Slide 1. Slide 2. Slide 3. The Thrower s Elbow: When to Operate. Medial Elbow Pain in the Athlete. Goal of This Talk

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1 Slide 1 The Thrower s Elbow: When to Operate Luke S. Oh, MD Massachusetts General Hospital Team Physician, Boston Red Sox Team Physician, New England Revolution Consultant, Harvard University Athletics Slide 2 Medial Elbow Pain in the Athlete Differential Diagnosis UCL Injury Medial Epicondylitis Ulnar Neuritis Subluxating Medial Triceps Posteromedial Impingement Posteromedial Trochlear Chondral Erosion Slide 3 Goal of This Talk Understand pathomechanics of throwing elbow Learn special diagnostic physical exam maneuvers Be able to diagnose common medial elbow pathology Review the role of elbow arthroscopy

2 Slide 4 Elbow Anatomy & Biomechanics Slide 5 Elbow Stability Bony Restraints Olecranon - Olecranon fossa articulation Primary stability at: <20 flexion >120 flexion Soft Tissue Restraints Primary static and dynamic stability flexion Arc of motion where overhead throwing occurs Slide 6 Medial Collateral Ligament Complex 3 Bundles: Anterior Primary restraint to valgus force from flexion Subjected to near-failure tensile stress during acceleration phase Posterior Transverse Oblique

3 Slide 7 The Baseball Pitch A Model to Study Elbow Biomechanics Slide 8 Phases of Throwing Spectrum of elbow injury can be best explained by examining forces at elbow during throwing motion Slide 9 Elbow Biomechanics in Pitching Effect on Medial Side = Valgus forces Late cocking/early acceleration phase = 64 N-m Ultimate strength of MCL in cadaver = 33 N-m To protect MCL, shoulder internal rotation and forearm pronation (flexor-pronator) provide dynamic stabilization Effect on Lateral Side = Compressive forces As elbow moves from 110 flexion to N at lateral radiocapitellar articulation Elbow extends at velocity as high as 3,000 /sec Pitch velocity greater due to actions of shoulder, trunk, hips

4 Slide 10 Valgus Extension Overload Syndrome Combination of large valgus load + rapid elbow extension Tension medially Compression laterally Shear posteriorly Basic pathophysiologic model of most of the common elbow injuries in the throwing athlete Slide 11 Specific Diagnostic Tests Slide 12 Valgus Extension Overload Test Detects presence of: Posteromedial olecranon osteophyte Olecranon fossa overgrowth Stabilize humerus, then apply valgus stress while quickly maximally extending the elbow.

5 Slide 13 Valgus Extension Overload Test Detects presence of: Posteromedial olecranon osteophyte Olecranon fossa overgrowth Stabilize humerus, then apply valgus stress while quickly maximally extending the elbow. Slide 14 Slide 15 Static Valgus Stress Test Evaluate anterior bundle of UCL Supine, forearm pronated, elbow flexed Note pain or instability Complete sectioning of MCL only results in 1-2 mm of opening (Calloway, et al.)

6 Slide 16 Static Valgus Stress Test Evaluate anterior bundle of UCL Supine, forearm pronated, elbow flexed Note pain or instability Complete sectioning of MCL only results in 1-2 mm of opening (Calloway, et al.) Slide 17 Static Valgus Stress Test Evaluate anterior bundle of UCL Supine, forearm pronated, elbow flexed Note pain or instability Complete sectioning of MCL only results in 1-2 mm of opening (Calloway, et al.) Slide 18 Milking Maneuver

7 Slide 19 Moving Valgus Stress Test Not Mayo Valgus Stress Test Slide 20 Arthroscopic Valgus Stress Test Slide 21 Role of Imaging Studies

8 Slide 22 Plain X-Rays Plain Radiographs AP, Lat, 2 Obliques Oblique Axial with 120 deg flexion Slide 23 Stress X-Rays Comparison Views Stress Radiographs Not standardized Uninjured baseball pitchers have mild laxity at baseline Ultrasound Stress Slide 24 Stress X-Rays Comparison Views Stress Radiographs Not standardized Uninjured baseball pitchers have mild laxity at baseline Ultrasound Stress

