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Evaluation and Nonoperative Treatment of the Unstable Throwing Elbow

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The Unstable Elbow

Abstract

The throwing athlete places supraphysiologic stress across the elbow joint from repetitive throwing motion. Over time, and occasionally acutely, this stress may damage the ulnar collateral ligament (UCL), flexor–pronator mass, ulnar nerve and cause bone exostosis. A detailed history and physical examination, supplemented by imaging, aids in accurate diagnosis. This chapter focuses on diagnosis and nonoperative management of the throwing elbow. This process follows a multiphasic approach that focuses on pain-free functional range of motion (ROM) and strengthening the upper extremity. The rehabilitation program then implements a throwing program for gradual return to play.

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Abbreviations

UCL:

Ulnar collateral ligament

VEO:

Valgus extension overload

ROM:

Range of motion

References

  1. Chen FS, Rokito AS, Jobe FW. Medial Elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 2001;9(2):99–113.

    Article  CAS  PubMed  Google Scholar 

  2. Bain GI, Mehta JA. Anatomy of the elbow joint and surgical approaches. In: Baker Jr CL, Plancher KD, editors. Operative treatment of elbow injuries. New York, NY: Springer; 2001. p. 1–27.

    Google Scholar 

  3. O’Driscoll SW, Jupiter JB, King GJW, et al. The unstable elbow. J Bone Joint Surg Am. 2000;82:724–38.

    Article  Google Scholar 

  4. Callaway GH, Field LD, Deng XH, Torzilli PA, O’Brien SJ, Altchek DW, Warren RF. Biomechanical evaluation of the medial collateral ligament of the elbow. J Bone Joint Surg Am. 1997;79:1223–31.

    Article  CAS  PubMed  Google Scholar 

  5. Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res. 1987;5:372–7.

    Article  CAS  PubMed  Google Scholar 

  6. Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res. 1991;(271):170–9.

    Google Scholar 

  7. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11:313–9.

    Article  Google Scholar 

  8. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res. 1991;(265):187–95.

    Google Scholar 

  9. Park MC, Ahmad CS. Dynamic contributions of the flexor-pronator mass to elbow valgus stability. J Bone Joint Surg Am. 2004;86-A(10):2268–74.

    Article  PubMed  Google Scholar 

  10. Murthi AM, Keener JD, Armstrong AD, Getz CL. The recurrent unstable elbow: diagnosis and treatment. J Bone Joint Surg Am. 2010;92(8):1794–804.

    PubMed  Google Scholar 

  11. Conte S, Requa RK, Garrick JG. Disability days in major league baseball. Am J Sports Med. 2001;29(4):431–6.

    CAS  PubMed  Google Scholar 

  12. Posner M, Cameron KL, Wolf JM, Belmont PJ, Owens BD. Epidemiology of major league baseball injuries. Am J Sports Med. 2011;39(8):1676–80.

    Article  PubMed  Google Scholar 

  13. Fleisig GS, Escamilla RF. Biomechanics of the elbow in the throwing athlete. Oper Tech Sports Med. 1994;4(2):62–8.

    Article  Google Scholar 

  14. Werner SL, Fleisig GS, Dillman CJ, Andrews JR. Biomechanics of the elbow during baseball pitching. J Orthop Sports Phys Ther. 1993;17(6):274–8.

    Article  CAS  PubMed  Google Scholar 

  15. Cain E, Dugas J, Wolf R, Andrews J. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 2003;31:621–35.

    PubMed  Google Scholar 

  16. Fleisig GS, Andrews JR, Dillman CJ, et al. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23:233–9.

    Article  CAS  PubMed  Google Scholar 

  17. Dillman CJ, Smutz P, Werner S. Valgus extension overload in baseball pitching. Med Sci Sports Exerc. 1991;23:S135.

    Google Scholar 

  18. Schickendantz M. Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin. 2002;18:65–75. doi:10.1016/S0749-0712(02)00007-0.

