This is the portion of Doctor Bennett’s presentation to the Houston TX Caduceus Society, which discusses elbow injuries in athletes. Dr. Bennett specializes in treating issues of the shoulders, elbows, knees, and certain hand and wrist injuries.
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Doctor. J. Michael Bennett is a Board Certified Orthopedic Surgeon and a Fellowship Trained Sports Medicine Physician. A Houston native and University of Texas graduate, Doctor Bennett completed his orthopedic residency at the Baylor College of Medicine. This is the third part of Dr. Bennett’s talk to Houston’s Caduceus Society during the Grand Rounds lecture series on July 17, 2012.
This is a summary of Doctor Bennett’s presentation on elbow injuries in athletes. The slide titles are indicated in brackets.
[Elbow Injuries] Let’s just talk a little bit about the anatomy and some of the big things you’re worried about or have heard about like lateral or medial epicondylitis, little league elbow, avulsion fracture of the elbow, ulnar collateral ligament, distal bicep ruptures, and dislocations of the elbow. Some of the earlier elbow studies were done on javelin throwers, and that’s where they found out a lot of the problems with elbows, particularly in the ulnar collateral ligament. I think it was first described in javelin throwers.
[Elbow anatomy] Here’s some basic anatomy in the elbow. Basically, lateral epicondyle, medial epicondyle, radiocapitellar joint, ulnar humeral joint, just basic anatomy for you guys.
[Elbow anatomy 2] So as far as the capsular structures within the elbow, some of the main ones you want to think about are the lateral structures here, the radial collateral ligament here, which goes from the radius to the lateral epicondyle. You’ve got the ulnar collateral ligament, and these are the views that you want to look at here. The ulnar collateral ligament actually has three bands. The main band here is the anterior band; it actually splits into the anterior, inferior, and posterior band right here. Then you’ve got the transverse band and posterior band, and this is the main one that all of the pitchers are injuring right up front here. Here’s the radial collateral band, then you’ve got an ulnar band and a lateral collateral ligament right here. Those actually help stabilize the elbow.
[Elbow anatomy 3] These are just some basic pictures here of the anatomy. Here’s the radial collateral ligament, the ulnar band, and the lateral collateral ligament. If you’ve ever heard of posterolateral instability, where the radial head pops out of the joint to the side, that’s because this band of tissue here is disrupted. Sometimes you see patients that have had tennis elbow surgery or lateral epicondylitis elbow surgery, and the doctor will cut this ligament here and basically create an instability in the elbow, so we go in there and reconstruct this little hammock like structure that cradles that radial head so it doesn’t pop out of joint anymore. This is the ulnar collateral ligament, and once again this is that anterior bundle that we were talking about. This is the area that we reconstruct for the Tommy John procedure.
[Elbow anatomy 4] As far as the biceps and the musculature around the biceps, you’ve got your biceps brachii muscle here, and the biceps tendon here. This is the lacertus fibrosus over here. This is your pronator, and flexor mass over here, and extensors over here. Just some basic anatomy. A lot of the times that you see a patient who says they popped their biceps, and they come in and usually you think you’re going to see a deformity in their biceps. So like I said before, look at symmetry. Sometimes they look symmetric. What you do is a supination stress test. Have them supinate their arm to resistance and see if they have pain, and look at the bicep to see if it raises or lowers. If it doesn’t do that, then what’s happened is the biceps is ruptured and it’s retracted and this lacertus fibrosus or aponeurosis here is still holding it down. You can actually have a detachment in the biceps but this little band right here is still attached, so if that’s the case, you could be looking at a patient and they look okay, but they actually have a detachment in their biceps. An MRI would be indicated at that point to confirm the diagnosis.
[Elbow assessment] When it comes to assessments, look at their history: past history, mechanism of injury, when and where does it hurt, motions that increase or decrease pain. Does it hurt when you rotate a doorknob? Does it hurt when you do your backhand in tennis? Type and quality of pain: do you feel any numbness or tingling in your fingers when you have any of these symptoms? How long has it been going on? Swelling? Previous treatments? Do you have any clicking or popping in the elbow?
