Elbow Throwing Injuries
Youth Elbow Injuries
Throwing injuries of the elbow in youth baseball players also usually involve the growth plate. The growth plate is the weakest link in the ligament-bone-cartilage unit. The forces across the elbow can be high enough to cause a widening of the growth plate in the elbow as occurs in the shoulder. The growth plate usually involved is at the part of the humerus called the medial epicondyle. This is the prominence or bump on the inner part of the elbow where the ulnar collateral ligament and flexor bundle attach. Widening or stress reaction of this growth plate is known as Little Leaguer’s Elbow.
The symptoms of Little Leaguer’s Elbow are pain along the inner part of the elbow with throwing, loss of control, and loss of velocity with throwing. The pain usually gets better with rest and returns with throwing.
Widening of the Medial Epicondyle growth plate with fracture of the bottom aspect
Normal Medial Epicondyle growth plate
The treatment for this is similar to that for Little Leaguer’s Shoulder. It involves a period of rest followed by physical therapy, a throwing program, and analysis of pitching mechanics.
An extreme form of Little Leaguer’s Elbow is a Fracture of the Medial Epicondyle. This is when there is a fracture through the growth plate of the medial epicondyle. If the fracture is displaced, it requires surgery to repair it. If the fracture is not treated properly, it may lead to deformity, loss of motion, or Ulnar Nerve problems. The fracture is repaired by putting the bones back together and placing a screw across the fracture to hold it together while it heals.
An Olecranon Stress Fracture occurs due to repetitive stresses on the Ulna with throwing. The Olecranon is the back part of the Ulna, which is the bottom bone of the elbow and one of the two forearm bones. At ball release, the Olecranon bumps up against the back of the Humerus as the elbow is maximally extended. This may result in an Olecranon stress fracture or stress reaction, which may involve an injury to the growth plate. A stress reaction is an injury to the growth plate or bone that precedes a fracture; it’s not as bad as a fracture. If the fracture does not heal with rest, it may require surgery.
Olecranon Stress Fracture
Healed Fracture after surgery
Osteochondritis Dissecans (OCD) of the Capitellum is thought to be due to repetitive microtrauma to the Capitellum (part of the humerus on the outer half of the elbow). Throwing places compressive forces on the outer half of the elbow and this may result in injury to the cartilage and bone underneath it. OCD lesions occur when microtrauma causes a disruption in the blood supply to the bone impairing healing. A fragment of bone and the overlying cartilage (OCD lesion) may not heal to the surrounding bone and may become loose, resulting in a loose body. Symptoms can include painful clicking or catching at the outer part of the elbow or locking of the elbow that requires jiggling or manipulating the elbow to unlock it. Treatment is dependent on age, duration of symptoms, and fragment stability. It may range from rest and no throwing to surgery such as arthroscopic removal of a loose body, microfracture, pinning or screw fixation of the fragment, or cartilage transplantation. In general, nonoperative treatment is successful in those under 11-12 years of age and surgery may be required for those older than 12 years or with loose or unstable fragments.
Adult Elbow Injuries
Elbow injuries in adult pitchers may involve the Ulnar Collateral Ligament (UCL),flexor bundle, cartilage, and bone. UCL Sprains are due to excessive forces across the ligament with pitching. Pain is localized to the inner (medial) part of the elbow and is worse at the cocking and early acceleration phase of throwing.
These are classified as:
Grade I sprains – a stretch of the ligament
Grade II sprains – a partial tear of the ligament
Grade III sprains – a complete tear of the ligament
UCL Tear off the Ulnar attachment
UCL Tear in midportion of ligament
Grade I and II sprains are treated nonoperatively with a period of no throwing and physical therapy aimed at shoulder, forearm, and core strengthening. Most of these respond to rehabilitation and this may take 3 – 4 months. At times, severe grade II sprains may require surgery. An unproven, but promising treatment for UCL sprains is a Platelet Rich Plasma (PRP) injection. This is an injection of one’s own platelets and plasma, which contain growth factors that can help stimulate healing. Grade III sprains or UCL Tears require UCL Reconstruction or Tommy John Surgery (see section on UCL Injuries).
Flexor bundle injuries refer to muscle strain and tendon injuries (tendinitis or tear) of the common wrist flexor muscles and tendon attachment to the medial epicondyle (inner part of the elbow). Pain is localized to the inner (medial) part of the elbow, but is more noticeable at ball release rather than at the cocking or acceleration phases of throwing. This usually responds very well to rest and rehabilitation. A PRP injection may also aid in healing flexor bundle strains.
Valgus Extension Overload or Posterior Impingement are similar conditions causing pain in the back of the elbow. They are not the same entity but result from throwing and its long-term consequences. There is usually a loss of full extension, bone spur formation in the back of the elbow at the Olecranon, and some UCL laxity. This is initially treated with relative rest and rehabilitation. Occasionally, a cortisone injection may help and sometimes, arthroscopic surgery may be needed. The surgery removes scar and bone spur formation in the back of the elbow and improves the pain noted with full extension at the end of a throw.
Loose Bodies and Arthritis may develop after years of pitching or from Osteochondritis Dissecans of the Capitellum. Loose bodies may cause locking or catching of the elbow. Arthritis causes stiffness, loss of motion, and aching of the elbow. Arthroscopic surgery is recommended for removing loose bodies and may help with arthritis symptoms. Surgery is not always needed for arthritis and rest, rehabilitation, anti-inflammatory medications, and occasionally a cortisone injection may help.
Cubital Tunnel Syndrome refers to compression and irritation of the Ulnar Nerve. This is the nerve that goes around the back of the elbow on the inner or medial aspect in a boney groove. The Ulnar Nerve is commonly known as the “funny bone”. This nerve may slip out of its groove and this is called subluxation. Subluxation or compression of this nerve may lead to numbness and tingling in the small finger and outer half of the ring finger. This may occur at night when one sleeps on their arm with the elbow flexed or may occur with activities such as pitching. Treatment may include night splinting to keep the elbow straight, modified activity or rest, or surgery. Surgery to treat this may be an In Situ Decompression, which means cutting the constricting tissue over the nerve and leaving it in its groove. The other surgical option is an Ulnar Nerve Transposition, which involves releasing the nerve and moving out of its groove to the front of the elbow where it is held in place by a sling of tissue.