    Article  PubMed  Google Scholar 

  19. Morrey BF. Applied anatomy and biomechanics of the elbow joint. Instr Course Lect. 1986;35:59–68.

    CAS  PubMed  Google Scholar 

  20. Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985;(201):84–90.

    Google Scholar 

  21. Dillman CJ, Fleisig GS, Andrews JR. Biomechanics of pitching with emphasis upon shoulder kinematics. J Orthop Sports Phys Ther. 1993;18:402–8.

    Article  CAS  PubMed  Google Scholar 

  22. Pappas A, Zawacki R, Sullivan T. Biomechanics of baseball pitching: a preliminary report. Am J Sports Med. 1985;13:216–22.

    Article  CAS  PubMed  Google Scholar 

  23. Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. J Bone Joint Surg. 1992;74A:67–83.

    Article  Google Scholar 

  24. Jobe FW, Kvitne RS. Elbow instability in the athlete. Instr Course Lect. 1991;40:17–23.

    Google Scholar 

  25. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg. 1986;68A:1158–63.

    Article  Google Scholar 

  26. Timmerman LA, Schwarts ML, Andrews JR. History and arthroscopic anatomy of the ulnar collateral ligament of the elbow. Am J Sports Med. 1994;22:667–73.

    Article  CAS  PubMed  Google Scholar 

  27. Ahmed CS, Lee TQ, ElAttrache NS. Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation. Am J Sports Med. 2003;31(3):332–7.

    Google Scholar 

  28. Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010;29(4):619–44.

    Article  PubMed  Google Scholar 

  29. Boatright JR, D’Alessandro DF. Nerve entrapment syndromes at the elbow. In: Jobe FW, Pink MM, Glousman RE, Kvitne RE, Zemel NP, editors. Operative techniques in upper extremity sports injuries. St. Louis, MO: Mosby-Year Book; 1996. p. 518–37.

    Google Scholar 

  30. Gabel GT, Morrey BF. Operative treatment of medial epicondylitis: influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995;77:1065–9.

    Article  CAS  PubMed  Google Scholar 

  31. Harris JD, Lintner DM. Nerve injuries about the elbow in the athlete. Sports Med Arthrosc. 2014;22(3):e7–15. doi:10.1097/JSA.0000000000000038.

    Article  PubMed  Google Scholar 

  32. Hammond J, Cole BJ. Elbow injuries and the throwing athlete. In: Nicholson GP, editor. Orthopedic knowledge update: shoulder and elbow 4. Rosemont, IL: American Academy of Orthopedic Surgeons; 2013. p. 495–503.

    Google Scholar 

  33. Andrews JR, Wilk KE, Satterwhite YE, et al. Physical examination of the thrower’s elbow. J Orthop Sports Phys Ther. 1993;17:296–304.

    Article  CAS  PubMed  Google Scholar 

  34. Azar FM, Andrews JR, Wilk KE, et al. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28:16–23.

    Article  CAS  PubMed  Google Scholar 

  35. Fleisig GS, Kingsley DS, Loftice JW, et al. Kinetic comparison among the fastball, curveball, change-up, and slider in collegiate baseball pitchers. Am J Sports Med. 2006;34(3):423–30.

    Article  PubMed  Google Scholar 

  36. Dugas JR, Weiland AJ. Vascular pathology in the throwing athlete. Hand Clin. 2000;16:477–85.

    CAS  PubMed  Google Scholar 

  37. McCall BR, Cain Jr EL. Diagnosis, treatment, and rehabilitation of the thrower’s elbow. Curr Sports Med Rep. 2005;4(5):249–54.

    Article  PubMed  Google Scholar 

  38. O’Holleran JD, Altchek DW. The thrower’s elbow: arthroscopic treatment of valgus extension overload syndrome. HSS J. 2006;2(1):83–93.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Beals RK. The normal carrying angle of the elbow. Clin Orthop Relat Res. 1976;(119):194–6.

