ArticleLiterature Review

Common Elbow Injuries in Sport

Authors:
  • Mississippi Sports Medicine and Orthopaedic Center
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Abstract

Athletes of all ages and skill levels are increasingly participating in sports involving overhead arm motions, making elbow injuries more common. Among these injuries is lateral epicondylitis, which occurs in over 50% of athletes using overhead arm motions. Lateral epicondylitis is characterised by pain in the area where the common extensor muscles meet the lateral humeral epicondyle. The onset of this pathological condition begins with the excessive use of the wrist extensor musculature. Repetitive microtraumatic injury can lead to mucinoid degeneration of the extensor origin and subsequent failure of the tendon. Lateral epicondylitis can almost always be treated nonoperatively with activity modification and specific exercises. If the athlete fails to respond to nonoperative treatment after 6 months to 1 year, they are candidates for surgical intervention. Medial epicondylitis is characterised by pain and tenderness at the flexorpronator tendinous origin with pathology commonly being located at the interface between the pronator teres and flexor carpi radialis origin. Golfers and tennis players often develop this condition because of the repetitive valgus stress placed on the medial elbow soft tissues. Careful evaluation is important to differentiate medial epicondylitis from other causes of medial elbow pain. As with lateral epicondylitis, patients with medial epicondylitis not responding to an extensive nonoperative programme are candidates for surgical intervention. A less common cause of medial elbow pain is medial ulnar collateral ligament injury. Repetitive valgus stress placed on the joint can lead to microtraumatic injury and valgus instability. When the medial ulnar collateral ligament is disrupted, abnormal stress is placed on the articular surfaces that can lead to degenerative changes with osteophyte formation. As with other elbow injuries, a strict rehabilitation regimen is first employed; ligament reconstruction is only recommended if the injury fails to improve and only in athletes requiring a high level of performance. Excessive valgus stress can also lead to posteromedial olecranon impingement on the olecranon fossa producing pain, osteophyte and loose body formation. Arthroscopic elbow debridement can often be helpful in improving motion and in reducing pain in such patients.

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... Upper extremity insults caused by single stress or by repetitive microtrauma occur in a large variety of sport or professional activities [1,21,22,32,24,3]. Among these injuries, lateral epicondylitis could result from excessive use of the wrist extensor and forearm supinator muscles [14,27,7,12,13]. ...
... Recent studies have investigated distal muscles of the upper limb, particularly forearm and wrist muscles [15,16,18,23,26]. Some pathologies which result from sport activities and specific professional occupations involve these muscles [32,12,13,3]. In our Center, we are specifically challenged with patients suffering from chronic epicondylitis [14,7]. ...
... Incidentally we assume that, in a population practicing sports activity, this eccentric ratio could be quite different with regard to the specific activity [13,3]. ...
... These forces can lead to damage to the ulnar collateral ligament, pain disorders and chronic inflammatory. The summit of the medial epicondyle of the humerus can suffer medial epicondylitis [16] due to the constant pulling by the ulnar collateral ligament and the bending muscles. These symptoms are similar to the ones described by tennis players and golfers [16]. ...
... The summit of the medial epicondyle of the humerus can suffer medial epicondylitis [16] due to the constant pulling by the ulnar collateral ligament and the bending muscles. These symptoms are similar to the ones described by tennis players and golfers [16]. Our judokas expressed 82.52 and 85.02 degrees (expert 1 and 2 respectively), at the left elbow flexion performing uchi-mata and the next anatomical movement to finish the execution of the throw is an explosive extension of the arm that holds the uke´s sleeve. ...
... Se define epicondilitis crónica (o epicondilosis) como la persistencia del dolor mayor a 6 meses, o mantener por un tiempo mayor a 6 meses episo-Revisión de epicondilitis: clínica, estudio y propuesta de protocolo de tratamiento Ana Luisa Miranda M. (1) , natalia Llanos V. (1) , Carlos Torres B. (1) , Constanza Montenegro S. (1) , Catalina Jiménez (2) . (3) . Osgood y hughes señalaron la inflamación de la bolsa serosa extraarticular como el mecanismo causal de las molestias. ...
... Suele ser unilateral y tiene un curso clínico autolimitado con evolución cíclica. Las molestias suelen desaparecer a los 12 meses independientemente del tratamiento realizado (3,10) . ...
... These forces can lead to damage to the ulnar collateral ligament, pain disorders and chronic inflammatory. The summit of the medial epicondyle of the humerus can suffer medial epicondylitis [16] due to the constant pulling by the ulnar collateral ligament and the bending muscles. These symptoms are similar to the ones described by tennis players and golfers [16]. ...
... The summit of the medial epicondyle of the humerus can suffer medial epicondylitis [16] due to the constant pulling by the ulnar collateral ligament and the bending muscles. These symptoms are similar to the ones described by tennis players and golfers [16]. Our judokas expressed 82.52 and 85.02 degrees (expert 1 and 2 respectively), at the left elbow flexion performing uchi-mata and the next anatomical movement to finish the execution of the throw is an explosive extension of the arm that holds the uke´s sleeve. ...
Article
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Background Although the judo throwing techniques are not considered as injurious to the attacker, repetition of these techniques might cause repetitive strain type injuries. The goal of the study was knowledge about the degrees of flexion and extension and abduction and adduction of the main locomotive joints, performing the most employed throwing techniques in high-level competition. Material & Methods: Two world-class judoists, under the supervision of an elite Japanese expert, performed seoi-nage, uchi-mata, osoto-gari, ouchi-gari and kouchi-gari. They were analysed using three-dimensional technology. Results: Data of performance throws obtained from expert 1 and 2 respectively were very similar. Results indicate that systematic repetition of seoi-nage, uchi-mata and o-soto-gari can produce shoulder tendon pathologies. Longterm seoi-nage and uchi-mata practice might generate epicondylitis. Judokas who have suffered anterior cruciate ligament injuries must be careful when executing techniques that demand explosive knee extension (i.e. seoi-nage) against a great resistance. Judokas are not exposed to overuse injuries when they perform ouchigari and kouchi-gari throws. Conclusions: Systematic practice of the most employed judo throwing techniques in high-level judo can cause injuries by overuse in the upper-body joints (shoulder, elbow). Nevertheless, the lower-body joints (knee, ankle) do not seem to be at risk of injury by overuse.
... Elbow pain is commonly observed in athletes who perform frequent overhead arm motions, exert excessive stress to the elbow [1,2], and those who perform repeated forearm movements [3,4]. Common elbow pathologies result from inflammation or injury to the bones and para-articular structures [5]. ...
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.
... Entrapment of the posterior interosseus nerve, "radial tunnel syndrome", goes with pain on palpation of the site for entrapment (most often in the Frohse's arcade), and pain induced by resisted extension of the middle finger and resisted supination (Lawrence et al., 1995). Differentiation between TE and radial tunnel syndrome is primarily based on the character and location of the pain, and the site for maximal tenderness (Field and Savoie, 1998). It is relatively common that these two conditions, TE and radial tunnel syndrome, exist in conjunction. ...
... During the shot put delivery, wrist extension is the last motion in the kinetic chain of events and imposes a large amount of stress on the wrist joint (Judge & Bellar, 2012;Judge & Young, 2011). Excessive use of the wrist extensors can contribute to the onset of lateral epicondylitis, and this condition is reported to occur in approximately 50% of overhead throwing athletes (Field & Savoie, 1998). In addition to the ergogenic effect of helping to control the degrees of freedom in the final segment of the kinetic chain (Latash, 2010(Latash, , 2012Newell & Vaillancourt, 2001;Enoka, 2008), the restricted joint motion imposed by wrist wraps likely helps the thrower to better direct the application of force in the dominant arm at the desired release angle, and it may also conceivably reduce strain on the connective tissues in the wrist region during the shot put delivery (Su et al., 2005;Burgess et al., 2008;Currier & Nelson, 1992). ...
Article
Shot put throwing distances of 18 male Division I track and field athletes in the United States were compared among three wrist wrap conditions: 1) a large heavy wrist wrap, typically worn by athletes competing in the shot put event, 2) a small light wrist wrap and 3) no wrist wrap. The average and maximum throwing distances when the athletes were wearing the heavy wrist wrap (12.31 ± 1.699maximum; 11.92 ± 1.627average) were greater than when the athletes were not wearing a wrist wrap (12.05 ± 1.550maximum; 11.70 ± 1.457average). Performance increases exceeded criteria for the smallest worthwhile improvements in the shot put event, suggesting that heavy wrist wraps provide a competitive advantage. These results revealed previously undocumented, beneficial effects of taping and bracing on sports performance in the shot put throw.
