| Edward Staub, M.D. drstaub.com |
Orthopaedic Surgeon, Sports Medicine, Knee, Hip, Shoulder, Ankle, Spine
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ELBOW INJURIES By Edward Staub, M.D. |
| The following medical articles are intended only for general patient information and education. They are not necessarily specific to any one patient's needs and, therefore, should not be construed as formal medical advice or treatment. Obviously, if you have a similar medical problem, you should consult a physician and not rely on these articles in lieu of treatment. If you reside in Dr. Staub's area, he will be delighted to accept you as a patient, but his ultimate opinion and recommendations will be based on his personal examination of you. |
LATERAL EPICONDYLE
COMMON EXTENSOR TENDON
COMMON EXTENSOR TENDON
PITCHING INJURIES
Major league and Little League pitchers have one thing in common: they frequently develop pain
along the inner side of the elbow.
The pain is caused by throwing, and therefore it is important to understand the mechanism and to be
able to recognize and manage various injuries. As the arm accelerates forward, the muscles along
the inner side of the elbow become very active and stretch.
Four Phases of Throwing:
1. Stance Phase. The body is relaxed.
2. Windup. The shoulder lifts and rotates outward as the arm is cocked. The muscles in front of the
shoulders and around the elbow tighten. Because of increased tension, muscle injuries can occur.
The muscles and the biceps tendon in the front of the shoulder can be sprained or can become
inflamed(tendonitis).
3. Acceleration or forward motion. Considerable force is generated across the shoulder and
elbow during this short phase. The shoulder moves forward and swings from outward to internal
rotation producing a rather violent torque at the ball of the shoulder. There is little active shoulder
muscle contraction: the arm is hurled forward by trunk rotation and trunk muscles. Still, rotatory force
at the shoulder joint may produce muscular injuries in adults and fractures in children.
The muscles along the inside of the elbow are very active during this phase and are tensed and
stretched. If the elbow is overused and abused, inflammation, pain, and tenderness result.
4. Follow-through. As the ball is released, there is an increase of shoulder activity. Also, the
powerful triceps muscle behind the arm contracts to straighten the elbow. The forearm and wrist
rotate if a curve of slider is to be thrown. Sprains of the triceps muscle are common and, later, bone
spurs may occur behind the elbow. It has been reported that 50% of major league pitchers have
permanent elbow deformities and are unable to fully straighten their arms.
The final release of the ball requires powerful bending of the wrist and fingers. Their muscles
originate at the bump at the inner side of the elbow. Overuse can produce sprains or tears in the
muscle origin, resulting in an inflammatory tendonitis. See diagram below.
In growing children, the muscle origin is attached to growing bone, which is weaker than mature bone.
As a result of the stress, the muscle tugs this growing bone away from the remainder of the elbow
bone, thus ending in a small chip fracture.
Both conditions start slowly and develop gradually. Pain is present at the inner side of the elbow and
forearm. Hard throwing aggravates the pain. The bump ( medial epicondyle)at the inner side of the
elbow becomes painful to touch. X-rays of the elbow are useful because bony changes frequently
occur—especially when the condition is chronic. In adults, we may see calcium deposits or bone
spurs. Many major league pitchers have abnormal elbow x-rays. In children, fractures, or irregularity
of the growing bone is imminent. Sometimes the broken fragment may become displaced. In several
studies, x-ray abnormalities have been reported in a high percentage of Little League pitchers
between the ages of 9 and 14, compared to children of the same ages who did not play baseball.
Stress is also considerably increased by throwing curves or other breaking pitches, which require
greater work of the elbow muscles.
Treatment
The adult condition is treated with rest from throwing for one to two weeks. Initial treatment consists of
application of ice packs several times daily, anti-inflammatory medication. Possibly cortisone
injections are used to control inflammation. A sling may be worn to rest the arm. Failure to rest may
result in eventual scarring and permanent stiffness. If the pitcher recovers, he can start tossing the
ball gently, and muscle-strengthening and stretching exercises are recommended. Hard throwing
should be discouraged for about three weeks. Failure to rest may result in eventual scarring and
permanent stiffness. Calcium deposits, bone spurs, and loose pieces of bone in the elbow joint can
occur. In extreme cases, surgery may be required to remove them.
Little Leaguer’s elbow is a more serious problem because of the potential for permanent growth
damage and deformity of the elbow. If a growing bone is injured beyond repair, growth abnormalities
will ensue. Accordingly, all throwing activity must be stopped for at least six weeks. Anti-inflammatory
medication and physiothearpy could be considered. The child’s ultimate return to pitching depends
on improvement in symptoms and x-ray changes. Rarely, if a broken growth bone is displaced,
surgery may be necessary to pin it back.
Prevention
Little Leaguer’s elbow can be prevented by pre-game warm-up exercises and limitations of excessive
pitching. A limit of six innings per week is required by Little League rules. Curve ball pitching, which
places increased stress on the elbow, should also be discouraged.