    Google Scholar 

  40. King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop Relat Res. 1969;(67):116–23.

    Google Scholar 

  41. American Academy of Orthopedic Surgeons. Joint motion: method of measuring and recording. Chicago, IL: American Academy of Orthopedic Surgeons; 1965.

    Google Scholar 

  42. O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231–9.

    Article  PubMed  Google Scholar 

  43. Wilson FD, Andrews JR, Blackburn TA, McClusky G. Valgus extension overload in the pitching elbow. Am J Sports Med. 1983;11:83–8.

    Article  CAS  PubMed  Google Scholar 

  44. Ahmed CS, Conway JE. Elbow arthroscopy: valgus extension overload. Instr Course Lect. 2011;60:191–7.

    Google Scholar 

  45. Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med. 1994;22:26–32.

    Article  CAS  PubMed  Google Scholar 

  46. Cotton A, Jacobson J, Brossman J, Pedowitz R, Haghighi P, Trudell D, Resnick D. Collateral ligaments of the elbow: conventional MR imaging and MR arthrography with coronal oblique plane and elbow flexion. Radiology. 1997;204:806–12.

    Article  Google Scholar 

  47. Munshi M, Pretterblieber ML, Chung CB, Haghighi P, Cho JH, Trudell DJ, Resnick D. Anterior bundle of ulnar collateral ligament: evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic analysis. Radiology. 2004;231:797–803.

    Article  PubMed  Google Scholar 

  48. Sasaki J, Takahara M, Ogino T, Kashiwa H, Ishigaki D, Kanauchi Y. Ultrasonographic assessment of the ulnar collateral ligament and medial elbow laxity in college baseball players. J Bone Joint Surg Am. 2002;84:525–31.

    Article  PubMed  Google Scholar 

  49. Osbahr DC, Chalmers PN, Frank JS, Williams III RJ, Widmann RF, Green DW. Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: a variant of Little League elbow. J Shoulder Elbow Surg. 2010;19:951–7.

    Article  PubMed  Google Scholar 

  50. Hassan SE, Parks BG, Douoguih WA, Osbahr DC. Effect of distal ulnar collateral ligament tear pattern on contact forces and valgus stability in the posteromedial compartment of the elbow. Am J Sports Med. 2014;43(2):447–52.

    Article  PubMed  Google Scholar 

  51. Cain Jr EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426–34.

    Article  PubMed  Google Scholar 

  52. Savoie III FH, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008;36:1066–72.

    Article  PubMed  Google Scholar 

  53. Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med. 2008;36:1193–205.

    Article  PubMed  Google Scholar 

  54. Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am J Sports Med. 2013;41(7):1689–95. doi:10.1177/0363546513487979.

    Article  PubMed  Google Scholar 

  55. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Rehabilitation of the overhead athlete’s elbow. Sports Health. 2012;4(5):404–14. doi:10.1177/1941738112455006.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Coutts RD, Toth C, Kaita JH. The role of continuous passive motion in the rehabilitation of the total knee patient. In: Hungerford DS, Krackow KA, Kenna RV, editors. Total knee arthroplasty: a comprehensive approach. Baltimore, MD: Williams & Wilkins; 1984. p. 126–32.

    Google Scholar 

  57. Dehne E, Torp RP. Treatment of joint injuries by immediate mobilization: based upon the spinal adaption concept. Clin Orthop Relat Res. 1971;(77):218–32.

    Google Scholar 

  58. Haggmark T, Eriksson E. Cylinder or mobile cast brace after knee ligament surgery. A clinical analysis and morphologic and enzymatic studies of changes in the quadriceps muscle. Am J Sports Med. 1979;7(1):48–56.

    Article  CAS  PubMed  Google Scholar 

  59. Noyes FR, Mangine RE, Barber S. Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. 1987;15(2):149–60.

    Article  CAS  PubMed  Google Scholar 

  60. Perkins G. Rest and movement. J Bone Joint Surg Br. 1953;35(4):521–39.

    PubMed  Google Scholar 

  61. Salter RB, Hamilton HW, Wedge JH, et al. Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: a preliminary report of a feasibility study. J Orthop Res. 1984;1(3):325–42.