... Being related to repetitive movements and overuse, the location of such injuries is sport specific. Patellar tendinopathies, for instance, are often associated with jumping sports such as basketball, volleyball and high jump, [51] while tennis players and golfers are more prone to medial and lateral epicondyli- tis. [52] The use of PRP in this context might be focused on restoring the normal tissue composition while avoiding further degeneration. In these conditions, ultrasound-guided PRP injection may offer an alternative treatment over palliative or operative treatments. ...
Article
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Objective: To show an approach to profit of the main components of platelet rich plasma (PRP), i.e. the signaling proteins, and the fibrin scaffold and discuss the intervention within TIME (Tissue, Inflammation/Infection, Moisture, Edges) framework. Methods: Two patients with diabetic foot ulcers are treated with both liquid and gelled PRP, and the rationale for the PRP intervention is described herein. Autologous blood is withdrawn and, PRP is separated by single spinning and activated with CaCl2 prior to application. PRP is injected in an activated liquid form, i.e. freshly activated, before coagulation, within the wound edges. In fibrotic tissue PRP is introduced performing a needling procedure. In addition, PRP, clotted ex-vivo, is applied in the wound bed as a primary dressing. Results: Both patients responded positively to PRP intervention. Case 1 healed after five weekly PRP applications. Case 2 healed after eight weekly PRP applications. Patient satisfaction was high in both cases. The procedure had no complications, is well tolerated and easy to perform in any medical setting. Conclusion: PRP intervention is safe and if associated with correct tissue debridement and preparation of the host tissue it may help to decrease the burden of diabetic foot ulcers. Carefully designed randomized clinical trials with special attention to the PRP procedure are needed to assess the efficacy of these interventions.
... This overuse syndrome is associated with repetitive and/or forceful hand tasks and typically affects the dominant arm. Prevalence of LE increases to more than 50 % in tennis players, a population that uses regular repetitive hand functions [2]. The diagnosis is made clinically through history and physical examination [3]. ...
Article
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The objective of this study was to investigate the role of real-time sonoelastography (RTSE) in patients with lateral epicondylitis (LE) and whether it is associated with clinical parameters. Seventeen patients with unilateral LE were enrolled in the study. The healthy elbows of the participants constituted the control group. Using B-mode ultrasound, color Doppler ultrasound, and RTSE, we prospectively examined 34 common extensor tendon elbows of 17 patients. Both color scales and strain ratio were used for evaluating RTSE images. Two radiologists evaluated the RTSE images separately. Elbow pain was scored on a 100-mm visual analog scale (VAS). Symptom duration and the presence of nocturnal pain were questioned. Quick disabilities of arm shoulder and hand (DASH) Questionnaire was applied to assess the pain, function, and disability. Nottingham health profile (NHP) was used to determine and quantify perceived health problems. Both color scales and strain ratios of the affected tendon portions were significantly different from that of healthy tendons (p < 0.001). There was no significant association between NHP, VAS, Quick DASH scores, and color scales and strain ratio. Strain ratio of the medial portion of the affected tendon was significantly correlated with symptom duration (rho = -0.61 p = 0.010) and nocturnal pain (rho = 0.522 p = 0.031). Interobserver agreement was substantial for color scales (κ = 0.74, p = 0.001) and strain ratio (ICC = 0.61, p = 0.031). RTSE may facilitate differentiation between healthy and affected elbows as a feasible and practical supplementary method with substantial interobserver agreement. RTSE was superior to B-mode ultrasound and color Doppler ultrasound in discriminating tendons with LE. Strain ratio of the medial portion of the tendon is associated moderately with nocturnal pain and symptom duration. No other associations were present between RTSE findings and clinical or functional parameters.
... Nevertheless, clinicians and researchers are becoming increasingly interested in isokinetic assessment and exercise of upper extremity joints as the shoulder and the elbow [15][16][17][18][19] . Recent studies have investigated distal muscles of the upper limb, particularly forearm and wrist muscles 15,17,[19][20][21] . Some pathology which results from sport activities and speciic professional occupations involve these muscles 3,12,13,32 . ...
Article
The purpose of this study was to norm-referenced criteria of upper limb for Korean middle school baseball player. Ninety five male middle school students with age ranging 14 to 15 years were participated in this study. They didn't have any medical problem. HUMAC NORM (Stoughton, MA, USA) equipment system was used to obtain the values of peak torque, peak torque to body weight ratio. The results were presented as a norm-referenced criterion value using 5-point scale, by 5 groups (5 percent, 15 percent, 60 percent, 15 percent and 5 percent) and a few suggestions from this study as follows; • For the evaluation of strength, peak torque % body weights more than peak torque appeared to be more valuable information. • The provided criterion of peak torque % body weights are very information for baseball coach, athletic trainer, baseball player, sports injury rehabilitation specialists.
... Evidence from previous research has identified that chronic elbow injuries typically stem from overuse and abduction (valgus) stress (Hume, Reid, & Edwards, 2006). Furthermore, repetitive abduction (valgus) stress placed on the joint can lead to microtraumatic injury and valgus instability (Field & Savoie, 1998). Specifically, in terms of the aetiology of injury, Grana (2001) stated that repeated valgus (abduction) loading may increase the occurrence of medial epicondylitis. ...
Article
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Chronic elbow injuries from tumbling in female gymnastics present a serious problem for performers. This research examined how the biomechanical characteristics of impact loading and elbow kinematics and kinetics change as a function of technique selection. Seven international-level female gymnasts performed 10 trials of the round-off from a hurdle step to flic-flac with ‘parallel’ and ‘T-shape’ hand positions. Synchronized kinematic (3D-automated motion analysis system; 247 Hz) and kinetic (two force plates; 1,235 Hz) data were collected for each trial. Wilcoxon non-parametric test and effect-size statistics determined differences between the hand positions examined in this study. Significant differences (p 0.8) were observed for peak vertical ground reaction force (GRF), anterior–posterior GRF, resultant GRF, loading rates of these forces and elbow joint angles, and internal moments of force in sagittal, transverse, and frontal planes. In conclusion, the T-shape hand position reduces vertical, anterior–posterior, and resultant contact forces and has a decreased loading rate indicating a safer technique for the round-off. Significant differences observed in joint elbow moments highlighted that the T-shape position may prevent overloading of the joint complex and consequently reduce the potential for elbow injury.
... It commonly occurs at the origin of the extensor carpi radialis brevis muscle and less commonly at the 4 other extensors, with eventual brous adherence to the capsule . Lateral epicondylitis is often referred to as tennis elbow due to its common occurrence in tennis players, but in fact any sports or activity that requires gripping can cause this problem including [5][6] hammering and gardening. ...
Article
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Objectives: To study the effectiveness of steroid injection in early management of lateral epicondylitis. Study population: One hundred and twenty Patients presenting with unilateral lateral epicondylitis of less than two weeks duration reporting at Outpatient Department in department of Physical Medicine & Rehabilitation, AIIMS Patna, and Study Design: Prospective comparative study, for Period of 01 year, Results: There were 54(45 %) males and 66(55%) females. At one month and three months follow up assessments, there was signicant improvement in VAS Score and pain free grip strength in the Group A (steroids) as compared to Group B (NSAIDs), Conclusion: Local steroid injection is an effective treatment with an advantage of better relief of symptoms, which is sustained over a period of three months.
... Despite a relatively simple clinical diagnosis of lateral elbow pain that is provoked by palpation, resisted wrist and finger extension and gripping activities, LET has a multifactorial pathophysiology, including common extensor tendon pathology and sensory and motor system impairments [1]. LET is reported to affect 1-3% of the general population [2], 15% of workers in manual occupations [3], and over 50% of athletes in sports with repetitive overhead arm movements [4]. Evidence suggests that only half of individuals with LET consult a healthcare professional [5], implying that other modes and/or sources of evidence-based health-related information are required. ...
Article
Background Better access to evidence-based health information via mobile health apps could assist in information sharing, screening for severity/triage, and improving early intervention for individuals with lateral elbow tendinopathy (LET). Objectives To use a systematic review framework to identify and appraise the utility and quality of mobile health apps for the management of individuals with LET. Methods Apple iTunes and Google Play stores were searched using key words. Mobile health apps providing information related to the signs and symptoms, pathophysiology, and management of LET were included. The quality of the included apps was appraised by two reviewers using using the Mobile Application Rating Scale (MARS). Narrative synthesis was used to describe the key information from the included apps and compare the information presented to that of current evidence-based practice. Major Findings Seven mobile health apps were included in this review. The mean score for the MARS quality appraisal was 2.5 out of 5 (range 2.0–4.2), with apps scoring poorly in engagement, information, and the subjective scoring subsections. No apps were validated or used as a part of a clinical trial. Of the 37 individually recommended interventions only eight (22%) were supported by empirical evidence. No apps screened individuals for condition severity or used patient inputted data for individualisation of information. Conclusion A majority of currently available health apps for LET lack empirical evidence to support the information they provide. Future apps could include a data collection and screening process to help guide appropriate management.
