Elbow Injuries

Tommy John Surgery or reconstruction of the ulnar collateral ligament of the elbow is a well known procedure in the popular media and by throwing athletes.  The surgery was invented by Dr. Frank Jobe at Kerlan Jobe Orthopedic Clinic and first performed on LA Dodgers pitcher, Tommy John.  The surgery involves reconstructing the ulnar collateral ligament of the elbow to allow pitchers or other overhead athletes who have torn the ligament to return to their previous high level of play.  We have done a great deal of research on Tommy John surgery which is published in several journals, book chapters, presentations and in popular media.

Cause

A tear to the ulnar collateral ligament (UCL) of the elbow is commonly caused by repetitive trauma to the elbow caused by continued stress to the elbow.  The tear can occur gradually over time due to chronic stresses and can be noticed as pain in the elbow with throwing and a decrease in fastball velocity.  This can also occur as a more acute injury with one pitch or throw causing pain at the elbow.  This can also occur from a direct injury to the elbow and can be seen commonly in gymnastics or tumbling sports.  A tear of the UCL typically results in pain during throwing, but can occur after a pitch.  The pain is usually noted on the inside (medial) of the elbow and is commonly associated with a decrease in pitch velocity or the arm feeling “dead”. 

Anatomy

The ulnar collateral ligament runs from the medial epicondyle of the humerus to the ulna on a prominence called the sublime tubercle.  The ligament prevents the elbow from bending outward (prevents valgus stress), which is the position and stress to the arm during the acceleration (or arm coming forward) phase of throwing.

Imaging

X-ray imaging is typically obtained to evaluate for any bone spurs or loose bodies in the joint.  An MRI is commonly obtained and this can be performed with contrast in the joint if needed and this will help identify if a tear exists as well as other issues to the elbow.

Treatment

Treatment will depend on your activity level as well as your level of play in sport and your desire to continue to play.  Treatment will also depend on several tear characteristics such as complete or partial tear and where the tear is located to help determine if non-operative treatment will be more successful or not.  Non-operative treatment involves complete rest from throwing, physical therapy and sometimes injections to help the ligament to heal such as PRP can be used.  Operative treatment involves Tommy John Surgery, which is reconstruction of the injured ligament using a graft.  The graft most commonly used is the palmaris tendon in the forearm or the gracilis tendon of your leg.

Recovery

Initially after surgery you will be placed into a splint and transitioned to an elbow brace.  As the graft heals, range of motion can begin but is limited some to prevent graft tension.  Once the graft has initial healing, full elbow motion can be done.  It is then extremely important to allow the graft to mature and become a fully functional ligament and this involves gradual stress to the ligament without significant valgus stress until the elbow is ready.  A throwing program will begin once the ligament is stronger, however, full return to play is at least 12 months and ideally 14 months.  Some position players can return earlier and bat earlier.

As the biceps muscle enters the elbow to insert on the radius, a significant flexion force can cause the tendon to rupture at the elbow.  This is known as a distal biceps rupture.  This is commonly noted as a pop in the elbow while lifting something and is associated with significant bruising.

Cause

The distal biceps tendon is torn when the arm is contracted with significant force usually with the elbow bent at 90 degrees.  The force can be while lifting weights, carrying a heavy object like a couch or any other significant force to the elbow.  This is more commonly seen in middle aged men, but can be seen in much younger ages as well.

Anatomy

The biceps tendon inserts onto the radius at the biceps tuberosity.  The main function of the biceps is to supinate the hand, or turn the hand upward.  Flexion of the elbow is a secondary function of the biceps, although many confuse this as being the primary function.  With a rupture of the distal biceps, there can be significant loss of strength with supination (turning the hand up) like turning a wrench or opening a door and also some loss of flexion strength.

Imaging

The diagnosis is primarily made by physical exam and history, however, an MRI is often times needed to assess the retraction of the tear and at times the tear may not be complete.

Treatment

The majority of distal biceps tears are treated with surgery due to the significant amount of strength loss if left untreated.  It is important to address this injuries earlier rather than wait as it becomes much more difficult to treat chronic ruptures of the tendon.  The tendon is repaired by making a transverse incision near the elbow crease and using strong suture to secure the tendon and pass the tendon through a hole drilled at the insertion on the radius and held in place with a metal button and screw.

Recovery

After repair of the biceps tendon, the arm is placed into a splint to decrease the tension on the repaired tendon.  Over the next few weeks, an elbow brace is used to progress range of motion and eventual strengthening after the tendon is healed.  Full use of the elbow which would include impact activities or lifting weights will take several months to allow for full tendon healing.

