Golf Injuries in the Upper Extremity

Transcription

1 Golf Injuries in the Upper Extremity David S. Zelouf, MD Philadelphia Hand to Shoulder Center March Meeting 2019

2 I have nothing to disclose Except that I m an avid, competitive golfer and I ve had golfer s elbow for more than three years!

3 Golf related injuries Low back, elbow and wrist account for ~80% of the golf related injuries The golf swing is a dynamic movement with the potential to cause injury during all aspects of the swing

4 Five phases of the golf swing Backswing or takeaway (early, late and top of backswing) Forward swing or downswing Acceleration Early follow-through Late follow-through

5 Main causes of injury in golf Repetition and overuse, especially for the back Impact, especially for the elbow and wrist

6 Elbow injuries Medial epicondylitis Lateral epicondylitis

7 Medial epicondylitis Most common cause of medial elbow pain Degenerative lesion involving the common flexor tendon resulting from microtrauma Often referred to as golfer s elbow but can occur from other sports including tennis and throwing sports Can be occupationally induced Typically occurs in the fourth to sixth decade

8 Mechanism of injury Most believe it occurs as a result of repetitive eccentric loading of the muscles conducting wrist flexion and forearm pronation combined with valgus overload at the elbow Repetitive supraphysiologic stress on the tendon eventually results in microtrauma and degeneration

9 Pathology Historically thought to only be related to the pronator teres, but recent cadaver studies have implicated every medial musculotendinous unit except PL Staged process of pathologic tendon changes: Initial: peritendinous inflammation Later: angiofibroblastic hyperplasia Subsequent: structural breakdown, fibrosis and in some cases calcification

10 Presentation Activity related medial elbow pain, especially with repetitive or forceful pronation Dominant/trail arm in ~60% Associated ulnar nerve symptoms in ~50% 10-20% occurs in association with avocations such as golf Also seen in tennis players and swimmers

11 Presentation Not common in the professional golfer Physical exam typically demonstrates full range of elbow motion, with point tenderness over the anterior aspect of the medial epicondyle Resisted pronation causes pain in ~90%, while resisted wrist flexion causes pain in ~70%

12 Classification Based on the presence or absence of ulnar neuropathy 1A: No ulnar nerve involvement 1B: Mild ulnar nerve symptoms 2: Moderate to severe ulnar neuropathy with objective findings on exam or denervation on EMG

13 Workup Plain x-rays to rule out associated lesions and calcification Valgus stress x-rays if medial elbow instability is suspected MRI to identify degenerative lesion, particularly in WC population NCV/EMG in those with neuritic symptoms

14 Differential diagnosis Bony lesion Referred pain from shoulder/arm pathology Snapping medial triceps MCL insufficiency Isolated ulnar neuropathy

15 What is the most appropriate treatment? Nonoperative most often Patient education and activity modification Equipment modification NSAID s Medial counterforce brace Stretching regimen

16 Treatment Physiotherapy Corticosteroid injections sparingly PRP injections Surgery when all else fails

17 Effective activity modifications Rest will not cut it, especially in a hardcore golfer Avoid hitting off of mats Hit balls off a tee while warming up Hit very few balls and focus on the short game Flexor pronator stretching prior to playing and hitting balls

18 Effective equipment modifications The key is to dampen vibration Grip change from rubber to elastomer Increase grip size See a custom club fitter as shafts may be too stiff, and change iron shafts out to graphite or a composite such as Aerotech Change club heads to ones with vibration dampening properties, as in going from a forged head to a cavity backed design Drop down to lighter weight shaft by at least 15g

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21 Effective technique modifications Change from a digger to a sweeper Learn to decrease swing steepness by learning to swing on plane Lessons from a PGA professional

22 When should surgery be considered? Not before 6-12 months of proper conservative treatment, including activity, technique and equipment modifications

23 What is the most appropriate procedure? Depends on the presence or absence of ulnar neuropathy Without ulnar neuropathy a flexor pronator debridement while protecting the MCL is the most recommended procedure, debriding the tendinosis

24 Surgical options With concomitant ulnar neuropathy, flexor pronator debridement with ulnar nerve decompression, possibly in conjunction with a transposition An alternative is a debridement, ulnar nerve decompression along with a medial epicondylectomy The newest technique with early reports of success involve an ultrasonic percutaneous tenotomy

25 Open medial epicondylitis debridement

26 Lateral epicondylitis Typically affects the lead arm in a golfer, as opposed to medial epicondylitis that affects trail arm May result from overgripping, which may be a sign of proximal weakness Most believe the pathology is a degenerative tendinosis of the ECRB origin, though some maintain that is an articular issue rather than a tendon issue

27 Lateral epicondylitis treatment Treatment is much the same as medial epicondylitis, with equipment modifications, counterforce bracing, and supervised therapy Corticosteroid injections and PRP if above modalities fail Surgical debridement of the ECRB, either open or arthroscopic for prolonged, greater than one year of symptoms and treatment

28 Open debridement lateral epicondylitis

29 Open debridement lateral epicondylitis

30 Debridement lateral epicondylitis ECRB avulsion

31 Wrist injuries Can be from overuse, most commonly related to hitting too many balls at the range off of matts Can be from a sudden, forceful impact Hitting out of heavy rough Hitting a tree root unexpectedly Hitting a shot fat (hitting behind the ball rather than ball first contact)

32 Wrist tendinosis FCU occasionally, but more commonly involves ECU ECU tendinopathy may be related to overuse ECU tendinopathy may be isolated or be associated with subsheath tear and TFCC pathology ECU instability may require subsheath repair or reconstruction in high level golfer

33 ECU Instability Pathology is a separation of the ulnar anchor of the ECU subsheath from the ulnar border of the groove, resulting in the formation of a pouch that allows recurrent subluxation/dislocation of the ECU tendon Treatment: restore normal ECU function by obliterating the pouch with a repair of the subsheath if possible, reconstruction using retinaculum if necessary

34 The ECU is properly located in its groove in pronation But dislocates or snaps out of its groove in supination

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39 TFCC pathology Typically degenerative, but can occur from acute trauma Painful clicking needs to be distinguished from ECU instability as the treatment obviously differs

40 Hamate hook fracture/nonunion Typically seen in the leading wrist The patient may not recall acute trauma Always consider this diagnosis in any golfer with ulnar sided wrist pain in the leading wrist Pain may be dorsal rather than volar

41 Hamate hook nonunion

42 Hamate hook fracture/nonunion treatment I do not see a role for nonoperative treatment as there is no evidence that the hamate hook is capable of healing, and there is a risk of attritional FDP small finger rupture in asymptomatic nonunion I recommend early excision or delayed excision at the end of the golf season with complete dissection of Guyon s canal to avoid injury to the ulnar nerve

43 Hamate hook nonunion excision

44 Hamate hook nonunion excision

45 When asked how has he been able to play for so many year without injury, Langer said, exercise and stretch.

46 Thank you David S. Zelouf, M.D. March Meeting 2019