... When athletes throw repeatedly at high velocity, repetitive stress can lead to a wide range of overuse injuries, including most commonly that of the UCL. 14,22 The UCL is located medially on the elbow and consists of three bundles: anterior, posterior, and transverse ( Figure 1). [23][24][25][26][27] The anterior bundle serves as the primary restraint to valgus stress during the overhead throwing motion and inserts on a broad footprint on the sublime tubercle of the ulna ( Figure 1). ...
Article
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With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7-33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete's stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.
Article
Aim. The aim of this paper is to analyze a homogeneous group of adults suffering from lateral epicondylitis of the elbow (or tennis elbow) and compare the results of two local physiotherapies; classic Transcutaneous Electrical Nerve Stimulation (TENS) and Nd:YAG High Intensity Laser Therapy (HILT); the latter has recently been employed in Physical Therapy. Methods. We selected 42 patients who had been suffering from the disease for no less that one month and no more that three months. The patients were questioned about their sports and work activity; sonographic evaluation was performed to check local calcification and seven clinical tests were performed to quantify pain and functional lesions in five follow-ups, the first before treatment and the last six months after. Results. The results showed that there was no unequivocal etiology: the disease was present in all patient categories, not only athletes, hard workers and workers who used repetitive forearm rotation but in sedentary patients and in retired people too. These data seem to support the degenerative nature of the disease and several mechanical causal factors might contribute. Conclusion. With regards to the efficacy of the two therapies employed, TENS and LASER both led to a significant pain reduction in the 14 days after treatment, but in the other follow-ups laser HILT induced a higher and more lasting analgesic effect than TENS and above all, an improvement in function recovery. Finally, side effects related to the two physiotherapies were sparse and lasted for only a short time.
Article
Objective. To establish the inter-session reproducibility of isokinetic concentric strength and fatigue profile of the elbow flexors and extensors in sedentary women. Methods. Forty healthy women who were physically inactive or engaged in recreational sports were included in the study. Strength was evaluated at 60 and 180°/s. The fatigue protocol consisted of 30 maximal-intensity elbow flexion and extension at 180°/s. Results. The extensors were stronger than flexors while no dominance effect was apparent. In addition the work output of the extensors during the fatigue protocol was larger than the flexors', the previous being more fatigue resistant. A dominance effect was observed for the extensors in the fatiguing protocol. Reproducibility expressed by the coefficient of variation was less or equal to 11%. Conclusions. This study highlights satisfactory reproducibility of isokinetic strength and fatigue parameters. The values derived may be useful for interpretation of clinical tests or characterization of pathological states in women with similar characteristics.
Article
The round-off is a fundamental gymnastics skill and a key movement in the development of elite female gymnasts. The aim of this study was to determine whether differences in hand position during the round-off may influence the ground reaction forces and elbow joint moments in female artistic gymnastics. One international level active female gymnast from the Czech Republic participated in this study. Two force plates were used to determine ground reaction forces. A motion-capture system consisting of eight infrared cameras were employed to collect the kinematic data. The gymnast performed 10 trials of a round-off from a hurdle step to back handspring with a "parallel" hand position and 10 trials with a "T" shape hand position. Effect size statistics were used to establish differences in means. In conclusion "T" position of the second hand reduces vertical and anterior-posterior ground reaction forces. Differences in joint elbow moments and elbow kinematics indicated that the "T" position may prevent elbow joint complex and reduces potential of elbow injuries.
Article
This study determines the effects of increasing forces on different musculoskeletal load parameters, such as muscle activity and joint movement, during assembly task‐related dynamic hand strikes and isometric push forces. Fifteen subjects (12 men and 3 women) were instructed to strike and push on a force plate in two selected conditions. In the first condition, the palmar surface of the dominant hand is oriented horizontal to the measuring surface; in the second condition, the body position is maintained, but the hand is turned 90° to allow the use of the ulnar side of the hand (fist strike position). The subjects accomplished four force levels in ascending order (i.e., 150, 250, 350, and 400 N) within the corresponding striking and pushing conditions. The extracted kinematic variables of interest were strike velocity, recoil velocity, force plate contact time, peak vertical reaction force component (force plate), force impulse, muscle activity, and maximum joint ranges of motion during the push or strike process. Differences in the results between pushes and strikes and, under certain circumstances, between fist and palm strikes were identified. Increasing push forces correlate with the muscle activity in the pectoralis and lower arm extensor muscles. The fact that, at push forces > 250 N, the subjects modify and adapt their upper body and arm posture to achieve the required force could reveal an obvious feasibility limit and explain why assembly workers tend to use their hands as a hammer.
Article
Background The aim of the present study was to examine whether the primary stability of the medial ulnar collateral elbow ligament (UCL) of a double-bundle technique with anatomic drill hole position is superior to a non-anatomical position or a single-bundle technique. Materials and methods Ten fresh-frozen upper extremities (mean age 76 years (range 58–89)) were mounted in the testing apparatus. First, the valgus-stability with intact medial UCL was tested in 120, 90, 60, 30 and 0 ° of flexion with a continuously increasing load to 7.5 Nm. Afterwards the pronator was split and the anterior bundle of the medial UCL cut, followed by a new sequential testing. Ulnar drill holes were installed hereafter, both in an anatomical and non-anatomical position. Tendon grafts were placed to simulate two double bundle (double bundle 1 = drill hole anatomical position; double bundle 2 = drill hole extra-anatomical) and one single bundle reconstruction. Sequential testing was done of each reconstruction. Statistical analysis was performed by means of a variance analysis per Scheffe’s post hoc technique. Results In a valgus stress of 7.5 Nm, mean valgus deformation in an intact MUCL at 90° elbow flexion was 7.4 ± 2.4 ° and at full extension 7.4 ± 2.6 °. A significant increase in valgus instability was observed (p < 0.001) after section of the anterior bundle. The double-bundle and single-bundle reconstructions showed significant stabilization over the range of motion compared to the dissected medial UCL. There was no significant difference between the three reconstruction techniques. Conclusion In this biomechanical study, the single-bundle reconstruction proved equal to the double-bundle technique. Both techniques showed a sufficient stabilization against valgus stress.
The use of platelet-rich plasma (PRP) in sports medicine is a recently developed technique in which concentrated autologous blood is used to increase the healing rate of various tissues. PRP has been most extensively used in the treatment of different musculoskeletal disorders, particularly in athletic injuries. Owing to its apparent safety and ease of preparation and administration, there has been an increased interest in the efficacy of PRP in a large number of different clinical settings. PRP has been used to treat conditions such as lateral epicondylitis, ligamentous strains, muscular strains, and fracture nonunion in athletes. PRP can be injected to the site of the pathology, either during surgery or in the physician's office. The benefits of PRP in the clinical field appear to be promising, and many investigators are still exploring new ways to use this therapy effectively. However, the clinical evidence for the benefits of PRP in the field of sports medicine is unclear. The purpose of this article was to review the current evidence on PRP therapy in this field.
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Epicondylar injuries in sports with overhead or repetitive arm actions are frequent and often severe. Acute injury that results in inflammation should be termed epicondylitis and is usually the result of large valgus forces with medial distraction and lateral compression. Epicondylosis develops over a longer period of time from repetitive forces and results in structural changes in the tendon. Epicondylalgia refers to elbow pain at either the medial or lateral epicondyl of the elbow related to tendinopathy of the common flexor or extensor tendon origins at these points. Pain is usually associated with gripping, resisted wrist extension and certain movements such as in tennis and golf, hence the common terms ‘tennis elbow’ (lateral epicondylsis) and ‘golf elbow’ (medial epicondylossi). A variety of assessment and diagnostic tools are available to aid the clinician in their comprehensive evaluation of the patient to ensure correct diagnosis and the appropriate conservative or surgical management strategy. Corticosteroids and elbow straps are often used for treatment; however, there is only very limited prospective clinical or experimental evidence for their effectiveness. The most effective modalities of treatment are probably rest (the absence of painful activity) combined with cryotherapy in the acute stage then NSAIDs and heat in its various modalities including ultrasound. Cortisone injections may be used to create a pain-free window of opportunity to optimise the athletes’ rehabilitation exercises. Medical practitioners should have a good understanding of the mechanisms of injury in order to help treat and prevent the re-occurrence of injuries. More emphasis by medical and sport science personnel working with coaches and athletes needs to be placed on prevention of elbow injury in sport through improved joint strength, biomechanically sound sport technique and use of appropriate sport equipment.
