Transcript Throwing Elbow Problems.pps

Elbow injuries and the
throwing athlete
Michael J. Kissenberth MD
Orthopaedic Surgery, Sports Medicine
SHCC, Greenville Hospital System
First Question
What sport do
you play?
Most sport related elbow injuries are
caused by repetitive microtrauma…
And the underlying pathology is
directly related to the biomechanics
of the sport.
Second Question
2. Where does it
hurt?
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Anterior
Medial
Posteromedial
Posterior
Lateral
Third Question
3. When
does it hurt?
st
1
Andrews
Critical Instant
nd
2
Andrews
Critical Instant
Restraint to Valgus Torque
at 90 Degrees Flexion
UCL
RC Articulation
Capsule
54%
33%
10%
Effects of Valgus Torque
• Medial Tension
– ME injury
– Sigmoid rim fx
– FP mass injury
– UCL lesions
– UN neuritis
• Lateral Compression
– RC joint injury
– Synovitis
History
• Medial Pain
• Late Cocking, Early
Acceleration
• Recurrent Symptoms
• Pop on Single Throw
• Swelling, Stiffness
• Lost Performance!!!
Previous Treatment
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Lost Playing Time
Rehabilitation
Injections
Diagnostic Studies
Surgery (VEO)
Examination
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Medial Swelling
Motion Loss
UCL Tender
Valgus Stress Painful
Valgus Laxity
Associated Findings
Kids
• ME Apophysitis
• ME Fragmentation
• ME Avulsion
ME Apophysitis
With
Fragmentation
Without
Fragmentation
14 y/o BB Player
No prior symptoms
“Pop!”
FP Muscles - UCL
The flexor
pronator
muscles
provide
varus
torque
FPM
UCL
ME
Ulna
Flesig AJSM 95, Werner JOPST 93
Decreased
FCR activity
in throwers
with an UCL
injury
FPM / ME Injury
Pronator Muscle Tear
27 y/o RHP
Conjoined Tendon
Severe
FPM / ME
Think
UCL
Injury!!!
Rarely
inject
Deep Massage
FPM
Modalities
Rehabilitation
Repair
ME
Treatment
Relative / Active Rest
Ice, NSAID
Local Modalities
Prevent Atrophy
Treat Associated
Conditions
NO Steroid Injections!!!
Treatment
Strengthen FCU, FDS
Trunk, Scapula, Cuff Stab.
PNF, Plyometrics
Sport Specific Exercise
Review Throwing
Mechanics
Interval Throwing Program
Direct
Repair
UCL Complex
• Anterior Bundle
– Strongest portion
– Insertion on
sublime tubercle
• 18 mm posterior
to coronoid tip
– Origin is inferior
and posterior
to rotation axis
• Tighter in flexion
Milking Maneuver
UCL Tests
Static Valgus Stress
Moving VST
O’Driscoll
Likely best test
Modified UCL Recon
6 – 8 Millimeter Bridge
Three Incision Harvest
Docking Procedure
Avulsion Fracture
Sublime Tubercle
Glajchen AJR 1998
Rehabilitation
Initial Immobilization
Relieve Pain
Resolve Arm Swelling
Recover Range of Motion
Prevent Muscle Atrophy
Restore Aerobic Condition
Maintain/develop core
stability
Toss
4 - 5 Months
Mound
6 - 8 Months
Game
11 - 12 Months
Prevent Shoulder
Injury
Ulnar Nerve Injury
ME
Ulnar Nerve Injury
Fibrosis
Compression
Tension
UN subluxation
Elbow valgus
laxity
Non-operative Care
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Night Splint
NSAIDs
Oral Steroids
Activity Modification
Desensitization / Soft tissue
release
Decompression
4
3
2
1
ME
Fascia Sling
ME
Lateral Compression
Injuries
Rad-Cap
arthrosis
Stress fracture
OCD
Lateral
synovium
Kids – Lateral Elbow
1. Panner’s Disease
• <10 yo, self limited
2. OCD Capitellum
• Progressive!!!
Panner’s Disease
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OCD capitellum
5-10yo
Self limited
Tx conservatively
– Rest, ice, nsaids
– Gradual RTP. Must be able to
throw without sx
Posterior blood supply
peds lateral elbow
Repetitive injury to
epiphysis may alter
blood flow =
osteochondrosis
Osteochondritis
Dissecans
• Age 9 - 16
Years Old
• Progressive
• Remove loose
bodies
Loose Body
Lateral Plica Syndrome
Humerus
Ulna
RH
VEO Syndrome
2nd Critical Instant
History
Pain- posteromedial at ball
release and in follow
through
Past history pain
Past history UCL injury
Stiffness
Performance, warm-up
Examination
Local Tenderness
Motion Loss
Extension Painful
Extension Plus Valgus
Painful
Extension
Test
Posterior & Medial
Andrews
Olecranon Tip
Resection
KJOC / Mayo Ostectomy
“…removal of > 3 mm of
bone and cartilage places
the UCL at risk for injury.”
ElAttrache, Rosen, Morrey
Olecranon Tip
Osteophytes
Kids
Olecranon
Apophysis
Injury
Olecranon Apophysis NU
16 y/o RHP
Left
Right
10 Days
Post-Op
3 Months
Post-Op
Tip Stress Fracture
X-ray
MRI
The treatment plan is based
on the player’s history,
examination and response to
conservative care.
SUMMARY
• When evaluating elbow injuries
pay attention to age of athlete
and location of pain.
• Acute injuries with “pop” require
full evaluation.
• Most respond to conservative
treatment
Our Goals
• Not to operate on elbows
• If we have to – results pretty good
at getting pitchers back to play
• Use the down time to fully
evaluate the rest of the body
(shoulder / hips / core)
HAWKINS THROWING
ACADEMY
• TEAM APPROACH TO
THROWING INJURIES
• SHCC, Proaxis therapy, ASI
• One of a kind in the Southeast
• Focused on performance and
prevention
• Email:
[email protected]
THANK YOU