[Elbow assessment] Look for any deformity in the elbow, or any asymmetry and swelling. Look at the carrying angle. When patients come in, especially kids, have them drop their arms at their sides and their angles. Sometimes if they’ve had a growth abnormality, they could have a varus arm on one side and a normal arm on the other. That can actually predispose somebody to injuries in the elbow. Also, look at their flexion and extension as well.
[Elbow assessment 2] Once again, we’ll just go through the basic bony anatomy here and palpating these major structures, both soft tissue and bony.
[Elbow assessment 3] These are special tests on the elbow that you want to think about. Circulatory and neurological: I can’t tell you how many patients I see that come into the office that say that they have elbow pain when they’re actually suffering from cubital tunnel, which is actually the ulnar nerve being trapped. Cubital tunnel may actually give them symptoms at their fingers and they think it’s elbow pain because it starts in this area. It’s not necessarily elbow, it’s an issue with their nerve. Look at the pulses and make sure they’ve got good neurovascular fill or capillary refill. Good Tinel’s sign: like I mentioned before, use the ulnar nerve test, which is to tap on it a couple of times. If it feels like you bump the funny bone and it radiates down to their fourth and fifth fingers, that’s a positive sign for Tinel’s.
[Elbow assessment 3, cont.] The Varus/Valgus stress test: this helps only if you have a pretty severe elbow dislocation. If you have patients with very mild laxity in their elbow, it’s not going to show up too much, but what you want to look for is pain as opposed to laxity. So if you have any pain with the Varus or Valgus stress tests, then that would indicate a little more about what’s going on with the elbow joint.
[Elbow assessment 4, cont.] Pain and weakness are evaluated through active and passive range of motion and how much they can move on their own. Look at their flexion, extension, pronation and supination, particularly their rotation and supination and see if they have pain with any of those.
[Lateral epicondylitis] Lateral epicondylitis are overuse injuries, so they’re chronic. Also known as tennis elbow, it usually occurs with degeneration at the extensor carpi radialis brevis, which is basically the muscle/tendon unit that inserts at the lateral epicondyle. This can occur because of poor technique in their swing, wrong grip, wrong racket size, or poor string tension. There’s localized pain with resisted wrist extension. I like to do what’s called the piano key sign: have them extend their elbow and fingers, and push on this third digit, because that’s where the ECRB inserts, at the base of the metacarpal. If they have pain when you apply resistance to that third digit and it irritates the lateral epicondyle, that’s a positive sign. Another sign I have them do is the handshake test where I have them shake my hand and slowly bring their arm into extension while squeezing my hand, and if they have pain, then that’s another test that indicates lateral epicondylitis. And of course if they have localized tenderness with palpation. With other things to look at, you want to make sure you’re not having any issues with the biceps. Look at their supination or resistant supination. If they have that as well, that’s more indicative of a distal biceps pathology.
As far as treatment for lateral epicondylitis, the majority of epicondylitis is treated non-operatively. A lot of these can actually burn out after a period of six months or so. And there have been some very promising studies, and Adam probably referred to this, in regards to PRP and lateral epicondylitis. I usually start with a typical algorithm involving a counterforce brace, stretching, strengthening activities, and doing some deep tissue massage and cross-friction massage at the tendon itself. Things like ultrasound and heat and ice are helpful as well. With cortisone injections, I’ll usually do one or two. I don’t like to do a lot of cortisone injections. Cortisone is not necessarily good for the body; if you do a lot of these injections, it can discolor the skin or weaken the tendon, but I believe it’s okay to just get that patient jump-started and start the therapy and rehab, so it’s healthy for pain at that point.