Tennis elbow or lateral epicondylitis is a common condition that causes pain at the elbow during gripping and lifting activities. Tennis elbow is self-limiting, but may greatly interfere with people’s ability to participate in sports, recreational activities, or activities of daily living. This article will discuss the etiology, current conservative treatment options, surgical options, and provide rehabilitation guidelines for both conservative and surgical management of tennis elbow.
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Tennis elbow is one of the most common clinical problems. This disorder is still very much debated, because of the fact that with today´s knowledge the management is still not optimal and takes a long time. It is generally agreed that the problem arises from tendinopathy in the tendon to the extensor carpi radialis brevis muscle insertion area. The diagnosis is rather easy, although there are some other differential diagnostic options. The treatment is based on a progressive controlled exercise program which is the key to stimulate the biological healing response. The main part of this training program includes eccentric action and some stretching. Initially this exercise program needs supervision as it is difficult to dose correctly. Counterforce bracing has clinically some good effect. Among modalities acupuncture seems to be a possibility. Some people report good results with extracorporeal shock-wave therapy, but the scientific evidence is still not convincing. Cortisone injections are the last line of treatment and the effect is usually short lived. These injections should therefore be combined with some rest and gradually increased exercises. Surgery may be indicated in 5-10% of cases and consists of excision of the pathology in extensor carpi radialis brevis. The success rate is higher than 80%.
Article
Overuse injuries of the lateral and medial elbow are common in sport, recreational activities, and occupational endeavors. They are commonly diagnosed as lateral and medial epicondylitis; however, the pathophysiology of these disorders demonstrates a lack of inflammation. Instead, angiofibroblastic degeneration is present, referred to as tendinosis. As such, a more appropriate terminology for these conditions is epicondylosis. This is a clinical diagnosis, and further investigations are only performed to rule out other clinical entities after conventional therapy has failed. Yet, most patients respond to conservative measures with physical therapy and counterforce bracing. Corticosteroid injections are effective for short-term pain control but have not demonstrated long-term benefit.
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Athletic trainers and therapists encounter acute and chronic elbow injuries in a variety of environments. Careful and accurate differential assessment is imperative in formulating rehabilitation goals, developing treatment parameters, and providing proper referral. Follow-up diagnostic imaging will in most cases allow the physician to make a definitive diagnosis. Caution is urged when dealing with elbow injuries in the skeletally immature athlete.
Chapter
Many sports competitions involve the elbow joint. Throwing, pushing, opposing, and gripping are frequent in different sports. These activities can all lead to significant elbow stress. Acute traumas or repeated microtraumas can affect the joint surfaces, the capsular, ligaments, and muscles, damaging the elbow anatomy and affecting function. Medial elbow instability is a frequent lesion especially in baseball. Acute neurovascular lesions are very rare, while chronic neurovascular alterations are more common. Bony alterations due to repeated stress can cause the onset of clinical situations involving the elbow, such as bony hypertrophy, traction spurs, loose bodies, osteophytes, and osteochondral defects. These anatomical pictures involving the elbow joint basically determine the clinical picture of the degenerative stiff elbow. The arthroscopic technique has been developed in order to have a safe procedure. The use of safe portals and the arthroscopic retractors (developed by O’Driscoll) represent a high quality way to avoid complications till today.
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Please check the hierarchy of the section headings and correct if necessary.
Article
Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.
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The elbow, compared to the lower extremity and shoulder, is much less involved in sports injuries in general; however in specific sports it is nevertheless quite common (e.g., gymnastics). Acute injuries are relatively rare and most injuries are the result of overuse. From a biomechanical standpoint two major mechanisms are responsible for this. The first is the athlete who is involved in sports that require a large number of the same repetitive movements like in baseball, specifically in pitchers. The second mechanism is seen in athletes who basically use their arm as a weight-bearing limb like in gymnastics or weightlifting. All known imaging modalities are useful in elbow imaging each with their own merit. Plain films is almost always the first imaging modality used. The clinical situation and the findings on plain films direct the next step of imaging (if necessary). For the evaluation of the soft tissues ultrasound will usually suffice but if more information is needed, especially for the evaluation of the joint, MRI and CT both play important roles. It has to be emphasized that both have their own merits and that they often are complementary to each other.
Chapter
This chapter highlights the increasing prevalence of sports injuries and negative long-term effects on active players. It emphasized the importance of recognizing intrinsic and extrinsic factors responsible for the onset of injuries and their severity. Two factors should be considered for planning the training—individual variations among each person and gender. Physiological changes due to the aging process should also be taken into account. Prevention of sports injury starts with an analysis of all elements that might predict their development. A four-step prevention plan is suggested to minimize the negative consequences. Mechanisms of injuries specific to different sports are highlighted.
Chapter
This chapter introduces the kinesiology of the elbow joint both in normal and pathologic conditions. It starts by presenting a detailed anatomy and biomechanics of elbow joint. The forearm complex is also included in the chapter with its important pronation-supination movement and load transmission activity of interosseous membrane. The stability philosophy of elbow joint is explained, and the instability patterns are presented. The kinesiology of common disorders of elbow joint is comprehended as acute elbow trauma, sequela of elbow trauma, and elbow injuries in the athletes. To simplify understanding, the other disorders are classified as medial, lateral, posterior, and anterior elbow injuries. The pathomechanics of injuries and kinesiology during injured conditions are discussed in a clinical view.
Article
Repetitive microtrauma in the elbow from chronic overuse occurs in athletes and nonathletes. Although the diagnosis is often made clinically, imaging is helpful to confirm the diagnosis, grade the injury, and guide treatment. MR imaging is particularly helpful in evaluating overuse injuries in the elbow, as tendons, ligaments, and bones/cartilage can be assessed. Tendinopathy can be distinguished from partial- or full-thickness tears, and reactive changes in the bone marrow can be easily identified. This article focuses on the MR imaging appearance of overuse injuries of the elbow involving tendons, ligaments, and bones.
Article
BACKGROUND: Lateral epicondylitis (i.e., tennis elbow) is a condition caused by overuse of the arm, which can result in elbow pain. Recent evidence has shown wrist joint splinting as an effective intervention for people with lateral epicondylitis. AIM: The purpose of this study was to compare the effect of a 3 week wrist joint splinting and physical therapy intervention versus a standard physical therapy intervention on pain, wrist range of motion (ROM), and grip strength in people with lateral epicondylitis. DESIGN: Randomized clinical trial. SETTING: University hospital outpatient clinics. POPULATION: Forty participants diagnosed with lateral epicondylitis. METHODS: The participants were randomized into 2 groups. The standard care group followed a treatment program consisting of stretching exercises for the wrist extensors, ultrasonic therapy, and deep friction massage on the proximal attachment of the wrist extensor muscles. The intervention group followed a standard wrist joint splinting program in addition to the physical therapy program that the standard care group received. Participants in both groups received treatment 3 times per week for 3 weeks. The outcome measures were pain intensity, wrist extension ROM, wrist flexion ROM, and grip strength. Each outcome measure was assessed at baseline and after completion of the intervention. RESULTS: There were no significant between-group differences at baseline. After the treatment period, the intervention group showed statistically significant improvement in pain intensity. Other outcomes also improved including wrist flexion ROM, wrist extension ROM, and grip strength in comparison to the standard care group. CONCLUSIONS: Using wrist joint splinting in addition to physical therapy for a short duration is effective for improving pain intensity. The evidence from this study indicates that wrist joint splinting and physical therapy may also be effective for improving wrist ROM and grip strength in the treatment of patients with lateral epicondylitis, although more research is need in this area. CLINICAL REHABILITATION IMPACT: Wrist joint splinting is an effective intervention that can be applied in clinical rehabilitation practices for people with lateral epicondylitis.
Article
A growing number of workers in modern automotive assembly plants are confronted with occupational tasks involving repeated high‐impact hand strikes. Such repetitive physical workloads account for diseases of soft tissues or musculoskeletal disorders in the hand, wrist, or entire upper body. The purpose of this review was to identify and discuss the most pertinent occupational and physiological investigations concerning such hand strikes with particular emphasis on the biomechanical parameters examined. Articles were drawn from four databases to identify publications about occupational hand strikes. First, studies were selected that evaluated hand impact loads measured with the help of force measurement devices. For a deeper understanding of biomechanical factors regarding hand impacts, the scope of the search was extended to include ancillary studies about impacts on wrists or elbows. Overall, 945 abstracts were screened, and five full‐text articles were included in the final review. In addition, 34 ancillary articles about impact stress on the hand–arm complex were discussed because of positive relations between high forces, repetition rates or acceleration, and progressing stress in the hand–arm complex identified in studies about critical biomechanical load limits, in the field of fall arrests and sports, i.e. tennis. Furthermore, studies about effective arm movements and body postures during hand strikes as used in martial arts were reviewed. Although certain biomechanical parameters are both known and well documented, studies available at present cannot sufficiently account for specific disorders in the wrist or arm that are triggered by occupational hand strikes.
