Lateral Compression Injuries

The entities associated with lateral compression injuries are osteochondritis dissecans, osteochondrosis of the capitellum, and osteochondrosis or deformation of the radial head. Osteochondritis Dissecans (OCD) of the Capitellum The repetitive lateral compression forces placed on the elbow with throwing result in microfractures of the capitel-lar cartilage surface and subsequent edema of the underlying bone. This edema produces avascular necrosis because of the precarious circulation in the...

Biomechanics Of The Elbow During Baseball Pitching

One of the most demanding activities on the elbow in sports is the baseball pitch. The prevalence of overuse injury to the elbow due to pitching is well docu-mented.12,18-23 Most of these overuse throwing injuries result from repetitive trauma to the elbow. An understanding and application of proper pitching mechanics can help to maximize performance and minimize the potential for injury. Although the baseball pitch is one continuous motion, dividing the motion into phases helps in...

Arm Acceleration

The arm-acceleration phase is the short time from maximum shoulder external rotation to ball release (Fig. 2.1H,I). The entire phase lasts only a few hundredths of a second. A maximum elbow angular velocity of 2100 to 2700 per second occurs approximately halfway through the acceleration phase.24 Maximum elbow angular velocity is similar for the fastball, curveball, and slider pitches, but is markedly less during the change-up pitch (Table 2.2).35 This rapid elbow extension may be due primarily...

Nonoperative Treatment

Treatment options for UCL injuries vary according to the severity of the injury and the patient's athletic requirements. For ligament strains, the basic treatment princi FIGURE 7.6. (A) Lateral radiograph shows degenerative osteophyte formation at the anterior ulnohumeral joint (left arrow) and a loose body in the posterior fossa (right arrow). (B) Anteroposterior radiograph shows calcification at the origin of the ulnar collateral ligament. (C) Hyperflexion lateral radiograph demonstrates...

The Neural Tunnels Around the Elbow

Cubital Tunnel

The ulnar nerve is derived from the medial cord of the brachial plexus (C7-C8, T1). It passes posteriorly through the medial intermuscular septum 8 cm above the epi-condyle and continues distally along the medial margin of the triceps with the superior ulnar collateral artery. It provides no branches in the arm. The ulnar nerve enters the cubital tunnel (Fig. 1.9) posterior to the medial epi-condyle and grooves the posterior portion of the medial collateral ligament. A few small twigs supply...

Football Passing

Shapiro videotaped 12 collegiate football quarterbacks to quantify the dynamics of the passing motion.43 They found results similar to those of Fleisig et al., but discrepancies existed between the magnitudes of certain pa-rameters.43 One explanation for the differences is the sampling rates used for each study.42 Fleisig et al. collected data at 200 Hz, and Rash and Shapiro collected data at 60 Hz. Although football passing is qualitatively similar to baseball pitching, it requires markedly...

The Deep Fascia of the Upper Limb

The next layer encountered is the investing layer of deep fascia, which is strongest posteriorly where it covers the triceps muscle. Below the insertion of the deltoid, it is thickened on each side by a strong intermuscular septum that stabilizes the fascia to the respective supracondylar ridge and epicondyle. The intermuscular septa separate the posterior triceps muscle from the muscles of the anterior compartment of the arm and provide attachment for both. The radial nerve and the anterior...

Biomechanics Of The Elbow During Underhand Throwing

Although the traditional view is that underhand pitchers have minimal risk for sustaining pitching-related injuries, Loosli et al. found a high incidence of injuries to underhand pitchers.58 Thirty-one percent of these injuries were at or distal to the elbow. Unfortunately, research investigating the motion involved in underhand throwing is limited. Barrentine et al. estimated the amount of force experienced at the elbow during underhand softball pitching.59 During the acceleration phase, a...

Results And Expectations

Athletes who have isolated posterior compartment lesions usually return to their premorbid level of competition. At our clinic, we have found that 71 of athletes FIGURE 10.7. Intraoperative lateral radiograph of the elbow after arthroscopic excision of the osteophyte. FIGURE 10.7. Intraoperative lateral radiograph of the elbow after arthroscopic excision of the osteophyte. TABLE 10.1. Postoperative rehabilitative protocol for elbow arthroscopy. Goal Full wrist and elbow ROM, decrease swelling,...

Clinical Presentation Of Medial Epicondylitis

Medial epicondylitis is also known as golfer's elbow. It is far less common than lateral epicondylitis. Typically, the patient profile is similar to that for lateral epicondylitis. The exception is the young (i.e., 15 to 25 years of age) throwing athlete who presents with either acute or subacute onset of symptoms. Tenderness is present at the origin of the common flexor tendon at the medial epicondyle. Resisted wrist flexion with the forearm supinated or resisted pronation reproduces the...

