptoms with chrondromalacia.
Article
Peripheral nerve lesions are uncommon but serious injuries which may delay or preclude an athlete’s safe return to sports. Early, accurate anatomical diagnosis is essential. Nerve lesions may be due to acute injury (e.g. from a direct blow) or chronic injury secondary to repetitive micro-trauma (entrapment). Accurate diagnosis is based upon physical examination and a knowledge of the relative anatomy. Palpation, neurological testing and provocative manoeuvres are mainstays of physical diagnosis. Diagnostic suspicion can be confirmed by electrophysiological testing, including electromyography and nerve conduction studies. Proper equipment, technique and conditioning are the keys to prevention. Rest, anti-inflammatories, physical therapy and appropriate splinting are the mainstays of treatment. In the shoulder, spinal accessory nerve injury is caused by a blow to the neck and results in trapezius paralysis with sparing of the sternocleidomastoid muscle. Scapular winging results from paralysis of the serratus anterior because of long thoracic nerve palsy. A lesion of the suprascapular nerve may mimic a rotator cuff tear with pain a weakness of the rotator cuff. Axillary nerve injury often follows anterior shoulder dislocation. In the elbow region, musculocutaneous nerve palsy is seen in weightlifters with weakness of the elbow flexors and dysesthesias of the lateral forearm. Pronator syndrome is a median nerve lesion occurring in the proximal forearm which is diagnosed by several provocative manoeuvres. Posterior interosseous nerve entrapment is common among tennis players and occurs at the Arcade of Frohse — it results in weakness of the wrist and metacarpophalangeal extensors. Ulnar neuritis at the elbow is common amongst baseball pitchers. Carpal tunnel syndrome is a common neuropathy seen in sport and is caused by median nerve compression in the carpal tunnel. Paralysis of the ulnar nerve at the wrist is seen among bicyclists resulting in weakness of grip and numbness of the ulnar 1.5 digits. Thigh injuries include lateral femoral cutaneous nerve palsy resulting in loss of sensation over the anterior thigh without power deficit. Femoral nerve injury occurs secondary to an iliopsoas haematoma from high energy sports. A lesion of the sciatic nerve may indicate a concomitant dislocated hip. Common peroneal nerve injury may be due to a direct blow or a traction injury and results in a foot drop and numbness of the dorsum of the foot. Deep and superficial peroneal nerve palsies could be secondary to an exertional compartment syndrome. Tarsal tunnel syndrome is a compressive lesion of the posterior tibial nerve caused by repetitive dorsiflexion of the ankle — it is common among runners and mountain climbers. Morton’s interdigital neuroma is common amongst dancers and usually responds well to a metatarsal pad. Prophylactic measures are only modestly successful. Fortunately, the vast majority of these injuries are transient and respond well to conservative therapy. It is the exceptional injury that becomes permanent or requires surgical intervention. However, early recognition and treatment are vital to prevent associated morbidity of these rare but serious injuries.
Article
The elbow, by its design and position, is accountable for promoting profitable shoulder, arm. and hand maneuvers that are used in routine activities and sports participation. Primarily responsible for flexion and extension, the elbow also assumes the functions of pronation and supination as a result of the integrity of the proximal radioulnar articulation. For any sport injury, obtaining an accurate history is foundational to successful treatment. Pertinent information is best gleaned from quality questions. It is an advantage for both the athlete and the examining physician that the entire medical team be present in the training room, at practice, and at the contest venue on a routine basis. Mass screening and office visits are viable procedures to adequately depict elbow characteristics, properties, and inadequacies. The actual physical examination. from visualization, strength evaluation, and palpation, to assessment is presented in a structured fashion. Special attention is allotted to each elbow compartment with regard to functional anatomy and pathology. Paragraphs on imaging, special studies, and prevention conclude the article.
Article
This review focuses on the relevant clinical anatomy and pathomechanics of the elbow as they directly relate to specific athletic activities and injury patterns. An appreciation of the anatomy and mechanics of the elbow will facilitate health care professionals in the care of sports-related injuries.