Chapter
Tennis players are frequently exposed to repetitive, sudden, and explosive stressors during competition, resulting in demands on their musculoskeletal system that are unique to the sport. During a tennis stroke, the elbow is subject to extraordinarily high loads and forces. Not surprisingly, then, it is believed that elbow symptoms and injuries occur in at least 40–50% of tennis players at some point in their career [1, 2]. First described by Runge in 1873, lateral epicondylitis, or “tennis elbow,” is the most common upper extremity diagnosis in recreational tennis players, with injury rates ranging from 75% to 85% of elbow injuries [3–6].
Article
Dieser Artikel gibt einen Überblick über die Normalanatomie und häufige Pathologien der Sehnen und Ligamente des Ellenbogens in der Magnetresonanztomographie (MRT). Neben der knöchernen Sicherung, insbesondere durch den großflächigen Formschluss der Gelenkpartner im humeroulnaren Gelenk, ist die Stabilisierung des Ellenbogengelenks abhängig von passiven ligamentären und aktiven muskulären Systemen. Mittels MRT können neben posttraumatischen Veränderungen wie Bandrupturen bei Sportlern oder Folgen von Ellbogenluxationen auch chronische Pathologien, z. B. muskuläre Reizzustände und Degenerationen, verlässlich diagnostiziert werden. Bei der Befundung ist eine Einteilung in sich funktionell ergänzender anatomischer Strukturen in Kompartimente sinnvoll. Dabei können ein anteriores, ein posteriores, ein mediales und ein laterales Kompartiment voneinander unterschieden werden.
Article
Objectives: To determine the true and immediate effect of applying Kinesio tape (KT) on the pain intensity, pain-free grip strength, maximal grip strength, and electromyographic activity with facilitatory KT, inhibitory KT, sham KT, and untaped condition in patients with lateral epicondylitis (LE) who were ignorant about KT. Design: Deceptive crossover trial. Participants: Thirty-three patients with unilateral chronic LE who were ignorant about KT, 30 of them were successfully deceived in this study. Interventions: Patients were randomly allocated into different sequences of four taping conditions: facilitatory KT, inhibitory KT, sham KT, and untaped condition. Outcome measures: Pain intensity, pain-free grip strength, maximal grip strength, and electromyographic activity of wrist extensor muscles were assessed immediately after each tape application. Results: No significant differences in the pain intensity (p = 0.321, η(2) = 0.04); pain-free grip strength (p = 0.312, η (2) = 0.04); maximal grip strength (p = 0.499, η(2) = 0.03); and electromyographic activity (maximal grip: p = 0.774, η(2) = 0.01; and pain-free grip: p = 0.618, η(2) = 0.02) were recorded among various taping conditions. Conclusions: Neither facilitatory nor inhibitory effects were observed between different application techniques of KT in patients with LE. Hence, alternative intervention should be used to manage LE.
Chapter
Elbow injuries are common in athletes, mostly those involved in martial arts, racket sports, and overhead throwing. Each lesion will depend on the sport’s features and devices used to perform the athletic activity. Size, weight, material properties, and additional instruments incorporated to the athletic devices are also important points to be considered.
Chapter
Medial and lateral epicondylitis are frequent painful syndromes of the elbow due to repetitive functional stress of muscle groups inserted by a common tendon at the medial and lateral epicondyle, respectively. The medial epicondylitis involves the flexor carpi radialis or pronator teres or both close to their origin, while the lateral epicondylitis, much more common than medial epicondylitis, is generally characterized by lesions of the tendon of the extensor carpi radialis brevis. They were considered inflammatory conditions, but the epicondylitis are characterized, however, by tendon alterations resulting from an incomplete reparative response. In chronic cases, microtears are represented and can evolve to complete rupture of the tendon. Both conditions can be treated without surgery in most patients. Several surgical treatments have been proposed in the treatment of epicondylitis; however, no one appears to be superior to others, and there isn’t, therefore, a universally accepted consensus (Leach and Miller, Clin Sports Med 6:259–273, 1987).
Chapter
Lateral epicondylitis, also known as tennis elbow, is a common cause of chronic pain of the elbow and dysfunction of the wrist extensors. It consists of a bothersome pain on the lateral surface of the elbow and a debilitating weakness that extends along the forearm, particularly during elbow flexion and wrist extension. It affects about 1–3 % of the adult population, especially between 35 and 55 years; tennis players account for only 5–8 % of cases, although there is 40–50 % risk of getting this disease during sporting life. The disease process concerns the extensor tendons of the wrist and especially their insertion on the lateral surface of the lateral epicondyle where it is possible to identify granulation, devascularization, and finally calcification. The tendon of the extensor carpi radialis brevis is the most frequently involved, while the extensor carpi radialis longus, the front portion of the extensor digitorum communis, and the extensor carpi ulnaris are less frequently affected. The cause of this disease seems to be connected with a repetitive stress that causes microtrauma at the tendons’ insertion. Surgical treatment should be reserved in case of failure of the conservative treatment that should last at least 6 months. Surgical treatment can be percutaneous, open, or arthroscopic.
Chapter
Die Bildgebung des Ellenbogengelenkes stellt im Rahmen der Subtilität der Befunde hohe Herausforderungen an den befundenden Radiologen. Bereits durch die richtige Wahl der Untersuchungsmodalität kann er dem klinischen Kollegen helfen, schnellstmöglich zu einer Diagnosefindung zu kommen. Neben der Projektionsradiographie und der Computertomographie als Grundbausteine der Bildgebung ist die Magnetresonanztomographie zur Diagnostik der periartikulären Weichteile sowie der nervalen und ligamentären Strukturen wegweisend und erlaubt meist die verlässliche Diagnosefindung. Abhängig von der zu evaluierenden Struktur kann die Sonographie eine sinnvolle Alternative darstellen. Dies Kapitel geht auf die komplexe Anatomie samt Normvarianten des Ellenbogengelenkes, wie z. B. akzessorische Knochen und Muskeln sowie Plicae, ein und handelt die häufigsten ossären, chondralen, muskulären und ligamentären Verletzungen ab. Außerdem wird auf chronische Reizzustände von umliegenden Nerven und am Ellenbogengelenk inserierenden Muskeln eingegangen.
Chapter
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.
Article
PurposeTo clarify the fibular head insertion of the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and biceps femoris tendon and related osseous landmarks on three-dimensional (3-D) images. Methods Twenty-one non-paired, formalin-fixed human cadaveric knees were evaluated in this study. The fibular head insertions of the FCL, PFL and biceps femoris tendon were identified and marked. 3-D images were created, and the surface area, location, positional relationships, and morphology of the fibular insertions of the FCL, PFL, and biceps femoris tendon and related osseous structures were analysed. ResultsThe fibular head had a unique pyramidal shape, and the relationships of the fibular insertion of the FCL, PFL, and biceps femoris tendon were consistent. The fibular head consists of three aspects: lateral aspect, posterior aspect, and proximal tibiofibular facet. The insertions of the FCL, PFL, and biceps femoris tendon were attached to the centre from the distal side of the lateral aspects of the fibular head, posterior aspect of the fibular styloid process, and lateral aspect surrounding the FCL, respectively. The mean surface areas of the FCL and PFL fibular insertions were 100.1 ± 29.5 and 18.5 ± 7.2 mm2, respectively. Conclusion This study showed that the relationships between the characteristic features of the fibular head and insertions of the FCL, PFL, and biceps femoris tendon were consistent. The clinical relevance of this study is that it improves understanding of the anatomy of the insertions of the PLC and biceps femoris tendon.
Chapter
Der vorliegende Fortbildungsbeitrag geht auf die MR-tomographischen Besonderheiten und krankhaften Veränderungen von Muskeln, Nerven sowie der das Ellenbogengelenk auskleidenden Synovia ein. Die typischen Befunde der Bildgebung werden veranschaulicht und diskutiert. Außerdem werden die Schnittbildanatomie und anatomische Normvarianten wie z. B. akzessorische Muskeln und Plicae besprochen. Verletzungen der das Ellenbogengelenk umgebenden Muskeln sowie deren chronische Reizzustände insbesondere bei Sportlern sind häufig und deren MRT-morphologische Veränderungen z. B. beim „Tennis-“ oder „Golferellenbogen“ typisch. Durch individuelle Anpassung der Untersuchungssequenzen, der Patientenlagerung und der Schichtführung können Sehnenreizungen sowie -rupturen verlässlich diagnostiziert werden. Obwohl die klinische und die elektrophysiologische Untersuchung in aller Regel die Basis in der Diagnostik von peripheren Neuropathien bilden, kann die Magnetresonanztomographie (MRT) aufgrund der hohen Ortsauflösung und des guten Weichteilkontrasts nützliche Zusatzinformationen zur genauen Lokalisation liefern und helfen, Differenzialdiagnosen auszuschließen. Synoviale Erkrankungen wie z. B. inflammatorische Arthritiden und proliferative Erkrankungen, aber auch eine Impingement-Symptomatik verursachende Plicae müssen in der MRT-Diagnostik des Ellenbogengelenks berücksichtigt werden.