If they fail with at least two injections and extensive therapy and have had tennis elbow for six months to a year, that’s when we start talking about something surgical. I do these arthroscopically, so I actually go in there with a scope, we debride the degenerative tendon, and I actually repair the defect arthroscopically as well. Occasionally I’ll do these with a mini open, and I’ll only do that if I have involvement of the collateral ligament or radial collateral ligament because that’s a structural defect that I don’t want to repair as well. So I’ll do that through a mini open, but the majority are done arthroscopically. Like I said, it’s very rare that people would need something surgical done, because most of these are treated non-operatively. But we see a fair number of elbows and I’ve done a few of these as well.
[Medial epicondylitis] Medial epicondylitis, also known as golfer’s elbow, is on the inside of the elbow as opposed to the outside of the elbow. It’s less common and a little bit more difficult to treat. It affects the pronator teres-flexor carpi radialis interface, so this whole flexor wad here on the inside of the elbow. It inserts right there at the medial epicondyle. The treatment is the same as lateral epicondylitis. However, if you’re going to inject this medial side, be very careful because some of these patients will have subluxating cubital or ulnar nerves that can actually subluxate into the way. So you want to palpate that nerve and know good and well where that nerve is, because if that nerve subluxates into the area that you’re going to inject, you’ve got to be very careful. Nowadays, with ultrasound technology, you can avoid a lot of these problems.
[Little League elbow] Little league elbow: these are more for kids and young adults that still have open growth plates. This is osteochondrosis with the younger kids that you see fragmentation of the cartilage. It’s called Panner’s disease. The majority of these are self-limiting: they actually burn out and heal up pretty well. We’re still trying to figure out exactly why; we think it has to do with the vascularity of the growth plates in kids. However, when you start getting into the older kids and teenagers, they can develop what’s called osteochondritis dissecans where they actually have fragmentation of the cartilage due to a vascularity issue. It’s usually due to overuse and overloading of the radiocapiteller joint. It can involve the ulnatrochlear joint, and you can have a patient show up with acute pain in the elbow caused by repetitive trauma, or sometimes these fragments can dislodge and float into the joint and cause a locking sensation or catching sensation in the elbow, and if that’s the case, as far as treatments are concerned, those little fragments don’t disappear, so we have to arthroscopically remove them. For these kids, what we’ve been doing is the osteochondral transfer for these large defects that they have because we’ve seen that if you just take that piece out and leave that big crater alone in that cartilage, they can develop early-onset arthritis. So what we’ll do now is take a chondral plug or cartilage plug, sometimes from the knee or from a donor, and use it to plug up those defects to give them a normal cartilage surface. I’ve had patients that have gone back to pitching and throwing and back to their sports when this used to be considered a debilitating diagnosis.
[Little league elbow] Little league elbow features localized pain, and a lot of the time they will present with a flexion contracture or an inability to fully extend the elbow. That’s usually due to capsular inflammation, so don’t get too worried. A lot of times, this will actually get better on its own. But you’ve got to shut these kids down and explain to their parents that they have to stop throwing and stop going out there and playing baseball seven days a week. That’s the hardest part of my job. Still, they just have to understand what’s going on. The growth plates are immature, they haven’t ossified, so that makes them an eassy target for these high-stress forces across it. The first place they injure is their growth plates, so you’ve got to be careful about that.
[Little league elbow 2] This is what a typical patient will show up with. Look at symmetry here with the straight arm and flexed arm; they have good flexion here, but they can’t extend all the way, so something is going on with his elbow. It could just be inflammation, it could be a loose body, but you’ve got to do some further diagnostic tests to see what’s going on here.
[Little league elbow 3] With treatment, early stretching, ice and rest, avoidance of throwing, and counsel the overachieving parent (like I said, that’s the hardest part). Continued throwing can cause further fragmentation and permanent deformity and cubitus valgus/varus deformity. I think education is the key here. I think once you educate the patient and their family and parents, they understand that if they you keep throwing, it’s going to cause further damage. Osteochondritis dessicans and loose bodies may develop if you don’t shut it down and let things heal up properly.
