Abstract
The throwing athlete places supraphysiologic stress across the elbow joint from repetitive throwing motion. Over time, and occasionally acutely, this stress may damage the ulnar collateral ligament (UCL), flexor–pronator mass, ulnar nerve and cause bone exostosis. A detailed history and physical examination, supplemented by imaging, aids in accurate diagnosis. This chapter focuses on diagnosis and nonoperative management of the throwing elbow. This process follows a multiphasic approach that focuses on pain-free functional range of motion (ROM) and strengthening the upper extremity. The rehabilitation program then implements a throwing program for gradual return to play.
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- UCL:
-
Ulnar collateral ligament
- VEO:
-
Valgus extension overload
- ROM:
-
Range of motion
References
Chen FS, Rokito AS, Jobe FW. Medial Elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 2001;9(2):99–113.
Bain GI, Mehta JA. Anatomy of the elbow joint and surgical approaches. In: Baker Jr CL, Plancher KD, editors. Operative treatment of elbow injuries. New York, NY: Springer; 2001. p. 1–27.
O’Driscoll SW, Jupiter JB, King GJW, et al. The unstable elbow. J Bone Joint Surg Am. 2000;82:724–38.
Callaway GH, Field LD, Deng XH, Torzilli PA, O’Brien SJ, Altchek DW, Warren RF. Biomechanical evaluation of the medial collateral ligament of the elbow. J Bone Joint Surg Am. 1997;79:1223–31.
Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res. 1987;5:372–7.
Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res. 1991;(271):170–9.
Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11:313–9.
Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res. 1991;(265):187–95.
Park MC, Ahmad CS. Dynamic contributions of the flexor-pronator mass to elbow valgus stability. J Bone Joint Surg Am. 2004;86-A(10):2268–74.
Murthi AM, Keener JD, Armstrong AD, Getz CL. The recurrent unstable elbow: diagnosis and treatment. J Bone Joint Surg Am. 2010;92(8):1794–804.
Conte S, Requa RK, Garrick JG. Disability days in major league baseball. Am J Sports Med. 2001;29(4):431–6.
Posner M, Cameron KL, Wolf JM, Belmont PJ, Owens BD. Epidemiology of major league baseball injuries. Am J Sports Med. 2011;39(8):1676–80.
Fleisig GS, Escamilla RF. Biomechanics of the elbow in the throwing athlete. Oper Tech Sports Med. 1994;4(2):62–8.
Werner SL, Fleisig GS, Dillman CJ, Andrews JR. Biomechanics of the elbow during baseball pitching. J Orthop Sports Phys Ther. 1993;17(6):274–8.
Cain E, Dugas J, Wolf R, Andrews J. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 2003;31:621–35.
Fleisig GS, Andrews JR, Dillman CJ, et al. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23:233–9.
Dillman CJ, Smutz P, Werner S. Valgus extension overload in baseball pitching. Med Sci Sports Exerc. 1991;23:S135.
Schickendantz M. Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin. 2002;18:65–75. doi:10.1016/S0749-0712(02)00007-0.
Morrey BF. Applied anatomy and biomechanics of the elbow joint. Instr Course Lect. 1986;35:59–68.
Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985;(201):84–90.
Dillman CJ, Fleisig GS, Andrews JR. Biomechanics of pitching with emphasis upon shoulder kinematics. J Orthop Sports Phys Ther. 1993;18:402–8.
Pappas A, Zawacki R, Sullivan T. Biomechanics of baseball pitching: a preliminary report. Am J Sports Med. 1985;13:216–22.
Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. J Bone Joint Surg. 1992;74A:67–83.
Jobe FW, Kvitne RS. Elbow instability in the athlete. Instr Course Lect. 1991;40:17–23.
Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg. 1986;68A:1158–63.
Timmerman LA, Schwarts ML, Andrews JR. History and arthroscopic anatomy of the ulnar collateral ligament of the elbow. Am J Sports Med. 1994;22:667–73.