Triceps ruptures are relatively uncommon injuries but can occur with a significant extension force of the elbow or direct force to the back of the elbow.  With complete tears, this creates significant weakness in elbow extension power.

Cause

Triceps ruptures are caused by a strong resistance to extension of the elbow or a direct blow to the back of the elbow.

Anatomy

The triceps muscle is the muscle on the back of the arm that inserts onto the back of the elbow.  The triceps is responsible for extension of the elbow.

Imaging

The diagnosis is mostly made on physical exam but MRI is often performed to evaluate the extent of the tear.

Treatment

A complete triceps tendon rupture will often times require surgery because of the lack of extension power without repair.  Repair of the tendon involves securing the tendon with strong suture and anchoring the tendon in place with suture anchors.

Recovery

Initially the arm is placed into a splint and transitioned to a brace.  Range of motion is allowed once the tendon begins to heal and full strengthening and contact activity is allowed after several months to allow the tendon to completely heal.

Golf and Tennis elbow, otherwise known as medial and lateral epicondylitis, respectively are common tendinopathies of the elbow.  Golf elbow occurs on the inside of the elbow and tennis elbow to the outside.  Although commonly caused by these sports, they can be caused by other activities just as easy.

Cause

Golf elbow and tennis elbow occur because of continued force and contraction of the muscles that originate at the elbow.  Because of this continued stress, the elbow becomes painful at the insertion of these muscles and leads to irritation during activity.  The muscles that originate at the elbow are responsible for flexion of the wrist (golf elbow) and extension of the wrist (tennis elbow) and therefore are more painful with these movements.

Anatomy

The flexor tendons of the wrist are the tendons that allow the wrist to flex or bend the palm up.  These tendons originate from the medial epicondyle of the elbow or the bump you can feel on the inside of the elbow.  These muscles are the cause of pain in golf elbow.  The extensor tendons of the wrist are the tendons that allow the wrist to extend or bend the back of the hand up.  These tendons originate from the lateral epicondyle of the elbow or the bump you can feel on the outside of the elbow.  These muscles are responsible for the pain in tennis elbow.

Imaging

This diagnosis is made by exam only and an MRI would only be obtained if there was concern for a retracted tear of the tendons, which is rare.

Treatment

Treatment of these injuries are similar.  Often times avoiding the activity that causes the pain is the first step, but sometimes this may not be a possibility.  Antiinflammatories can help with some of the pain and sometimes a steroid injection into the area of pain can help as well.  PRP injections could be a consideration as well.  Physical therapy is often a part of treatment as well.  The unfortunate part of treatment is that these injuries take months and months to completely resolve and this can be very discouraging.  Surgery is rarely needed to treat these conditions but is performed in certain cases.

Recovery

As stated, recovery can take a very long time to completely feel back to normal and this may take months and months to get better.

The ulnar nerve is a nerve in the upper extremity that as part of its course to the hand, runs on the medial (or inside) of the elbow.  This nerve is what is responsible for the “funny bone”.  When the nerve becomes entrapped or irritated at the elbow it can lead to pain and numbness in the hand usually at the little and ring finger, and can even lead to hand weakness.

Cause

The pain and numbness from ulnar neuritis is caused by the nerve being irritated or partially compressed at the elbow.  This is commonly seen in athletes like pitchers due to the stress of pitching on the elbow, but more commonly seen in the general population due to everyday activities.  The nerve becomes compressed in the elbow and is at maximal compression during elbow compression, like when using a cell phone.

Anatomy

The ulnar nerve exits from the arm and runs on the medial (inside) side of the elbow behind the medial epicondyle.  The nerve is responsible for innervating some muscles of the forearm and is primarily responsible for the intrinsic muscles of the hand and sensation on the ulnar side of the hand which involves the little and ring fingers.  If weakness exists it is commonly seen with decreased grip strength and less able to cross over fingers.

Imaging

An EMG may be performed to confirm the diagnosis and other imaging would be performed if concern for other pathology.

Treatment

Treatment is often times non-operative, which includes decreasing inflammation using antiinflammatories and also includes avoiding positions of compression like deep flexion.  These symptoms will usually resolve over time.  However, if symptoms persist and continue to be bothersome, surgery can be performed in which an incision is made and the nerve decompressed from each compression site to allow for the nerve to heal.

Recovery

If surgery is performed, the elbow is usually immobilized initially to allow for the skin to heal.  Once the skin is healed, there are no major restrictions, however, because the nerve has been compressed and is now free, it takes time for the nerve to regenerate and numbness may still persist while the nerve heals for up to a few months.