Article
In many sports, large forces and torques are produced at the elbow that lead to fast movements and a full range of motion. In baseball pitching. varus torque is produced when the arm is in external rotation. This torque includes compression at the radiocapitellar joint and tension in the ulnar collateral ligament (UCL). After ball release, compressive force approaching 100% of bodyweight is produced to prevent elbow dislocation. Compared to baseball pitching, football passing produces greater elbow flexion and medial force, and less varus torque: Furthermore, elbow extension is not as rapid and arm deceleration compressive force is not as great. During the tennis serve, elbow extension is largely due to triceps contraction. During javelin throwing. the elbow extends fairly quickly, terminating well short of full extension. During underhand Softball pitching, the elbow produces compressive force and fairly rapid flexion. Elbow compressive force during pushups is equal to 45% of bodyweight. Compressive force during two-arm pushups (which are similar to falling on an arm) is 31% greater.
Article
Elbow arthroscopy is a very useful modality in the diagnosis and treatment of athletic elbow injuries. Over the past decade, the indications for elbow arthroscopy have broadened to include loose body and osteophyte removal, synovectomy, joint contracture release, evaluation of undiagnosed elbow pain, evaluation and treatment of acute fractures, and diagnosis of ulnar collateral ligament (UCL) tears. Advantages over open techniques include the ability to view the entire elbow joint and carry out treatment with minimal soft tissue dissection, low morbidity, and a rapid return of the athlete to competition. Complications may be avoided by an understanding of normal elbow anatomy and by use of meticulous arthroscopic technique. As the interest in elbow arthroscopy continues to expand, further indications will be delineated.
Article
Osteochondritis dissecans of the capitellum is seen most commonly in adolescents. Usually repetitive motion, e.g., throwing, or activities that increase the load across the elbow, e.g., gymnastics, are causative factors. Initial symptoms may be pain, loss of motion (especially extension), catching, locking, or swelling. Diagnosis is made by plain x-rays, although computed tomography (CT) and/or magnetic resonance imaging (MRI) are sometimes required. Initial treatment is conservative unless the patient presents with an advanced stage. Recommended surgery is elbow arthroscopy with removal of all loose fragments and abrasion chondroplasty, followed by early active motion and strengthening. This allows return to activities in most individuals. (C) Lippincott-Raven Publishers.
Article
The rehabilitation program following an elbow injury or elbow surgery plays a vital role in ultimate outcome. The unique orientation of the elbow complex, high degree of joint congruence, and capsular configuration contribute to much of the difficulty experienced by the therapist in treating the elbow after injury or surgery in order to obtain normal function. Rehabilitation of elbow injuries in sports should progress through a multiphased, sequential, progressive approach that is based on current clinical and scientific research. The rehabilitation principle applied should include immediate controlled motion, immediate strengthening, dynamic stabilization, and functional progression. The purpose of this article is to describe the rehabilitation processes for various elbow pathologies and the specific postoperative care for selected procedures (postarthroscopic chondroplasty, ulnar collateral ligament reconstruction, elbow dislocation, valgus extension overload, posttraumatic ar-throfibrosis, lateral epicondylitis, and osteochondritis dessicans). (C) Lippincott-Raven Publishers.
Article
Sixteen fresh cadaver elbows were examined by arthroscopy and dissection to evaluate the usefulness and the anatomic relationships of seven previously described portals for elbow arthroscopy. Most of the examined portals were found to be relatively close to neurovascular structures. The nerves that were found to be located closest to the portals were the posterior antebrachial cutaneous nerve at the direct lateral and antero-lateral portals, the radial nerve at the antero-lateral portal, and the medial antebrachial cutaneous nerve at the high and low antero-medial portals. The degree of flexion and fluid distension of the joint were found to influence the position of nerves and vessels in relation to the arthroscopy portals. At least three different portals were found to be required for thorough examination of the elbow joint. The combination of the low postero-lateral, the direct lateral, and the high antero-medial portals provided the largest visualized area.
Article
The elbow joint is stabilized by the conforming shape of its articular surfaces, by the joint capsule and collateral ligaments, and by muscles that pass across the joint. Each of these static and dynamic stabilizers serve to keep the joint surfaces in apposition. The relative contribution of these structures to stability varies as a function of joint orientation and the extent of muscle activation. In this article our present understanding of the stabilizers of the elbow is reviewed. Important implications regarding the management of osseous and ligamentous injuries about the elbow are highlighted.