[Osteochondritis dessicans] I apologize for this slide. It’s kind of crazy. In a nutshell, like I mentioned before, it’s a problem with blood supply that leads to degeneration and fragmentation of the cartilage due to repetitive movements across the elbow over time. It’s seen in young patients, usually throwers. Panner’s disease, like I mentioned before, is usually in kids less that age ten. That actually resolves on it’s own. Patients are presented with locking and pain in the elbow, swelling, and decreased range of motion. X-rays can show a flattening of the radiocapiteller joint, particularly the capitulum with some loose bodies in there. Management: activity restriction for six to 12 weeks, and sometimes you can get these to heal up. The great thing about kids is they’ve got great vascularity and they could actually heal, but you’ve got to let them rest it and let them heal. Anti-inflammatories are good, and splinting and casting are good to keep them shut down, so if they won’t listen to you, I just put a cast on them; you can’t take that off. If they keep having symptoms, then you’re going to have to discuss something surgical, like removing the loose bodies.
[Osteochondritis dessicans 2] This is what it looks like arthroscopically and on radiographs. In the MRI’s here, you can see the deformity. This black circle here is actually dead. That’s just vascular necrosis or basically osteochondritis dessicans, which means there’s no vascularity in this region here. This is an area that’s kind of lighter here on this x-ray, and this is what it looks like arthroscopically.
[Loose bodies] These are loose bodies in the joint. This is what they look like arthroscopically in the joint. We’re actually seeing them in the joint here. This is a big loose body; sometime’s well go in there and see a couple of little fragments that were taken out, and some of these are Easter eggs. There are some big loose bodies that are out there that we have to take out sometimes.
[Avulsion fractures of the throwing athlete] Avulsion fractures usually occur due to high-tensile stresses across the medial epicondyle, the medial side of the elbow, usually across the collateral ligaments pulling on the growth plates. It can cause a detachment of the epicondyle or a fracture of the epicondyle.
[Avulsion fractures] This is what it looks like. Patients will show pain, tenderness, and decreased motion. This is a fragment here that’s been pulled off because this growth plate was over-stressed because they didn’t rest and didn’t listen to the fact that the elbow hurt or splint it or protect it for a period of time and let it heal up. If you keep on throwing, this is what would happen.
[Avulsion fractures 2] Treatment for this just depends on where the fracture is. Usually we have to put in a screw if it’s down here at the base of the ulna. Approximately where on the medial epicondyle depends on how much displacement; if it’s completely displaced, we have to put a screw across it.
[Ulnar collateral ligament tears of the elbow] This is basically the typical injury for throwers that we see a lot of. It’s a result of the valgus stress across the elbow; you can see here that the elbow is going one way while the arm’s going the other. This is the stress in the medial collateral ligament right here and the ulnar collateral ligament in the elbow. Like I mentioned before, that anterior band that we showed is the primary restraint to the valgus stress across the elbow. Patients report pain and laxity with valgus stress testing. Usually, if it’s an athlete, they’ll come in saying “My velocity is dropping, and I’ve got significant pain in the medial side of the elbow.” Or they’ll be throwing and they’ll feel a pop or snap on the inside of the elbow. So those are the things you want to think about. Treatment is reconstruction of the ligament after failure of conservative measures, and that all depends, once again, on the patient, their expectations, and the type of tear that they have. If it’s a partial tear, the majority of these do great with non-operative management. Adam would be great to talk about with ulnar collateral ligaments with PRP because I think there are some studies that talked about PRP injections with these partial tears and actually showing some pretty good results. For full-thickness tears in a high-velocity throwing athlete, if these guys want to keep playing, they’re probably going to need a reconstruction, which is the Tommy John.
[Ulnar collateral ligament tears of the elbow 2] This is what we do in a Tommy John reconstruction: we’ll take a ligament, a lot of times, we’ll take the palmaris longus, which is on the opposite hand, and we weave it through some tunnels here on the medial side of the elbow, and then tie a native ligament back on itself. There are a number of different ways of doing this, this is just one way that will give us back stability in the medial side of the elbow.