    Article  CAS  PubMed  Google Scholar 

  62. Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage: an experimental investigation in the rabbit. J Bone Joint Surg Am. 1980;62(8):1232–51.

    Article  CAS  PubMed  Google Scholar 

  63. Wilk KE, Arrigo C, Andrews JR. Rehabilitation of the elbow in the throwing athlete. J Orthop Sports Phys Ther. 1993;17(6):305–17.

    Article  CAS  PubMed  Google Scholar 

  64. Kottke FJ, Pauley DL, Ptak RA. The rationale for prolonged stretching for correction of shortening of connective tissue. Arch Phys Med Rehabil. 1966;47(6):345–52.

    CAS  PubMed  Google Scholar 

  65. Sapega AA, Quedenfeld TC, Moyer RA, Butler RA. Biophysical factors in range-of-motion exercise. Phys Sports Med. 1981;9(12):57–65.

    Article  CAS  Google Scholar 

  66. Warren CG, Lehmann JF, Koblanski JN. Heat and stretch procedures: an evaluation using rat tail tendon. Arch Phys Med Rehabil. 1976;57(3):122–6.

    CAS  PubMed  Google Scholar 

  67. Warren CG, Lehmann JF, Koblanski JN. Elongation of rat tail tendon: effect of load and temperature. Arch Phys Med Rehabil. 1971;52(10):465–74.

    CAS  PubMed  Google Scholar 

  68. Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007;42(4):464–9.

    PubMed  PubMed Central  Google Scholar 

  69. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004;34(7):385–94.

    Article  PubMed  Google Scholar 

  70. Wilk KE, Obma P, Simpson CD, Cain EL, Dugas JR, Andrews JR. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther. 2009;39(2):38–54.

    Article  PubMed  Google Scholar 

  71. Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. The advanced throwers ten exercise program: a new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete. Phys Sports Med. 2011;39(4):90–7.

    Article  Google Scholar 

  72. Schulte-Edelmann JA, Davies GJ, Kernozek TW, Gerberding ED. The effects of plyometric training of the posterior shoulder and elbow. J Strength Cond Res. 2005;19(1):129–34.

    PubMed  Google Scholar 

  73. Wilk KE, Voight ML, Keirns MA, Gambetta V, Andrews JR, Dillman CJ. Stretch-shortening drills for the upper extremities: theory and clinical application. J Orthop Sports Phys Ther. 1993;17(5):225–39.

    Article  CAS  PubMed  Google Scholar 

  74. Reinold MM, Wilk KE, Reed J, Crenshaw K, Andrews JR. Interval sport programs: guidelines for baseball, tennis, and golf. J Orthop Sports Phys Ther. 2002;32(6):293–8.

    Article  PubMed  Google Scholar 

  75. Fleisig GS, Bolt B, Fortenbaugh D, Wilk KE, Andrews JR. Biomechanical comparison of baseball pitching and long-toss: implications for training and rehabilitation. J Orthop Sports Phys Ther. 2011;41(5):296–303.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, ONS Foundation for Clinical Research and Education, Greenwich, CT, USA

    Paul Sethi MD

  2. ONS Foundation for Clinical Research and Education, Greenwich, CT, USA

    Craig J. Macken BS

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  1. Paul Sethi MD
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Correspondence to Paul Sethi MD .

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Editors and Affiliations

  1. Department of Orthopedics, University of Utah School of Medicine, Salt Lake City, Utah, USA

    Robert Z. Tashjian

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Sethi, P., Macken, C.J. (2017). Evaluation and Nonoperative Treatment of the Unstable Throwing Elbow. In: Tashjian, R. (eds) The Unstable Elbow. Springer, Cham. https://doi.org/10.1007/978-3-319-46019-2_11

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  • DOI: https://doi.org/10.1007/978-3-319-46019-2_11

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