Article
Athletic injuries of the elbow are common, especially in throwing sports such as baseball or tennis. The primary care team physician must be prepared to diagnose these injuries, initiate treatment, make appropriate referrals for surgical management, and ultimately decide when an athlete can safely return to competition.Elbow disorders in the athlete can be due to muscle-tendon, bone, cartilage, or nerve injuries. These injuries can occur from acute trauma or chronic overuse of the joint. Inappropriate treatment or misdiagnosis can lead to further injury or a loss of elbow motion, which may affect an athlete's ability to compete.This article deals with common disorders of the elbow encountered by the team physician. Etiology, pathophysiology, typical history, physical findings, differential diagnosis, treatment options, and timing for return to play for various disorders are discussed.
The purpose of the present investigation was to analyse the hypothesis that posterior interosseous nerve entrapment could be a cause of lateral elbow pain. To ascertain this the following investigations were carried out: (1) Patients with longstanding lateral elbow pain in whom entrapment of the posterior interosseous nerve was the suspected cause of pain were operated on by decompression of the nerve where it enters the supinator muscle and then subjected to a follow-up for two years. The preoperative symptoms and signs and observations at surgery were related to the results. (2) The topographical anatomy at the suspected entrapment site in the entrapment series was compared with observations at dissections in an unselected autopsy series. (3) The epidemiology and symptomatology in the entrapment series was compared with that in a retrospective series of lateral epicondylitis. The operative and autopsy techniques are reviewed, and the results are surveyed.
Article
An epidemiologic study of the incidence and recurrence of tennis elbow among over 500 tennis players (278 men, 254 women; age range, 20 to 50 years) indicated that age and amount of playing time per day were contributing factors to the injury. Both incidence and recurrence rates increased with age. An interactive effect of playing time and age was observed with increased playing time associated with higher incidence at younger ages. Larger grip size was also associated with higher incidence in the older group. These findings were interpreted as being consistent with the hypothesis that tennis elbow is a degenerative disease, the onset of which is hastened by overuse of the arm and elbow. Changes in stroke technique and types of racket were successful in preventing recurrence. Least successful was the forearm brace.
Article
Of the 1,213 clinical cases of lateral tennis elbow seen during the time period from December 19, 1971, to October 31, 1977, eighty-eight elbows in eighty-two patients had operative treatment. The lesion that was consistently identified at surgery was immature fibroblastic and vascular infiltration of the origin of the extensor carpi radialis brevis. A specific surgical technique was employed, including exposure of the extensor carpi radialis brevis, excision of the identified lesion, and repair. The results at follow-up were rated as excellent in sixty-six elbows, good in nine, fair in eleven, and failed in two. There was an over-all improvement rate of 97.7 per cent, and 85.2 per cent of the patients returned to full activity including rigorous sports.
Article
Ulnar nerve entrapment at the elbow has been described in the literature. This paper deals with 19 skeletally mature baseball players with ulnar nerve entrapment who underwent surgery for correction of the problem. The surgery consisted of anterior transfer of the nerve and placement deep to the flexor muscles. Six players quit baseball because of continuing elbow problems, nine returned to playing, and four were lost to follow-up. Ulnar nerve entrapment is thought to represent one syndrome in a spectrum of diseases involving the medial side of the elbow in baseball players. The lesion is amenable to surgery.
Article
The histopathologic features from 11 patients who were treated surgically for lateral epicondylitis were graded and compared to similar tissue from 12 cadaveric specimens. All studies were done by a single pathologist who had no knowledge of the origin of the specimen. The surgical specimens were interpreted as abnormal in all 11 specimens, and all 12 of the control specimens were reported as being without histologic abnormality. Vascular proliferation was present in 10 of 11 and focal hyaline degeneration was recorded in all 11 of the surgical specimens. Neither feature was present in any of the control material (P < 0.001). These data suggest that chronic refractory lateral epicondylitis requiring surgery is a degenerative rather than inflammatory process. This may account for the lack of response to rest and antiinflammatory medication.
Article
The histology of pathologic tennis elbow tissue reveals noninflammatory tissue, thus the term angio-fibroblastic tendinosis. The goal of nonsurgical treatment is a revascularization and collagen repair of this pathologic tissue by rehabilitative exercise. In the event of rehabilitation failure, surgical correction by removal of this pathologic tissue is the surgical technique of choice.