Ahmed CS, Lee TQ, ElAttrache NS. Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation. Am J Sports Med. 2003;31(3):332–7.
Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010;29(4):619–44.
Boatright JR, D’Alessandro DF. Nerve entrapment syndromes at the elbow. In: Jobe FW, Pink MM, Glousman RE, Kvitne RE, Zemel NP, editors. Operative techniques in upper extremity sports injuries. St. Louis, MO: Mosby-Year Book; 1996. p. 518–37.
Gabel GT, Morrey BF. Operative treatment of medial epicondylitis: influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995;77:1065–9.
Harris JD, Lintner DM. Nerve injuries about the elbow in the athlete. Sports Med Arthrosc. 2014;22(3):e7–15. doi:10.1097/JSA.0000000000000038.
Hammond J, Cole BJ. Elbow injuries and the throwing athlete. In: Nicholson GP, editor. Orthopedic knowledge update: shoulder and elbow 4. Rosemont, IL: American Academy of Orthopedic Surgeons; 2013. p. 495–503.
Andrews JR, Wilk KE, Satterwhite YE, et al. Physical examination of the thrower’s elbow. J Orthop Sports Phys Ther. 1993;17:296–304.
Azar FM, Andrews JR, Wilk KE, et al. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28:16–23.
Fleisig GS, Kingsley DS, Loftice JW, et al. Kinetic comparison among the fastball, curveball, change-up, and slider in collegiate baseball pitchers. Am J Sports Med. 2006;34(3):423–30.
Dugas JR, Weiland AJ. Vascular pathology in the throwing athlete. Hand Clin. 2000;16:477–85.
McCall BR, Cain Jr EL. Diagnosis, treatment, and rehabilitation of the thrower’s elbow. Curr Sports Med Rep. 2005;4(5):249–54.
O’Holleran JD, Altchek DW. The thrower’s elbow: arthroscopic treatment of valgus extension overload syndrome. HSS J. 2006;2(1):83–93.
Beals RK. The normal carrying angle of the elbow. Clin Orthop Relat Res. 1976;(119):194–6.
King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop Relat Res. 1969;(67):116–23.
American Academy of Orthopedic Surgeons. Joint motion: method of measuring and recording. Chicago, IL: American Academy of Orthopedic Surgeons; 1965.
O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231–9.
Wilson FD, Andrews JR, Blackburn TA, McClusky G. Valgus extension overload in the pitching elbow. Am J Sports Med. 1983;11:83–8.
Ahmed CS, Conway JE. Elbow arthroscopy: valgus extension overload. Instr Course Lect. 2011;60:191–7.
Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med. 1994;22:26–32.
Cotton A, Jacobson J, Brossman J, Pedowitz R, Haghighi P, Trudell D, Resnick D. Collateral ligaments of the elbow: conventional MR imaging and MR arthrography with coronal oblique plane and elbow flexion. Radiology. 1997;204:806–12.
Munshi M, Pretterblieber ML, Chung CB, Haghighi P, Cho JH, Trudell DJ, Resnick D. Anterior bundle of ulnar collateral ligament: evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic analysis. Radiology. 2004;231:797–803.
Sasaki J, Takahara M, Ogino T, Kashiwa H, Ishigaki D, Kanauchi Y. Ultrasonographic assessment of the ulnar collateral ligament and medial elbow laxity in college baseball players. J Bone Joint Surg Am. 2002;84:525–31.
Osbahr DC, Chalmers PN, Frank JS, Williams III RJ, Widmann RF, Green DW. Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: a variant of Little League elbow. J Shoulder Elbow Surg. 2010;19:951–7.
Hassan SE, Parks BG, Douoguih WA, Osbahr DC. Effect of distal ulnar collateral ligament tear pattern on contact forces and valgus stability in the posteromedial compartment of the elbow. Am J Sports Med. 2014;43(2):447–52.
Cain Jr EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426–34.