Cartilage damage to the elbow can be either long standing wear and tear causing arthritis or can create a discrete defect in the cartilage from an acute trauma to the elbow.

Cause

Wear and tear to the elbow, just as in any other joint, can lead to arthritis of the elbow and cause pain and limited range of motion to the elbow.  Discrete cartilage defects to the elbow in which a piece of cartilage may come free are more commonly caused by a specific injury to the elbow, often times landing on an outstretched hand.  There is also a condition known as Osteochondritis Dessecans (OCD) of the elbow that is caused by a disruption of blood supply and is more commonly seen in younger patients.

Anatomy

The elbow joint is formed by the end of the humerus with two articulating portions known as the trochlea and capitellum, and these articulate the the forearm bones at the radial head (radius) and the ulna.  Cartilage damage can occur at any location that cartilage is present, but most commonly occurs off the humeral side and the radius and most commonly at the radial capitellar joint, which is more to the lateral side or outside of the elbow.

Imaging

X-rays are taken to evaluate for any joint space narrowing or spur formation seen with arthritis and also any cartilage defects like an OCD lesion.  An MRI is often used to evaluate the cartilage in more detail to aid in treatment.

Treatment

Depending on your activity level and symptoms, this will determine how you can be treated.  There are times when time off from activity, like throwing or gymnastics, may help, but if severe enough, surgery may be indicated.  There are a wide variety of surgical treatments depending on your specific injury.  These treatments can vary from elbow arthroscopy with fragment removal, debridement of the elbow or direct fixation of the fragment.

Recovery

Your recovery will depend on the treatment you receive and can vary from regaining elbow motion after a debridement to allowing the fragment to completely heal if fixation is performed.

Stress fractures can occur in multiple areas of the body and are typically caused by chronic stresses with increased force to a bone and may be associated with bad diet or lack of nutrients like calcium and vitamin D.  Stress fractures to the elbow commonly occur to the olecranon, which is the bone on the back of the elbow, and occurs more commonly in pitching athletes.

Cause

The cause of an olecranon stress fracture are related to the increased force from contraction of the triceps to the elbow during repetitive stress in activities such as throwing a baseball.  These can be associated with lack of nutrition, specifically with vitamin D or calcium.

Anatomy

The olecranon in the bone on the back of the elbow that can be felt as the “tip” of the elbow.  It is involved in motion of the elbow from full extension to flexion.  The triceps tendon inserts directly onto the olecranon.

Imaging

X-ray imaging may confirm the diagnosis, but if not shown on x-ray, a CT scan or MRI of the elbow may be performed to evaluate for a small non-displaced fracture not seen on x-ray.

Treatment

Treatment of olecranon stress fractures depend on the demands required by the patient.  There are times when this can be treated with rest from the inciting activity like pitching.  However, there are times when this may need to be fixed with surgery, which often times requires a small incision to place a screw across the fracture site to allow the bone to heal.

Recovery

Recovery is completely dependent on the time it takes the bone to heal.  Often times, bone is completely healed by 6 weeks or longer, however, stress fractures often take longer to heal and need to be followed with x-rays and exam to determine full healing.

The overhead athlete presents unique issues to the elbow.  Because of the throwing motion, the elbow faces significant stresses throughout the throwing motion, but face the greatest force in the late cocking and early acceleration phase of throwing.  The force to the elbow is primarily focused to the inside of the elbow (medial) with a compression force to the outside of the elbow (lateral).  There are many factors that affect the amount of stress that the elbow faces.  The muscles around the elbow are responsible for dynamic stability and strength and fatigue of these muscles changes the force the bones and ligaments face.  Motion, strength and synchronicity of the shoulder is very important in the way forces are directed to the elbow.  As any pitcher knows, there is also significant contribution of the lower extremities, pelvis/hips and core in creating good pitching mechanics to continue peak performance and limit stress to any one body part.

Because of the coordination of the lower extremity, pelvis, core and shoulder in creating proper pitching mechanics, several things can contribute to elbow injuries.  The common elbow injuries seen in pitchers are all related to the valgus torque (arm cocked back to come forward) required during a pitch.  This valgus force is directly limited by the UCL or Tommy John ligament.  The force is also transferred to the lateral elbow as compression and can lead to radiocapitellar compression.  The constant force can also cause impingement in the posteromedial elbow at the olecranon.  As the ulnar nerve runs on the medial side of the elbow, this can also become irritated from pitching as well.  In preventing these injuries, it is important to maintain a strong core and upper extremity as well as maintain proper pitching mechanics to prevent undue stress to the elbow.