Article
In the past 15 to 20 years gymnastics has become very popular. The increased participation exposes a greater number of athletes to potential injury. The risk of gymnastic injuries seems to be proportional to the level of the athletes; the higher the level of gymnastics, the more hours are spent in practice, with a greater exposure time. With the increased risk in gymnastics, the incidence of acute injuries will also increase, and as the skill level increases, the load during the workout will also increase, providing more opportunity for chronic injuries. As in many sports, the ankle is the most injured body part. Some injuries, however, seem to be specific to gymnastics. In gymnastics the upper extremities are used as weightbearing limbs, so high impact loads are distributed through the elbow and wrist joint. Back problems appear to result not only from single episodes of macrotrauma, but also from repeated microtrauma caused by specific impact loads during vaults and hyperextension. Early detection is the key to treating elbow, wrist and back pain in the gymnast. Reinjury following an acute injury may be reduced by allowing for complete rehabilitation before returning to full practice. Some studies indicate that maturation rate could play a potential role in injury predisposition. The combination of periods of rapid growth and intense training could provide for conditions where the gymnast is more injury prone.
Article
From September 1974 to December 1987, seventy-one patients were operated on for valgus instability of the elbow. The average length of follow-up of sixty-eight patients (seventy operations) was 6.3 years (range, two to fifteen years). At the operation, a torn or incompetent ulnar collateral ligament was found. Fourteen patients had a direct repair of the ligament, and fifty-six had a reconstruction of the ligament using a free tendon graft. The result was excellent or good in ten patients in the repair group and in forty-five (80 per cent) in the reconstruction group. Seven of the fourteen patients who had a direct repair returned to the previous level of participation in their sport. Of the fifty-six who had a reconstruction, thirty-eight (68 per cent) returned to the previous level of participation. Twelve of the sixteen major-league baseball players who had a reconstruction as the primary operation (no previous operation on the elbow) were able to return to playing major-league baseball, and two of the seven major-league players who had a direct repair returned to playing major-league baseball. Previous operations on the elbow decreased the chance of returning to the previous level of sports participation (p = 0.04). Fifteen patients had postoperative ulnar neuropathy. This was transient in six patients, only one of whom was unable to return to the previous level of sport. The other nine patients had an additional operation for the neuropathy; four were able to return to the previous level of sport.
Article
Golf is a different sport from all others discussed in this issue in one important aspect: Almost all of its practitioners play more, rather than less, as they mature. A great many of them play better, too. This additional play and skill can be highly satisfying to the participants; however, it puts them at risk for a number of overuse syndromes directly caused by the motion requirements of golf. In addition, the repetitive nature of the activity can exacerbate pre-existing and age-related orthopedic pathology as well. There is no substitute for attention to the preplay aspects of golf (warm-up, flexibility, and strengthening).
Article
The stabilizing structures of the elbow that resist valgus stress were studied with a tracking device in a model simulating active motion and muscle activity. By varying the order of serial release of the medial collateral ligament complex and removal of the radial head, each structure's contribution to valgus stability against the effect of gravity was determined. In the otherwise intact elbow, absence of the radial head does not significantly alter the three-dimensional characteristics of motion in the elbow joint. Isolated medial collateral release, on the other hand, causes increases in abduction rotation of about 6 degrees-8 degrees in magnitude. Releasing both structures results in gross abduction laxity and elbow subluxation. This study defines the medial collateral ligament (MCL) as the primary constraint of the elbow joint to valgus stress and the radial head as a secondary constraint. This definition facilitates the proper management of patients with radial head fractures and MCL disruption. The comminuted radial head fracture uncomplicated by MCL insufficiency should be treated by excision without the need for an implant and without concern of altering the normal kinematics of the elbow.
Article
The anatomy of the cubital tunnel and its relationship to ulnar nerve compression is not well documented. In 27 cadaver elbows the proximal edge of the roof of the cubital tunnel was formed by a fibrous band that we call the cubital tunnel retinaculum (CTR). The band is about 4 mm wide, extending from the medial epicondyle to the olecranon, and perpendicular to the flexor carpi ulnaris aponeurosis. Variations in the CTR were classified into four types. In type 0 (n = 1) the CTR was absent. In type Ia (n = 17), the retinaculum was lax in extension and taut in full flexion. In type Ib (n = 6) it was tight in positions short of full flexion (90 degrees to 120 degrees). In type II (n = 3) it was replaced by a muscle, the anconeus epitrochlearis. The CTR appears to be a remnant of the anconeus epitrochlearis muscle and its function is to hold the ulnar nerve in position. Variations in the anatomy of the CTR may explain certain types of ulnar neuropathy. Its absence (type 0 CTR) permits ulnar nerve displacement. Type Ia is normal and does not cause ulnar neuropathy. Type Ib can cause dynamic nerve compression with elbow flexion. Type II may be associated with static compression due to the bulk of the anconeus epitrochlearis muscle.