Chapter
Injury to the myotendinous, ligamentous, osseus, and nervous structures of the elbow can result from acute macrotrauma or recurrent microtrauma. Acute macrotrauma primarily results from direct impact of the elbow with the ground, collision of an outstretched hand with the ground, or high intensity movement involving the elbow joint in an unconditioned individual. Recurrent or chronic repetitive microtrauma to the elbow is usually the result of either eccentric overuse of the extensors of the forearm or repetitive valgus stress overload, as occurs with overhead throwing or work-related tasks. In these settings, the ability of MRI to achieve superb soft tissue contrast is of particular utility. It can evaluate for and distinguish between myotendinous, ligamentous, osseus, cartilaginous, and nervous etiologies in the athlete who presents with nonspecific symptoms.
Chapter
Die Erfahrungen in der Kreuzbandchirurgie sind bereits 100 Jahre alt [70], aber erst seit Brückner 1966 [20, 21] wurden Techniken mittels Patellarsehnentransplantat vorgestellt, welche auch heute noch Gültigkeit besitzen.
Article
This review article discusses the magnetic resonance imaging (MRI) features and pathological changes of muscles, nerves and the synovial lining of the elbow joint. Typical imaging findings are illustrated and discussed. In addition, the cross-sectional anatomy and anatomical variants, such as accessory muscles and plicae are discussed. Injuries of the muscles surrounding the elbow joint, as well as chronic irritation are particularly common in athletes. Morphological changes in MRI, for example tennis or golfer's elbow are typical and often groundbreaking. By adapting the examination sequences, imaging planes and slices, complete and incomplete tendon ruptures can be reliably diagnosed. Although the clinical and electrophysiological examinations form the basis for the diagnosis of peripheral neuropathies, MRI provides useful additional information about the precise localization due to its high resolution and good soft tissue contrast and helps to rule out differential diagnoses. Synovial diseases, such as inflammatory arthritis, proliferative diseases and also impinging plicae must be considered in the MRI diagnostics of the elbow joint.
Article
Full-text available
One of several factors suspected in the development of lateral epicondylitis, often referred to as tennis elbow, is the impact-induced vibration of the racket-and-arm system at ball contact. Using two miniature accelerometers at the wrist and the elbow of 24 tennis players, the effects of 23 different tennis racket constructions were evaluated in a simulated backhand stroke situation. The influences of body weight, skill level, and tennis racket construction onto the magnitude of vibrations at wrist and elbow were investigated. Amplitudes, integrals, and fourier components were used to characterize arm vibration. More than fourfold reductions in acceleration amplitude and integral were found between wrist and elbow. Off-center as compared with center ball impacts resulted in approximately three times increased acceleration values. Between subjects, body weight as well as skill level were found to influence arm vibration. Compared with proficient players, a group of less skilled subjects demonstrated increased vibration loads on the arm. Between different racket constructions, almost threefold differences in acceleration values could be observed. Increased racket head size as well as a higher resonance frequency of the racket were found to reduce arm vibration. The vibration at the arm after ball impact showed a strong inverse relationship (r = -0.88) with the resonance frequency of tennis rackets.
Article
Full-text available
A prospective study was done of the results of lateral release of the common extensor origin in sixty-three patients who had a tennis elbow. Fifty-seven of these patients were followed for a mean of fifty-nine months (range, fifty to sixty-five months). At the time of the operation, the extensor origin was macroscopically normal in all but six patients. Forty-seven (76 per cent) of the sixty-two patients who were evaluated at one year had no pain or only slight pain, whereas before the operation three patients (5 per cent) had had slight pain and sixty (95 per cent), severe pain. Of the fifty-seven patients who were re-examined after five years, fifty-two (91 per cent) had no pain or only slight pain. At one year, twenty patients (32 per cent) had an excellent over-all result; twenty-three (37 per cent), a good result; twelve (19 per cent), a fair result; and seven (11 per cent), a poor result. At five years, there were thirty-two excellent results (56 per cent), nineteen good results (33 per cent), four fair results (7 per cent), and two poor results (4 per cent). No association between the preoperative findings and the results of the operation was found. It was concluded that lateral extensor release, a relatively simple operation that can be performed in an outpatient setting, may be regarded at this time as the operative procedure with which other operations for tennis elbow should be compared.
Article
Tennis elbow or humeral epicondylitis is a minor ailment, but to a tennis player, a golfer, a gardener, or a skier, it can be a threat to his way of life. The entity is therefore worthy of prevention and treatment. This is a report on the study of 174 patients with epicondylitis of the elbow, with special reference to the effective treatment by an elbow brace.
Article
Dissections of 10 fresh cadaver specimens revealed an important insertion of the posterior portion of the lateral collateral ligament to the ulna at the crista supinatoris. The humeral origin of the medial ligament attachments was found to lie posterior to the axis of elbow flexion; in this position a cam effect is created so that ligament tension varies with elbow flexion. The three-dimensional distance between the origin and the insertion of the anterior portion of the medial collateral ligament was found to increase slightly from extension to approximately 60 degrees of flexion; thereafter, it remained nearly constant. The distance of the posterior portion increased by about 9 mm from 60 degrees to 120 degrees of flexion. The flexion axis was shown to pass through the origin of the lateral collateral ligament, so the length of this structure was not changed during elbow flexion.
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
The clinical findings, roentgenographic findings, and results of various forms of treatment of osteochondritis dissecans in 50 elbows were reviewed in a study of the records of 42 patients. All the patients were males; two-thirds were between 9 and 15 years of age when they first had symptoms. Pain, loss of motion, locking, and clicking were the most common symptoms. Roentgenographically, rarefaction and flattening of the capitellum were common features. Some form of surgical treatment was used for 38 elebows; removal of loose bone and curettage and trimming of the crater were the most frequent procedures. The results of treatment were generally satisfactory. This review suggests that loose bodies should be removed and that, in most instances, no other procedures are indicated.
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
Thirty-one patients with osteochondritis dissecans of the capitellum humeri were followed for an average of 23 years. There were symptoms in about half of the elbows at the follow-up examination. Impaired motion and pain on effort were the most common complaints. Roentgenographic signs of degenerative joint disease were present in more than half of the elbows and correlated with a reduced range of motion. The diameter of the radial head increased in comparison with the contralateral elbow in two thirds of the patients.
Article
The effectiveness of cushion grip bands in reducing impact shock and vibration transfer, and slipping in tennis racquets has been investigated. The results also apply, in principle, to badminton and squash racquets, and to golf clubs. An artificial arm (manusimulator) replicating the structure and all the important properties of the real human arm (shoulder, upper- and forearm, hand, soft tissue- and muscle simulators, etc.) was used together with a standard tennis racquet for the investigation. Laser beams were employed for precision adjustment of the spatial racquet position and the ball impact location. The impact velocity was standardized at 20 m.s-1 +/- 1.2%, while the impact point was located 32.5 +/- 2 mm distal to the sweet spot (the nodal point of the fundamental transverse vibration mode) on the racquet long axis. The grip circumference for the 26 different grip bands tested was controlled at 116 +/- 1 mm (grip size 5), and the adjustable manusimulator grip pressure was kept at preset values. Impact shock and post-impact racquet vibrations were determined by manusimulator-accelerometry, while slipping resistance was measured by friction methods. The major finding was that cushion grip bands do statistically significant (at P = 0.05) reduce impact shock and vibration transfer in tennis racquets, albeit to varying degrees depending on the brand. At present, there is no clear indication whether these reductions are, in fact, biologically relevant. Very large differences were found to exist between the various grip band types as regards the reduction of slipping.
Article
Electromyography and high-speed film were used to examine the muscle activity in the elbows of pitchers with medial collateral ligament insufficiency compared to the activity in uninjured elbows. Ten competitive baseball pitchers with medial collateral insufficiency and 30 uninjured competitive pitchers were tested while throwing the fastball and the curveball. The extensor carpi radialis brevis and longus in the injured pitchers showed greater activity than in the uninjured pitchers for both pitches. The triceps, flexor carpi radialis, and pronator teres all showed less activity in the injured pitchers during the fastball, but only the triceps had less activity during the curveball. The differences were seen during the late cocking and acceleration phases, which place the greatest stress on the medial collateral ligament. If the flexor carpi radialis and pronator teres were substituting for the deficient medial collateral ligament and functioning as dynamic stabilizers, one would expect enhanced muscle activity. However, the opposite was found. This pattern of asynchronous muscle action with medial collateral ligament injury may predispose the joint to further injury. The muscular differences seen are critical to the understanding of the pathomechanics of patients with medial collateral ligament deficiency, and provide a basis for rehabilitation.