Treatment

Tendond Sutturing

In the past, nonoperative management of distal biceps tendon ruptures was popular.2,4,6,7,10-12 Authors of numerous case reports suggested that early motion and strengthening exercises could restore normal strength. Authors of subsequent studies in which they used dynamometers demonstrated the deficits of nonoperative treatment.4,6 They found that patients who were treated nonoperatively for their distal biceps tendon ruptures had weaker supination and flexion than patients who had the ruptured...

Pathogenesis of Injury

Elbow Ossification Center Fusion

Skeletal maturation of the elbow centers on the primary ossification centers of the humerus, ulna, and radius and on six distinct secondary centers of ossification. The chronological appearance and closure of these centers has been well documented6,7,8 (Fig. 5.1). Childhood terminates with the appearance of all secondary centers of ossification, adolescence terminates with the fusion of all secondary centers of ossification, and young adulthood terminates with the completion of all bone growth...

Contents

v xi 1 Anatomy of the Elbow Joint and Surgical 1 2 Biomechanics of the Elbow and Throwing 29 Steven W. Barrentine, Glenn S. Fleisig, Charles J. Dillman, and James R. Andrews 3 History and Physical Examination of the 41 4 Magnetic Resonance Imaging of the 55 Stephen J. Augustine, George M. McCluskey III, and Luis Miranda-Torres 6 Lateral and Medial Epicondylitis 79 George M. McCluskey III and Michael S. Merkley 7 Ulnar Collateral Ligament Injuries 89 Nathan M. Breazeale and David W. Altcheck 8...

History And Physical Examination History

A detailed history and physical examination is essential in evaluating the elbow for UCL insufficiency. Most athletes who present for evaluation participate in activities involving repetitive overhead throwing motions. Knowledge of previous elbow injuries and treatments aids the examiner in the initial examination. The chronology of the development of elbow pain can give clues to the underlying problems and can indicate where the injury lies on the spectrum of UCL injury. A history of mild pain...

Physical Examination And Diagnosis

Because the injuries occurring in throwing athletes are complex and subtle, the treating physician needs to take a detailed history and complete a thorough physical examination of the injured athlete. Finding concomitant shoulder and elbow pain in the thrower is common. The patient may have only slight discomfort with throwing, but may have a subjective and documented decrease in velocity, distance, or control. Commonly, pitchers who have VEO report early release, high pitches, and pain during...

Surgical Failure

The surgical procedures to address tennis elbow are extremely reliable. Success rates of approximately 90 can be expected. Typically, the most common cause of perceived surgical failure is a return to activity that is too aggressive. In the absence of secondary gain issues (i.e., workers' compensation claims), pain from 6 to 9 months after surgery is unusual in a compliant patient. Morrey differentiated surgical failures into two types type I, patients whose symptom complex is similar to their...

Introduction

Lateral and medial epicondylitis are diagnostic terms that describe the constellation of pain and localized tenderness at the epicondyles of the distal humerus. Major originally coined the term tennis elbow in 1883.1 This eponym remains despite the fact that 95 of affected people are not tennis players.2 However, 10 to 50 of persons who regularly play tennis will, at some time, experience symptoms characteristic of this disorder.3 Lateral epicondylitis is far more common than medial...

Entrapment Neuropathies

The ulnar nerve is well seen on axial MR images as it passes through the cubital tunnel.61,62 Anatomic variations of the cubital tunnel retinaculum may contribute to ulnar neuropathy.63 These variations in the cubital tunnel retinaculum and the appearance of the ulnar nerve itself can be identified with MRI. The retinaculum may be thickened in 22 of the population, resulting in dynamic compression of the ulnar nerve during elbow flexion. In 11 of the population, the cubital tunnel retinaculum...

Diagnosis

Lateral Elbow Positioning

Patients who have lateral elbow instability present with a variable history and symptoms. Previous trauma can involve a documented dislocation of the elbow or an injury without dislocation. Patients report a sensation of their elbow intermittently giving way or going out. Common mechanical symptoms include popping, catching, or snapping of the elbow. The symptoms typically manifest during loading of the joint in a slightly flexed position with the forearm in supination, such as when picking up...

Physical Examination

Physical examination of the elbow for UCL injury entails assessing the integrity of the ligament and evaluating the joint and surrounding structures for associated injuries. Inspection of the upper extremity in overhead athletes often reveals hemihypertrophy of the dominant extrem-ity.23 In acute cases of UCL injury, pain or guarding might limit elbow range of motion. In chronic cases and especially in throwers, motion might be limited at terminal extension due to bony changes in the posterior...