TENNIS ELBOW
One of the most frustrating problems for the tennis player is tennis elbow (lateral epicondylitis). It is
not an exceedingly painful or disabling condition, but it can produce enough discomfort to interfere
with enjoyable or competitive playing.
Tennis elbow is caused by stress placed on the muscles of the forearm. They are attached to the
elbow by board tendons. The bump on the outer side of the elbow is the lateral epicondyle and the
tendon which attaches there is called the common extensor tendon (see diagram below). The
muscles that connect to the common extensor tendon bend and straighten the wrist and turn the
forearm. When a ball strikes the racquet, its force is transmitted along the forearm to the elbow. The
tendons at the elbow become inflamed (tendonitis) and later, scarred.
Ninety percent of people with tennis elbow develop pain at the outer side of the elbow. This results
from stress on the muscles that straighten the wrist. It occurs as a result of a faulty backhand with
abnormal wrist movement. Less commonly, the pain can be present at the inner side of the elbow due
to the forehand or serve. The serve may produce pain in players who snap their wrists while serving.
Treatment
In mild cases, aspirin or anti-inflammatory medicines can be taken and ice should be applied after
play. Also a snug Velcro strap worn below the elbow may be helpful. The brace works by limiting
muscle excursion and pull at the elbow. Partially avoiding using a painful stroke, such as the
backhand, may also be needed.
In more severe cases, complete rest from tennis for a few weeks is necessary. Rest subdues the
inflammation and helps promote healing. During this time physical therapy consisting of whirlpool and
ultrasound is helpful. Frequently, a cortisone injection may be beneficial.
Prolonged rest or immobilization of the limb is not recommended because muscle wasting or joint
stiffness could result. Maintenance of adequate muscular strength is an important factor in
treatment. Graduated stretching and strengthening exercises should be done after the initial painful
phase has ended. Isometrics are initially done with the elbow and wrist straight. When there is no
pain from a firm handshake, strengthening exercises are started. A three to five pound hand weight is
used to strengthen the forearm muscles. A good exercise is one which is performed with the forearm
flat on a table and the wrist hanging over the edge. A hand weight is held, and the wrist is flexed and
extended. The small muscles of the hand should also be strengthened by squeezing a tennis ball or
by spreading the fingers against a thick rubber band. People with tennis elbow have definite arm
weakness, so a formal exercise program is most important. In recreational players, the dominant arm
should be 5% stronger than the non-dominant arm. In competitive players, the dominant arm should
be 10% strong.
After recovery, routine stretching and strengthening exercises should be continued.
As a last resort, surgery may be necessary in a patient who is resistant to treatment. Although the
surgery is relatively simple and frequently effective, most people recover without an operation.
Technical and Equipment Modifications
At the top of the list is tennis lessons which may help alleviate poor technical habits, such as faulty
arm positions during the backhand. Poor stroke techniques and mis-hits probably contribute to elbow
problems more than anything else. Overheads or serves with the elbow flexed in a forward direction –
adding to exaggerated spin or a whip motion can lead to tennis elbow. Most pros and top notch tennis
players all seem to agree that many tennis related ailments are caused not by equipment but by faulty
technique.
Modifications in equipment are simple enough and useful:
1. Surface: A fast court such as grass or cement will speed the velocity of the ball and increase
impact force generated toward the elbow. Therefore, playing on slower surfaces, such as clay or Har-
true is preferable.
2. Balls: Heavyweight, dead, or wet balls are heavier and therefore produce more force on the
racquet. Fresh, regular-duty balls are recommended.
3. Racquet: In the past,there were different racquet materieals like wood or some type of composit,
but today most racquets consist of graphite, albeit perhaps different degrees of graphite. However,
the lighter, medium-flex, evenly-balanced racquets or light headed racquets are probably best.
Oversized racquets are useful for increasing the “sweet spot,” thus making the ball less likely to hit the
frame, producing less elbow stress.
4. Strings: A moderate tension on the strings (52 to 55 lbs) is recommended. 58-60 lbs is tighter.
Gut is more resilient and slightly better than nylon, but costs more. More racquets have polyester
stringing.This material is stiffer than synthetic nylon. Because polyseter causes less give,more stress
can be transmitted to the arm. Therefore, many tennis shops recommend stringing with only 50%
polyester and the other 50% with nylon to offset the stiffness. A tighter stringing pattern will allow
better control but less power and more arm stress. Conversely, a looser stringing pattern allows less
control(trampoline effect) but more power and less shock onto the arm. Vibration dampeners placed
between the strings will help relieve stress.
5. Grip: A correct hand grip size will produce less stress. Most players tend to use a handle that
is too large. The proper size can be determined by measuring the distance between the tip of the ring
finger and the first palm crease. Many pros feel that it is better to err on the side of a larger grip. A
smaller grip could lead to a player holding the grip tighter to keep control and thus also this can
transmit more stress to the forearm
To conclude, in all of these injuries, prompt recognition and treatment, as well as thoughtful medical
and technical measures, is important to prevent permanent impairment.