Elbow injuries in athletes Babette Pluim IOC Advanced Team Physician s Course, Oslo Case # 1 13 yr old junior elite tennis player Medial and lateral elbow pain 24-month history with episodes of elbow pain, up to a few weeks each Has just been selected to the national junior squad 10 flexion and 5 extension deficit Pain on palpation of the radial head, the radiohumeral joint line and the posteromedial joint line Can play despite the pain, wears an elbow strap Patella 1
Differential diagnosis Panner s disease Medial apophysitis Osteochondritis dissecans Posteromedial impingement Ulnar collateral ligament injury Panner s disease Age 5 to 10 years Osteochondrosis of the growth plate of the capitellum Relatively mild injury Epiphysis becomes revascularised and develops normal configuration 2
Symptoms Intermittent pain and stiffness in the affected elbow that lasts for several month Symptoms relieved by rest and aggravated by activity Physical exam Local tenderness over capitellum Slight effusion and synovial thickening 20 to 30 degrees extension limitation Slight loss of pronation and supination with tenderness 3
Imaging X-ray elbow Irregularity and delayed development of capitellum Little League elbow (medial epicondylar apophysitis) Age 9 to 14 years Separation and fragmentation of the growth plate (apophysis) of the medial epicondyle Duration 6 weeks to 3 months 4
Symptoms Pain on the medial side of the elbow with throwing. Pain may occur suddenly after one hard throw or gradually over the course of a season Loss of speed and accuracy with throwing Physical exam Tenderness at the medial epicondyle. Swelling and some loss of elbow motion. 5
Imaging X-ray: widening of the apophysis MRI: Bone marrow oedema deep to the apophysis Osteochondritis dissecans Age 11 to 17 6% of all cases of OD concerns the elbow Males: females = 85 : 15 4.1 per 1000 men Duration of symptoms before diagnosis appr. 1 year Osteochondrosis of the anterolateral aspect of capitellum 6
Cause Repeated valgus stress Tenuous blood supply capitellum Symptoms Insidious and progressive dull pain Aggravated by activity and relieved by rest Catching or locking of the elbow is late symptom (fragmentation and loose bodies) 7
Physical exam Tenderness over radiocapitellar joint Limited extension Pronation and supination in full extension may elicit symptoms Imaging MRI X-ray 3D CT scan 8
Conservative treatment Stable lesion: an open capitellar growth plate near-normal elbow motion radiographic findings of subchondral flattening or radiolucency. Operative treatment An unstable lesion: radiographic fragmentation a closed physis restriction of elbow motion greater than 20 degrees 9
Conservative treatment Rest and activity modification Strengthening exercises: shoulders, biceps, triceps, wrists Healing can take up to 6 months 10
Case # 2 16 yr old elite tennis player Left medial elbow pain Woke up with elbow pain during a tennis tournament, does not recall any acute incident No previous history of elbow pain Stabbing pain during serving, backhands and on wide volleys, unable to compete. Medial pain provoked by specific elbow tests 11
Differential diagnosis Medial apophysitis Posteromedial impingement Ulnar collateral ligament injury Posteromedial impingement valgus extension overload Repetitive hyperextension, valgus stress and supination of the elbow Mechanical abutment of bony or soft tissues in the posterior fossa of the elbow 12
Symptoms Medial olecranon pain during throwing/serving Joint effusion Locking, catching and crepitus Extension deficit Loss of speed and accuracy during throwing/serving Physical exam Posterior elbow pain with forced elbow hyperextension. Loss of full extension Posteromedial tenderness Valgus instability Locking or catching 13
Imaging Bone spurs, synovitis, bone marrow oedema, loose bodies Injury ulnar collateral ligament Acute partial tear or gradual failure of the ulnar collateral ligament Caused by repetitive valgus stress during the acceleration phase of the overhead throw 14
Symptoms Medial elbow pain, especially during the acceleration phase of the overhead throw. Pain is often chronic or recurrent Rest helps to relieve the pain There may be acute pain and a popping sensation over the medial elbow Physical examination Medial elbow pain Swelling and loss of ROM Ecchymosis (acute) Pain when making a clenched fist. Valgus stress with the elbow in 25 of flexion reproduces pain 15
Imaging MR arthrography: a partial-thickness tear of the UCL at the attachment on the sublime tubercle Treatment 3 to 6 months of rehabilitation Avoid valgus stress Isometric strengthening: wrist, elbow, shoulder Concentric strengthening exercises Plyometric training Gradual increase in training program If conservative treatment fails or if complete tear, reconstruction of UCL 16
Take home message OCD can be career ending have a high level of suspicion for it! A partial UCL tear can have an insidious onset include the valgus stress test in your physical exam of medial elbow pain! Thank you! 17