Article
Tennis elbow (lateral epicondylitis) is the pattern of pain most commonly seen at the origin of the wrist extensors from the lateral epicondyle of the humerus and less commonly seen at the origin of the flexor-pronator from the medial epicondyle. This article discusses methods of diagnosis and both conservative and operative treatment techniques.
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
The ligamentous contribution to elbow joint stability is a product of morphology and biologic parameters of each of the collateral ligaments. Better understanding of these characteristics is of paramount importance for successful ligament reconstruction in the surgery for joint replacement and traumatic injury. Two experiments were performed. In the first, the arc of elbow flexion where the individual ligament was either taut or slack was measured; in the second, the structural properties of each collateral ligament were determined by using bone-ligament-bone preparations. The anterior medial collateral ligament (AMCL) and radial collateral ligament (RCL) were taut throughout most of the entire arc of flexion. The posterior medial collateral ligament (PMCL) was taut only when the elbow was in a flexed position. Among the collateral ligaments, the AMCL was the strongest and stiffest with an average failure load of 260 N. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, was similar in strength (357 N).
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
Ulnar neuritis at the elbow is a common entity affecting the athlete especially those involved in overhand sports. Inflammation of the ulnar nerve is a component of the disorders that affect the medial side of the elbow in athletics owing to the large tensile forces encountered. The treatment of the athlete with medial elbow pain should not be isolated to the findings of ulnar neuritis especially when attenuation of the ulnar collateral ligament is encountered. The prognosis of the athlete to return to their prior level of competition is related to their preoperative presentation. Patients with long-standing ulnar neuritis and severe lesions that include intrinsic muscle dysfunction and profound findings on EMG and nerve conduction studies have a less favorable outcome. The prognosis is also related to other associated conditions such as ulnar collateral ligament attenuation and degenerative arthritis. In athletes with symptoms primarily secondary to ulnar neuritis with minimal neurologic deficits and early treatment, the prognosis for return to competitive play is excellent.
Article
Classic tennis elbow, or lateral epicondylitis, has been described as an overuse or misuse injury resulting in a tendinitis. The extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC) have been impli cated as primary culprits in this pathology. Tennis elbow has been treated using a constrictive band placed several centimeters distal to the origin of these two muscles. Aircast (Aircast Inc., Summit, NJ) has devel oped a new style of band that employs an air-filled bladder as the counterpressure element. This study tested the effect of both standard and Aircast bands on EMG activity of the EDC and ECRB proximal to the band compared to control values. Ten normal subjects, ranging in age from 20 to 43 years, were tested. Right upper extremities were tested in all cases. The subjects' forearms were stabilized in the CYBEX II forearm stabilization V-pad. The ECRB and EDC were then impaled with monopolar EMG needle electrodes. The CYBEX data were recorded using the HUMAC system and the EMG data were recorded and analyzed using the Cadwell 7400. EMG data were recorded at 80% of maximum voluntary isometric contraction (MVIC) with no band, the standard band, and the Aircast band. An analysis of variance (ANOVA) with repeated meas ures of integrated EMG (IEMG) and Duncan's multiple comparison tests revealed that the Aircast caused a significant reduction in IEMG of the ECRB and EDC when compared with control values and the standard band. The decrease in IEMG with the standard band was not statistically significant. This may begin to pro vide an explanation for the anecdotal reports of the clinical effectiveness of the air-bladder type of counter force bracing.
Article
Tennis injuries are common in both the upper and lower extremities. The most common, and often most difficult, upper extremity injuries are shoulder tendinitis and tennis elbow (lateral and medial). Key considerations in the treatment of tendinitis include an understanding of the injury process and the resultant character and quantity of the pathologic spectrums. Tendon degeneration rather than tendon repair is the primary pathologic entity secondary to intrinsic muscle-tendon overload. For best treatment results, the protocols of treatment, both surgical and nonsurgical, must be individualized.
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
Tennis elbow is a common condition, with the extensor carpi radialis brevis attachment being the usual site of pain. Conservative care including decreased activity, ice, nonsteroidal anti-inflammatory medications, and muscle strengthening will help most people. The small percentage of cases that require surgery usually benefit from debridement of the damaged portion of the extensor carpi radialis brevis attachment. The postoperative course must include muscle strengthening and a gradual return to activity.
Article
In 12 osteoligamentous autopsy elbow preparations, the stability of the elbow was independent of the collateral ligament with flexion of less than 20 degrees and greater than 120 degrees. The anterior part of the collateral medial ligament was the prime stabilizer of the elbow in this range of motion, i.e., the flexion range of function. The maximum valgus and internal rotatory instability after transection of the medial collateral ligament, 20.2 degrees and 21.0 degrees, respectively, were found at elbow flexions from 60 degrees to 70 degrees. Selective repair or reconstruction of the anterior part of the elbow medial collateral ligament may prove to be effective in the treatment of acute or chronic elbow instability.
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
Biomechanical data on most bracing and protective equipment systems is lacking. To better understand the clinical success of counterforce bracing, a biomechanical analysis of braced and unbraced tennis players (serve and backhand strokes) was undertaken. Three-dimensional cinematography and electromyographic techniques were used. Three commonly used counterforce braces (lateral elbow, medial elbow, and radial-ulnar wrist) were compared with the unbraced condition. The overall results basically reveal positive biomechanical alterations in forearm muscle activity and angular joint acceleration dependent upon the brace and joint area analyzed.
Article
A clear understanding of the unique anatomic features of the elbow joint aids in a more full appreciation of the biomechanical aspects of this joint. This knowledge may, it is hoped, be translated into a broader understanding of the scientific basis of the management of elbow problems.
Article
Relatively little is known about the incidence of the risks facing those who exercise regularly. Clinical reports suggest a variety of musculoskeletal ailments, and several pathophysiologic conditions may result from the various aerobic activities most likely to be pursued by large parts of the U.S. population. But adequate epidemiologic data are scarce. Careful epidemiologic studies are needed to develop incidence information.
Article
This paper reviews 14 patients who underwent elbow arthrotomy for osteochondritis of the capitellum. The etiology in 7 of the 14 cases appears to be the result of repeated trauma from throwing sports. Five of the 14 described a singular significant traumatic episode, and in 2 of the 14, a clear etiology is uncertain. The diagnostic features including signs, symptoms, and el bow range of motion are examined. The operative findings are correlated with plain x-ray films of the elbow in all cases and with an elbow arthrogram in 11 out of 14 cases. The average length of followup was 24 months. The postoperative range of motion was in creased an average of 18°. Eighty-six percent (12 out of 14) patients returned to organized, competitive ath letic activity without restrictions. The Little League background of those patients with apparent repetitive microtrauma to the elbow is exam ined in terms of length of pitching experience and types of pitches thrown. In addition, the throwing mechanism of these patients is evaluated with respect to the type of delivery at possible risk for the development of osteochondritis. We conclude that after a failure of conservative ther apy, surgical treatment, including removal of the intraar ticular loose bodies, excision of capitellar lesions, and curettage to bleeding bone can be expected to produce pain relief and improvement in joint motion. A return to organized competitive sport activities can be expected.
Article
Between 1956 and 1972, 871 patients were treated for tennis elbow; all but 37 were treated conservatively. The 37 patients who did not respond to non surgical treatment had good results after surgery. Twenty eight of the patients had a modified Bosworth III procedure - excision of the proximal portion of the annular ligament, release of the origin of the extensor muscles, excision of the bursa if present, and excision of the synovial fringe. The results from the procedure were good.
Article
This experiment demonstrates that infiltration of hydrocortisone into rabbit calcaneal tendons has a direct effect on the tendon, producing necrosis of collagen at the site of injection. The repair of the lesion so produced is incomplete even after eight weeks, and is often complicated by dystrophic calcification. Similar morphological changes may account for spontaneous rupture of tendons in patients receiving steroid infiltration.
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
The repeated use of local steroid injections in the treatment of tenosynovitis in the active athlete is to be abandoned, not only because it masks the symptoms of tenosynovitis, giving the patient a false sense of security, but also because local injection of steroid decreases the tensile strength of tendon and predisposes it to complete rupture.
Article
Tennis elbow or humeral epicondylitis is a minor ailment, but to a tennis player, a golfer, a gardener, or a skier, it can be a threat to his way of life. The entity is therefore worthy of prevention and treatment. This is a report on the study of 174 patients with epicondylitis of the elbow, with special reference to the effective treatment by an elbow brace.