Arm Cocking

The arm-cocking phase, which lasts from 0.10 to 0.15 second, begins at lead foot contact and ends at maximum shoulder external rotation (Fig. 2.1E-H). Arm cocking is a more accurate description of this phase than cocking, because only the arm is cocked during this entire phase.24 Some parts of the body, such as the pelvis and lower extremities, accelerate or decelerate during this phase. Shortly after the arm-cocking phase begins, the pelvis and upper torso rotate to face the batter. Elbow...

References

Lateral Positioning Elbow Surgery

Bony injuries about the elbow in the throwing athlete. Instructional Course Lect 1985 34 323-331. 2. Andrews JR, Craven WM. Lesions of the posterior compartment of the elbow. Clin Sports Med 1991 10 637-652. 3. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995 23 407-413. 4. Barnes DA, Tullos HS. An analysis of 100 symptomatic baseball players. Am J Sports Med 1978 6 62-67. 5. Bennett GE. Shoulder and elbow lesions of the...

Lateral Epicondylitis and Lateral Collateral Ligament Injury

Epizondylus Radial

Lateral epicondylitis, also called tennis elbow, is caused by degeneration and tearing of the common extensor ten-don.22 This condition often occurs as a result of repetitive sports-related trauma to the tendon, although it is seen far more commonly in nonathletes.9 In the typical patient, the degenerated extensor carpi radialis brevis tendon is partially avulsed from the lateral epicondyle.22 Scar tissue FIGURE 4.4. Clinically suspected tennis elbow in a patient who did not respond to a local...

Authors Preferred Method

Sublime Tuercle Elbow

The preoperative examination in the throwing athlete who has a UCL injury often reveals an intra-articular injury that needs to be evaluated and addressed at the time of ligament reconstruction. In addition, some athletes who have suspected ligament laxity might have equivocal opening on valgus stress examination. For these reasons, we often evaluate the elbow using arthroscopic surgery in conjunction with the ligament reconstruction procedure. The arthroscopic evaluation permits visualization...

Procedures

Vangsness Jobe Medial Epicondylitis

Before considering surgery, the surgeon should re-examine the patient to confirm the exact location of the tenderness and to assess the results of provocative maneu- FIGURE 6.3. Axial view of the elbow reveals calcification at the lateral epicondylar extensor tendon attachment site. This finding suggests a chronic and advanced pathologic process. FIGURE 6.3. Axial view of the elbow reveals calcification at the lateral epicondylar extensor tendon attachment site. This finding suggests a chronic...

Provocative Tests Lateral

Chair Lift Test Tennis Elbow

Stress to the extensor carpi radialis longus and brevis muscles reproduces the discomfort associated with lateral epi-condylitis. To create this stress, the patient fully extends the elbow and resists active wrist and finger extension (Fig. 3.15). This maneuver elicits pain at the lateral epicondyle and is the most sensitive provocative maneuver for lateral epicondylitis. Passive flexion of the wrist with the elbow FIGURE 3.14. (A) Positive test for posterolateral rotatory subluxation of the...

Functional Anatomy

Lateral elbow instability is most commonly a posttrau-matic condition. In most instances, the injury involves a combination of axial compressive, external rotatory, and valgus forces applied to the elbow.3,4 Researchers also have proposed varus extension as a mechanism of injury.1 It also may have an iatrogenic origin, because this instability has been reported following overly aggressive de-bridement of the lateral soft tissues for recalcitrant lateral epicondylitis, or tennis elbow.1,5 This...

The Subcutaneous Plane

The subcutaneous plane consists mainly of adipose tissue that is abundant except over each epicondyle and on the subcutaneous border of the ulna and olecranon. This plane contains the veins, which are predominantly anterior and drain into the cephalic lateral and basilic medial veins Fig. 1.2 . The subcutaneous plane also contains the cutaneous nerves, which are located in the depth of the subcutaneous fat and just superficial to the investing fascia.1 The lateral cutaneous nerve of the forearm...

Medial Epicondylitis

Epizondylus Radial

Medial epicondylitis, also known as golfer's elbow, pitcher's elbow, or medial tennis elbow, is caused by degeneration of the common flexor tendon secondary to overload of the flexor-pronator muscle group that arises from the medial epicondyle.7-9 The spectrum of damage to the muscle-tendon unit that may be characterized with MRI includes muscle strain injury, tendon degeneration tendinosis , and tendon disruption Fig. 4.3 . MRI is useful for detecting and characterizing acute muscle injury and...