Article
The term "tennis elbow" has been used in the medical literature for over 100 years to describe a variety of conditions on the lateral aspect of the elbow. Recent writers seem to agree that the two most common causes for this condition, which may be either distinct or coexisting, are lateral epicondylitis and radial tunnel syndrome. Lateral epicondylitis is not limited to tennis players; 95% of the reported cases occur in non-players. The presenting symptoms are pain over the origin of the extensor carpi radialis brevis and weakness in the wrist and digital extensors. The location of maximal tenderness differentiates lateral epicondylitis from other conditions. A variety of treatments has been suggested, but the most successful is conservative treatment with rest, restriction of lifting with the palms down, anti-inflammatories and local applications of ice. Once the acute inflammatory phase has passed, a flexibility and strengthening program is recommended. Steroid injection may be utilized at this stage if the discomfort has not been reduced. In a small percentage of cases, surgery may be required.
Article
Ten cases of osteochondritis dissecans of the humeral capitellum are reviewed in seven high-performance female gymnasts, ranging in age from 10 to 17 years old. All but one were evaluated and treated with arthroscopy and/or arthrotomy, with curettage of loose articular margins, drilling of the lesion, and removal of loose bodies. The average length of follow-up is 2.9 years, and includes interview, physical examination, and roentgenographic evaluation. This injury has been previously described in relation to compressive forces across the radiocapitellar joint from repetitive valgus loading in a developing epiphysis. Only one of the athletes, at the time of follow-up, was still in competitive gymnastics. Each has a minimal limitation in range of motion, with crepitus and often catching noted by history and on examination. These cases double the limited literature on this injury in young, female gymnasts. They stimulate concern for the proper and early evaluation and treatment of elbow injuries in this at risk group. Once the bony changes in the capitellum are detected, and pain remains despite conservative management, we have found that symptoms can be improved with surgery, but persist in female gymnasts. Our experience in this more-advanced group is that the return to high-level competitive gymnastics is unlikely.
Article
Muscle activity about the elbow during tennis strokes in nine professional and collegiate level players was studied using indwelling EMG and high speed photog raphy. Eight muscles were evaluated for the serve, forehand, and backhand strokes. The serve was di vided into six stages and the ground strokes into four stages. EMG tracings were subjected to analog-to- digital conversion and a relative measure of quantity was obtained. Analysis of variance and Tukey tests were then done to assess statistical significance (P < 0.05). The ground strokes showed low activity in all muscles tested during the preparation phase. During the accel eration phase, both the backhand and forehand showed a generalized increase in all muscle activity. Both strokes showed marked activity of the wrist extensors and, in addition, the forehand showed high activity in the brachialis and biceps. In the follow-through phase, there was a generalized decrease in muscle activity. The serve showed low activity in all muscles tested during the wind-up phase. The wrist extensors in creased their activity in the cocking phase, with marked activity in late cocking. The pronator teres and the triceps showed increased activity in the acceleration phase. Follow-through phase showed low muscle activ ity except for the biceps, which increased in late follow- through. In conclusion, the muscles of the elbow help stabilize the elbow as a unit during the ground strokes in these high level players. Power in the serve comes from increased activity in the triceps and pronator teres. The predominant activity of the wrist extensors in all strokes may be one explanation for predisposition to injury.
Article
This article enumerates and examines the existing epidemiologic data on racquet sports injuries. A framework is provided for the evaluation and interpretation of future studies and research.
Article
Rupture of the distal insertion of the biceps brachii tendon is a rare injury. There has been no unanimity in the literature concerning the best method of repair. Between March 1981 and July 1984, 14 ruptures (12 acute and two late) were repaired using a modification of the Boyd-Anderson technique. Cybex testing of the elbow flexion by applying an eccentric load demonstrated that strength and endurance in the repaired dominant arm were roughly equal to the noninjured, nondominant arm, but that strength and endurance of the repaired nondominant arm were only 64% and 50%, respectively, of the noninjured dominant arm. Surgical repair is a safe procedure that yields consistently good results.