9 Slide 25 MRI Chronic degeneration is characterized by thickening/scarring Acute on chronic injuries show T2SI and perhaps partial or full thickness fiber disruption Undersurface partial tears of distal fibers are common in throwers T-Sign T-Sign Slide 26 Baseball Pitcher s Treatment Options? Decision-making Surgery vs. More nonoperative treatment Choice of graft Choice of fixation technique Choice of surgical approach Ulnar nerve transposition? Slide 27 Elbow UCL Reconstruction Conway (56pts): 68% RTP at same level for at least 1 yr Thompson (32pts): 82% RTP min 2y f/u Azar (59pts): 81% RTP avg 3y f/u Altcheck (32pts): 92% RTP avg 3.3y f/u

10 Slide 28 Role of Elbow Arthroscopy Slide 29 Early Perspective of Elbow Arthroscopy The elbow is unsuitable for examination by arthroscopy and creating arthroscopic portals in the elbow is out of the question Michael S. Burman JBJS 1931 Slide 30 Birth of Elbow Arthroscopy A year later It was noted previously that arthroscopy of the elbow joint was not possible. Since then, we have had cause to revise our opinion, and have visualized the anterior compartment of the elbow joint excellently Michael S. Burman JBJS 1932

11 Slide 31 Indications for Elbow Arthroscopy Diagnostic arthroscopy Debridement/Microfracture of OCD Loose body removal Arthroscopic tennis elbow release Arthroscopic radial head excision Complete synovectomy for rheumatoid elbow Annular ligament release and repair Arthroscopic osteocapsular arthroplasty Slide 32 Complications Nerve Injury Infection Persistent contracture Compartment syndrome Prolonged Drainage from Portal Sites Slide 33 Risk of Nerve Injury Creates anxiety Limits indications for elbow arthroscopy Limits exposure for trainees

12 Slide 34 Slide 35 Anterior Capsule Posterior Interosseous Nerve Anterior Capsule Slide 36 Operating Room Setup

13 Slide 37 Slide 38 Slide 39

14 Slide 40 Slide 41 Slide 42 Cases

15 Slide 43 Arthroscopic Elbow Microfracture for OCD Slide year old Pitcher Loose Body Slide 45 Capitellum OCD

16 Slide 46 MRI Open Growth Plates Slide 47 Slide 48

17 Slide 49 Slide 50 Slide 51

18 Slide 52 Slide 53 Distal Ulnar Portal Slide 54

19 Slide 55 Slide 56 Slide 57

20 Slide Year Old Pitcher with OCD 2 wk f/u: Mild soreness 6 wk f/u: No pain. Full ROM. 3 mo f/u: Played on school s basketball team 6 mo f/u: Back to throwing and playing Short Stop Slide 59 Professional Baseball Pitcher Slide 60 Professional Baseball Pitcher 24 yo M with posterior elbow pain > anterior pain No pain with resisted elbow extension Pain with forced passive elbow extension h/o UCL reconstruction & ulnar nerve decompression ROM

21 Slide 61 Valgus Extension Overload Test Slide 62 Valgus Extension Overload Test Slide 63

22 Slide 64 Slide 65 Slide 66

23 Slide 67 Slide 68 Slide 69 Professional Baseball Pitcher Immediate Postop ROM No pain with terminal flex/ext Currently pitching in the Boston Red Sox Minor League Hasn t felt this good in 3 years

24 Slide 70 Arthroscopic Contracture Release Slide 71 Slide 72

25 Slide 73 Loose Bodies Coronoid Osteophyte Slide 74 Slide 75 Capitellum Radial Head Adhesions over Coronoid

26 Slide 76 Arthroscopic Complete Capsulectomy Slide 77 Posterior Interosseous Nerve Slide 78 Posterior Interosseous Nerve

27 Slide 79 2 Week Postop Visit For Suture Removal Slide 80 Slide 81

28 Slide 82 Thank You