Savoie III FH, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008;36:1066–72.
Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med. 2008;36:1193–205.
Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am J Sports Med. 2013;41(7):1689–95. doi:10.1177/0363546513487979.
Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Rehabilitation of the overhead athlete’s elbow. Sports Health. 2012;4(5):404–14. doi:10.1177/1941738112455006.
Coutts RD, Toth C, Kaita JH. The role of continuous passive motion in the rehabilitation of the total knee patient. In: Hungerford DS, Krackow KA, Kenna RV, editors. Total knee arthroplasty: a comprehensive approach. Baltimore, MD: Williams & Wilkins; 1984. p. 126–32.
Dehne E, Torp RP. Treatment of joint injuries by immediate mobilization: based upon the spinal adaption concept. Clin Orthop Relat Res. 1971;(77):218–32.
Haggmark T, Eriksson E. Cylinder or mobile cast brace after knee ligament surgery. A clinical analysis and morphologic and enzymatic studies of changes in the quadriceps muscle. Am J Sports Med. 1979;7(1):48–56.
Noyes FR, Mangine RE, Barber S. Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. 1987;15(2):149–60.
Perkins G. Rest and movement. J Bone Joint Surg Br. 1953;35(4):521–39.
Salter RB, Hamilton HW, Wedge JH, et al. Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: a preliminary report of a feasibility study. J Orthop Res. 1984;1(3):325–42.
Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage: an experimental investigation in the rabbit. J Bone Joint Surg Am. 1980;62(8):1232–51.
Wilk KE, Arrigo C, Andrews JR. Rehabilitation of the elbow in the throwing athlete. J Orthop Sports Phys Ther. 1993;17(6):305–17.
Kottke FJ, Pauley DL, Ptak RA. The rationale for prolonged stretching for correction of shortening of connective tissue. Arch Phys Med Rehabil. 1966;47(6):345–52.
Sapega AA, Quedenfeld TC, Moyer RA, Butler RA. Biophysical factors in range-of-motion exercise. Phys Sports Med. 1981;9(12):57–65.
Warren CG, Lehmann JF, Koblanski JN. Heat and stretch procedures: an evaluation using rat tail tendon. Arch Phys Med Rehabil. 1976;57(3):122–6.
Warren CG, Lehmann JF, Koblanski JN. Elongation of rat tail tendon: effect of load and temperature. Arch Phys Med Rehabil. 1971;52(10):465–74.
Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007;42(4):464–9.
Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004;34(7):385–94.
Wilk KE, Obma P, Simpson CD, Cain EL, Dugas JR, Andrews JR. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther. 2009;39(2):38–54.
Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. The advanced throwers ten exercise program: a new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete. Phys Sports Med. 2011;39(4):90–7.
Schulte-Edelmann JA, Davies GJ, Kernozek TW, Gerberding ED. The effects of plyometric training of the posterior shoulder and elbow. J Strength Cond Res. 2005;19(1):129–34.
Wilk KE, Voight ML, Keirns MA, Gambetta V, Andrews JR, Dillman CJ. Stretch-shortening drills for the upper extremities: theory and clinical application. J Orthop Sports Phys Ther. 1993;17(5):225–39.
Reinold MM, Wilk KE, Reed J, Crenshaw K, Andrews JR. Interval sport programs: guidelines for baseball, tennis, and golf. J Orthop Sports Phys Ther. 2002;32(6):293–8.
Fleisig GS, Bolt B, Fortenbaugh D, Wilk KE, Andrews JR. Biomechanical comparison of baseball pitching and long-toss: implications for training and rehabilitation. J Orthop Sports Phys Ther. 2011;41(5):296–303.
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Sethi, P., Macken, C.J. (2017). Evaluation and Nonoperative Treatment of the Unstable Throwing Elbow. In: Tashjian, R. (eds) The Unstable Elbow. Springer, Cham. https://doi.org/10.1007/978-3-319-46019-2_11
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