Article
The valgus stabilizers of the elbow have been identified anatomically, but their relative importance has not been quantified. The purpose of this study was to analyze the acute changes of the torque-displacement curve to valgus stress following (a) section of the posterior portion of the medial collateral ligament; (b) excision of the radial head; (c) prosthetic replacement of the radial head; and (d) excision of the anterior portion of the medical collateral ligament. Thirty cadaver specimens underwent load-displacement testing in three positions: 0 degrees, 45 degrees, and 90 degrees of flexion. The anterior portion of the medial collateral ligament was the primary stabilizer of the elbow to valgus stress. The relative contribution of the posterior ligament was minimal. After excision of the radial head alone, the slope of the load-displacement curve decreased an average of 30%. Silicone rubber radial head replacement did not significantly improve the stability to valgus stress after radial head excision.
Article
Our epidemiological study investigated lateral epicondylitis (tennis elbow) among 150 nonprofessional male tennis players (75% of the players approached consecutively) interviewed and examined physically at four local tennis clubs. The interview and examination covered over sixty possible risk factors, including demographic data, playing habits, anatomical measurements and racket characteristics. The "average" painfree player is 38 years old, has played tennis 11 years, and plays 5.5 hours a week, usually with a racket whose head area is 570 cm2. The "average" tennis elbow sufferer is a 45-year-old player who has been playing 16 years and has played 8 hours weekly before onset of pain with a racket whose head area is 613 cm2. Multivariate analysis indicated that number of playing years has no independent effect beyond its association with age. Playing hours per week, current age and age at pain onset have independent significant effects on number of pain episodes (0-7). Weekly number of playing hours is the best predictor of pain category (none, one or more currently or in the past).
Article
This article deals with soft-tissue injuries of the upper extremity incurred by competitive athletes. The authors describe the pathophysiology, conservative and operative management of musculotendinous elbow injuries, entrapment neuropathy, tendinous disorders, vascular injuries, and dermatologic conditions in athletes. Protective gear for many of the aforementioned injuries are also described.
Article
The most common elbow injuries include lateral and medial tennis elbow tendinitis, ulnar nerve dysfunction, and medial ligament sprain. Treatment includes proper rehabilitation and control of abuse. Surgery, when indicated, is directed to the correction of specific pathologic tissue change without harm to adjacent normal tissue.
Article
An end-result study was made of 16 cases of avulsion of the insertion of the biceps brachii tendon. The follow-up period spanned one to 25 years post-treatment (average, eight years). Fourteen of the 16 cases included in the study were acute cases with primary repair and reinsertion of the biceps tendon into the area of the radial tuberosity. One case, with the loss of function of the biceps muscle secondary to temporary paralysis of the musculocutaneous nerve, was explored. The tendon was found intact and did not require repair. The sixteenth case was included for comparison of a patient who chose to forgo surgical treatment. One surgical procedure, a modification of Bunnell's technique, was used in treating all patients from 1954 to 1977. The surgically repaired biceps showed various amounts of residual impairment, ranging from negligible to limited restriction of preinjury activities. The treatment successfully returned 14 patients to their previous occupations and activities. The one case not surgically treated of the ten work-related injuries resulted in continuing disability compensation based on no greater than 20% of the entire extremity. This end-result study substantiates the positive results of this surgical technique, presents modifications of the surgical repair procedures, and allows for a similar long-range study of other treatment techniques. The evaluation of treatment methods is easily attainable by low technological clinical methods.
Article
We did Cybex testing of thirteen patients who had had a rupture of the distal tendon of the biceps brachii. The tests were performed fifteen months to six years after injury. The ten patients who had had a surgical repair through the two-incision technique showed a return to normal levels of strength and endurance with regard to both flexion of the elbow and supination of the forearm. The three patients who had had conservative treatment showed a remaining deficit in those parameters which was clinically evident in several activities, such as use of a screwdriver or baseball bat.
Article
In a series of 1,000 patients with tennis or medial or lateral epicondylitis, adequate follow up was obtained on 339 patients. Of these, 278 responded to conservative therapy and 39 were operated on. Tears of the extensor or flexor tendon were seen in 28 patients. Resection of the torn or scarred portion of the tendon and suture, if feasible, gave generally satisfactory results.
Article
1. The throwing act may be associated with clinically significant symptoms and pathologic joint changes. 2. Insight into some of these lesions may be gained by an understanding of the basic act of throwing. 3. Two basic pathologic mechanisms seem apparent within the pitching act. 4. Violent rotational forces are present on the shoulder and proximal humerus as the arm is whipped from extreme external humeral rotation and internal rotation. 5. Medial elbow stress develops secondary to the valgus stress of the pitching act and may result in permanent joint changes.