If you follow this column with any regularity, you are aware that injuries in the overhead athlete are relatively common, Arguable, the shoulder bears the brunt of many injuries in throwing athletes, as was discussed in the last column. However, elbow injuries are exceedingly common in overhead athletes as well.
In many respects the elbow is a much-neglected joint. A relatively small amount of money goes into research involving the elbow and most people would be hard pressed to name more than one elbow injury. This, however, is not the case with respect to injuries in throwing athletes. Anyone who follows baseball closely will be familiar with the havoc that elbow injuries can wreak on baseball pitchers and other players. Three elbow injuries, medial collateral ligament sprain, medial epicondylitis and osteochondritis dissecans are either very common or very important elbow injuries and are the subject of today’s column.
All of the muscles that flex the wrist originate from a bony prominence on the humerus called the medial epicondyle. The problem with this arrangement is that the wrist flexors insert onto many different structure but have a common origin. As you might imagine, when a repeated stress is placed on the flexor mechanism, it manifests itself not at the many insertions but on the common origin. The wrist flexors are repeatedly stressed under a number of situations. For example, a baseball pitcher will flex the wrist in order to put spin on the ball. A tennis player flexes the wrist against some formidable resistance when serving, there are activities of daily living and many professions that require repeated wrist flexion against resistance.
The common flexor origin on the medial epicondyle can become inflamed under the above-mentioned conditions. This is termed medial epicondylitis. Please note that while medial and lateral epicondylitis (tennis elbow) may sound the same and have similar biomechanical pathologies, they are not the same injury. Symptoms of medial epicondylitis include pain over the medial epicondyle and the flexor tendon and pain on active flexion. Mild cases of medial epcondylitis can be treated with ice, oral anti-inflammatory medications, stretching, strengthening and rest. Moderate to severe cases may require more intense physical therapy and a steroid injection into the affected area. Surgery is rarely indicated.
Medial collateral ligament sprains can also cause problems for overhead athletes. The medial collateral ligament (MCL) serves to attach the ulna to the humerus. The ligament can become sprained in one or two commons ways.
First, repeated overhead movements such as those seen in football quarterbacks, javelin throwers and baseball pitchers place a significant stress on the medial elbow. Over time, small, microscopic tears can appear faster than the body’s ability to heal them. This leads to an overuse injury of the ligament. Overuse MCL problems may be traumatically ruptured. The classic history is one of the baseball pitchers making a throw that stresses the medial elbow and results in an audible pop. He or she is typically unable to continue pitching due to the elbow pain. In these cases, the ligament is usually either partially or completely ruptured.
Treatment for MCL sprains depends on the severity of the injury. In the overuse type of injury, ice, oral medications, and complete rest from throwing are usually sufficient. Additionally, pitching mechanics should be evaluated and corrected if necessary. For acute ruptures of the MCL, surgical exploration and ligament reconstruction are usually warranted.
A third elbow injury though not as common, can have fairly serious consequences if not managed correctly. Osteochondritis dessecans (OCD) of the elbow is an important injury to recognize in the overhead athlete. OCD consists of an inflammation of the bone and cartilage that typically affects adolescents and young adults. Clinical presentation includes an insidious onset and progression of symptoms including: localized pain, decreased range of motion (especially extension), swelling, catching, locking and a feeling of grinding within the elbow. Orthopaedic surgeons use the history and physical exam as well as plain and specialized X-rays and MRI to diagnose OCD. Treatment for OCD frequently involves arthroscopic exploration of the elbow with removal of any loose bodies. The arthroscope is also used to clean out the inflammatory tissue within the elbow and to encourage healing of the cartilage and bone.
If OCD is diagnosed and treated in a timely fashion, the prognosis is typically very good. If however, OCD is left untreated, it can progress to degenerative joint disease and the prognosis is much worse.
Of course, it is always prudent to have any elbow pain evaluated by an orthopaedist. But, if the pain is severe and/or begins abruptly, it is especially important to have it looked into promptly.