Overview
Overhand throwing places high levels of stress on the elbow, resulting in serious overuse injury. Baseball pitchers, tennis players, and other throwing athletes are prone to elbow injuries with their repetitive movements and lack of time to rest and heal. Pitchers who throw with arm pain or fatigue have the highest rate of elbow injuries.
The inside of the elbow is usually the most problematic with throwing activities because the force is concentrated over the inner elbow. Common throwing injuries of the elbow include:
- Flexor Tendinitis – The flexor/pronator tendons attach to the humerus bone on the inner side of the elbow. When throwing, pain is felt on the inside of the elbow and if severe enough, pain is experienced even while resting.
- Ulnar Collateral Ligament Injury – in throwing athletes, the ulnar collateral ligament (UCL) is the most commonly injured ligament. Pain on the inside of the elbow as well as decreased throwing velocity will be experienced.
- Valgus Extension Overload (VEO) – a condition in which the olecranon, protective cartilage, is worn away and bone spurs develop. Swelling and pain usually are felt in the back part of the elbow.
- Olecranon Stress Fracture – stress fractures occur when muscles are fatigued and unable to absorb shock, transferring the added stress to the bone causing a tiny stress fracture. In throwers, the olecranon is the most common location for stress fractures. Pain is usually felt on the underside of the elbow and worsens with strenuous activity, and occasionally during rest.
- Ulnar Neuritis – is a condition in throwing athletes when the ulnar nerve in the elbow is stretched repeatedly and slips out of place, causing an electrical shock from the inner elbow through the forearm. Symptoms typically include numbness, tingling, and pain in the ring and pinky fingers.
Elbow Diagram
The inside of the elbow is usually the most problematic with throwing activities because the force is concentrated over the inner elbow.
Treatment
Dr. Stowell will discuss your general medical health, symptoms, and frequency of athletic participation. He will check your range of motion, strength, and elbow stability. He may also evaluate your shoulder. He will compare the injured elbow with the opposite side, assessing muscle bulk and appearance. He may also assess sensation and muscle strength.
Dr. Stowell will try to pinpoint the exact location of your pain by using direct pressure over several distinct areas. He will perform the valgus stress test in which he will hold your arm still and apply pressure against the side of your elbow. If it is loose or if the test causes pain, it is considered a positive test. With the results of these tests, Dr. Stowell will determine whether additional X-rays or imaging of your elbow are necessary.
Imaging Tests that may be ordered by Dr. Stowell include:
- X-rays – provides clear pictures of dense structures, stress fractures, bone spurs, and other abnormalities.
- CT scan – provides a 3D image of bony structures that are helpful in defining bone spurs or other bony disorders causing you pain or limiting motion. It is not usually used to help diagnose throwers’ elbows.
- MRI scan – provides excellent views of the soft tissues of the elbow and can help Dr. Stowell distinguish between tendon and ligament disorders. It can help determine the severity of an injury, damaged or completely torn.
Nonsurgical treatment for throwing injuries in the elbow include:
- Rest – a short period of rest is critical.
- Physical Therapy – specific exercises to restore flexibility and strength as directed by Dr. Stowell and his team of physical therapists.
- Change of position – evaluation of throwing mechanics to correct body positioning that will relieve excessive stress on the elbow
- Anti-inflammatory medications – ibuprofen or naproxen may help reduce pain.
- Injections – partial tearing of the UCL may benefit from platelet-rich plasma injections that promote healing. For this procedure, a small amount of blood is drawn from the patient and the platelets are separated from other blood cells using a centrifuge, and then injected into the area of the injury.
Throwing athletes usually return to throwing in 6 to 9 weeks when nonsurgical treatment is effective.
Surgical treatment
Surgery may be considered if pain is not relieved with nonsurgical methods and the athlete desires to continue throwing. Surgical options include:
- Arthroscopy – using an arthroscope, a small camera, Dr. Stowell can see and use small surgical instruments to remove bone spurs on the olecranon and any loose bone or cartilage fragments within the elbow joint.
- UCL reconstruction – also known as “Tommy John surgery” because of a former major league pitcher who underwent a successful UCL reconstruction in 1974. Patients who have an unstable or torn UCL are candidates for surgical ligament reconstruction. Most ligament tears cannot be stitched back together; they must be reconstructed to restore elbow strength and stability. During this surgery, Dr. Stowell replaces the torn ligament with a tissue graft, which acts as a scaffolding for new ligament to grow on. In most cases of UCL injury, the patient’s own tendons can be used in reconstructing the ligament. In some cases, the need for a graft may be eliminated if the ligament is in good condition and able to be reattached to the arm with a high-strength suture reinforcement.
- Ulnar nerve anterior transposition – Dr. Stowell moves the ulnar nerve to the front of the elbow to prevent stretching or snapping.
Recovery from surgery depends on the procedure performed. For example, a UCL reconstruction may take an athlete 6 to 9 months or more to return to competitive throwing.
Elbow injuries in the throwing athlete can be prevented with proper conditioning, technique, and recovery time. Pitching guidelines have been implemented for younger athletes to protect children from injury.