Article
This is the second report in a series of projects dealing with electromyographic (EMG) analysis of the upper extremity during throwing. Better understanding of the muscle activation patterns could lead to more effective preseason conditioning regimens and rehabilitation programs. Indwelling wire electrodes recorded the output from the biceps, long and lateral heads of the triceps, pectoralis major, latissimus dorsi, serratus anterior, and brachialis for four professional baseball pitchers. These signals were synchronized electronically with high speed film records of a fast ball. The EMG signals were converted from analog to digital records. Results showed that wind-up and early cocking phases showed minimal activity in all muscles, and such firing which occurred was of low intensity. Late cocking, which occurred after the front foot was firmly planted, showed moderate activity in the biceps. Cocking was terminated by the pectoralis major and latissimus dorsi. At this point, the trunk began to rotate forward, while the arm remained elevated and the elbow flexed. Also, the shoulder was moving to maximum external rotation. During the acceleration phase, the biceps was notably quiescent, while the pectoralis major, latissimus dorsi, triceps, and serratus anterior were all active. Muscle action at this time terminated external rotation and elbow flexion; i.e., the muscles fired as decelerators and also initiated the opposite actions for ball acceleration, internal rotation and elbow extension. Follow-through was not only a time of eccentric contraction with muscle activity decelerating the upper extremity complex, it was also an active event with the shoulder moving across the body and the elbow into extension with forearm pronation.
Article
Five male subjects' throwing and pitching motions were analyzed by dynamic electromyography and high speed photography. Electrodes inserted into the deltoid and rotator cuff muscles attempted to define muscle activation patterns during the throwing and pitching cycle. The wind-up or preparation (Stage I) had no consistent pattern. Cocking (Stage II) had a sequential muscle activation pattern of first deltoid activity, followed by the S.I.T. muscles and finally by the subscapularis muscle. Acceleration (Stage III) had a lack of muscle activity, even though the arm was accelerating forward in space. Follow-through (Stage IV) was the most active stage with all the muscles firing intensely. The muscle patterns observed during the cycle were largely characteristic of attempts to decelerate the arm.
Article
A variety of symptoms associated with 15 cases of resistant tennis elbow and resistant radial tunnel pain are described. These included sensations of popping, paresthesias, and paresis. The duration of symptoms averaged 2.3 years before a definitive diagnosis of radial tunnel syndrome was made. Two unique anomalies were contributing factors in the radial nerve entrapment; one case demonstrated a completely tendinous proximal border of the extensor carpi radialis brevis and the other a bifid extensor carpi radialis brevis origin. Excellent pain relief, elimination of popping, and improvement of the paresthesias and paresis was achieved by release of the radial tunnel in cases unresponsive to conservative treatment.
Article
This paper describes 44 percutaneous epicondylar releases performed on 34 patients with humeral epi condylitis. There were 35 instances of lateral epicon dylitis and 6 of medial epicondylitis. Thirty-two of the lateral releases had an excellent result and 3 were unsatisfactory. Five of the medial procedures were rated as excellent and one unsatisfactory. Two of the three unsatisfactory lateral procedures were reoper ated upon with an excellent result. The one unsatis factory medial epicondylitis underwent reoperation and had excellent results. In our experience, percutaneous release has a high rate of success, is simple to perform, does not require hospitalization, and has been without complication.
Article
The anterior oblique component of the medial collateral ligament of the elbow is the mainstay of joint stability. Fractures of the medial epicondyle must be anatomically reduced, open if necessary. A fibrous union of a minimally displaced fractured medial epicondyle may result in lengthening and functional compromise of the medial collateral ligament. Chronic elbow instability is an unusual lesion. Repair of chronic elbow instability is best performed by restitution of medial collateral ligament function.
Article
The extent that the medial collateral ligament complex could be visualized by arthroscopy was determined in 10 fresh cadaveric elbows from 10 individuals. We carefully exposed the medial collateral ligament complex through a muscle-splitting incision before performing arthroscopy. The anterior and posterior bundles were identified and marked by placing 4.0 nylon sutures deep to the bundles to aid in arthroscopic visualization. A portion of the anterior bundle was visible in only one elbow and in that elbow only the most anterior 25% of the anterior bundle was seen. Attempts to visualize the anterior bundle through additional portals were unsuccessful. Varying the flexion angle of the cadaveric elbow from 0 degrees to 130 degrees also failed to improve visualization. Conversely, the entire posterior bundle, including humeral and ulnar insertion sites, could be seen in all 10 specimens using the posterior portals. We also noted that direct pressure was placed on the ulnar nerve in all specimens when the arthroscope or any arthroscopic instrument was advanced into the posteromedial gutter in contact with the posterior bundle because of its proximity immediately adjacent to the ulnar nerve. The inability to reliably see the anterior bundle and the humeral or ulnar insertion sites of this ligament may limit the value of the arthroscope when assessing medial collateral ligament injuries. Additionally, great care should be taken when using the arthroscope or other instruments in the posteromedial gutter because the ulnar nerve lies immediately adjacent to the thin posterior bundle and capsule.
Article
Ten fresh cadaveric elbows were used to evaluate the proximity of the radial nerve and its branches to three anterolateral portals. A proximal anterolateral portal used routinely at our institution and located 2 cm proximal and 1 cm anterior to the lateral epicondyle was compared with the distal anterolateral portal described by Andrews and with a mid-anterolateral portal. The three portals were initially established without joint distention while the elbows were flexed 90 degrees. Measurements were then obtained with and without joint distention at flexion angles of 0 degrees and 90 degrees. The radial nerve was found to be an average distance of 3.8 mm at extension and 7.2 mm at 90 degrees of flexion from the distal anterolateral portal, located 3 cm distal and 1 cm anterior to the lateral epicondyle. Conversely, the distance between the proximal anterolateral portal cannula and the nerve was statistically greater (p < 0.05), averaging 7.9 mm in extension and 13.7 mm in flexion. The remaining anterolateral portal, located 1 cm directly anterior to the lateral epicondyle, was found to be at a statistically greater average distance from the nerve than was the distal anterolateral portal but statistically closer than was the more proximal portal. The ability to visualize the joint arthroscopically was assessed using the three portals, and although the ulnohumeral joint could be adequately seen using all portals, radiohumeral joint visualization was most complete and technically easiest using the most proximal portal.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Seven fresh-frozen cadaveric elbows were used to evaluate the extent to which the medial collateral ligament must be injured before arthroscopic evidence of valgus instability is seen, the amount of ulnohumeral joint opening that does occur after such an injury, and the elbow position that maximizes visualization of this opening. While visualizing the most medial aspect of the ulnohumeral joint arthroscopically through the anterolateral portal, we sequentially sectioned the medial collateral ligament complex until all of the medial ligamentous restraints were cut. A valgus load was applied after each incision, and the extent to which the ulnohumeral joint opened was measured. Ulnohumeral joint opening was not visualized in any specimen until complete sectioning of the anterior bundle was performed. After the anterior bundle was released, 1 or 2 mm of joint opening was present in all specimens. Complete release of the medial collateral ligament led to dramatic increases in medial joint opening in all seven specimens (4 to 10 mm). Varying the angle of elbow flexion from 15 degrees to 120 degrees revealed that visualization of the medial joint opening was best at 60 degrees to 75 degrees. Finally, forearm pronation increased ulnohumeral joint opening and supination decreased joint opening in all specimens. We found that the entire anterior bundle must be sectioned before measurable and reproducible medial joint opening can occur.
Article
Epicondylitis of the elbow involves pathologic alteration in the musculotendinous origins at the lateral or medial epicondyle. Although commonly referred to as "tennis elbow" when it occurs laterally and "golfer's elbow" when it occurs medially, the condition may in fact be caused by a variety of sports and occupational activities. The accurate diagnosis of these entities requires a thorough understanding of the anatomic, epidemiologic, and pathophysiologic factors. Nonoperative treatment should be tried first in all patients, beginning with an initial phase of rest, ice, nonsteroidal anti-inflammatory agents, and possibly corticosteroid injection. A second phase includes coordinated rehabilitation, consisting of range-of-motion and strengthening exercises and counterforce bracing, as well as technique enhancement and equipment modification if a sport or occupation is causative. Nonoperative treatment has been deemed highly successful, yet the few prospective reports available suggest that symptoms frequently persist or recur. Operative treatment is indicated for debilitating pain that is diagnosed after the exclusion of other pathologic causes for pain and that persists in spite of a well-managed nonoperative regimen spanning a minimum of 6 months. The surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin to the lateral or medial epicondyle. Surgical treatment results in a high degree of subjective relief, although objective strength deficits may persist.
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