[Biceps tendon rupture]
Audience member: “What kind of time frame do you shut them down for?”
Dr. Bennett: “If it’s a partial tear?”
AM: “Partial.”
Bennett: “I start them in a hinged brace immediately with no throwing at all, and they wear the hinged brace for six weeks.
AM: “Six weeks?”
Bennett: “And then after that, I’ll say that they can take the hinged brace off, and they can do batting only but no pitching until about 10 or 12 weeks. I have them start a throwers ten protocol for another six weeks, so that’s a total healing of about 12 weeks.”
AM: “We just had one that was like six months. They shut him down for six months.”
Bennett: “It depends on the tear and the size of the tear, but for partial tears, I’d usually spend about 12 weeks across the board.”
So biceps tendon ruptures are a rare injury with peak incidence between the fourth and sixth decade of life. We see a lot of these as well, but they are rare in the general population and general orthopedic surgery practice. They’re more common in men and in the dominant arm. Due to a strong extension moment – I see these in a lot of patients that are grabbing things. They’re reaching for a prayer on the floor, and they supinate it, extend it, and are flexing. All at once, that stress on the distal biceps will cause a pop and actually cause a rupture of the biceps. The defect may be palpable, sometimes it may not depending on if they have a serious fibrosis intact on the medial side. Sometimes we may not see a palpable defect. This is key here: weakness with elbow flexion and supination. So if you have them resist you, you put your hand on their wrist and have them resisting supination. If they hurt, and then they hurt when they flex, that’s indicative of an injury. Usually it’s a pull off of the tuberosity.
[Biceps Tendon Rupture 2] Treatment for a complete tear depends on the patient. So if you’re an active patient and you want to get back to weightlifting (and I have a lot of patients that want to get back to their sports and activities), then I usually fix them. But I also have patients that don’t do a lot; I have patients just working their garden, or maybe the biggest part of their day is just getting up turning the TV off or something. You don’t necessarily have to fix these. This is not going to hinder the ability to reach out and grab something and do your daily activities. It will hinder the ability to give you strength with resistant supination. So someone that wants to work with tools for a living or does a lot of heavy lifting. I had some bodybuilders that did a lot of this, and they had to get back to their weights, so we have to fix these. So restore supination and flexion. There was a study in 1960 that basically reported a threefold increase in disability for unrepaired cases. Morrey, in 1985, reported only 61 percent flexion strength and 65 percent supination strength in unrepaired cases, so this shows you how much of a deficit in strength there is if you leave them alone, but with repair, you can get 95% of the strength back.
[Biceps tendon rupture 3] I’ve seen these, and the key with these is to treat them early and diagnose them early. If you don’t treat these early, they will retract and they will scar and they become very difficult to pull back down. And I do these in chronic patients; I think the longest one I’ve done with a patient is a year out, and his biceps was up here, but we put in an Achilles graft from a cadaver and spanned the biceps to go back down to the tuberosity. Now he’s got good strength and motion, and he was doing this because of work so he wanted his strength back and we were able to fix that.
[Biceps tendon rupture 4] This is just basically what a tendon rupture looks like and how we fix it. This is the tendon rupture right here, and this is actually some sutures running through it and running it back down to the tuberosity.
[Dislocation of the elbow] This basically occurs with falls, traumatic injury, or falling on an outstretched extremity. Bones can be displaced back and forth or sideways. It’s distinguished from a fracture just from an x-ray because you look for the alignment between your radial head and humeral joint, and if they’re not lining up appropriately on your lateral reviews, then you have a dislocation. You just want to make sure that you reduce these immediately if you haven’t called your local orthopedist. Severe pain, swelling, disability that makes them not be able to move their elbow at all. Complications with medial and radial nerve injury, sometimes blood vessel and vascular injury. Often a radial head fracture is involved.
[Dislocation of the elbow 2] Like I said, refer for reduction if it happens. Neurological and vascular exam are key; you want to make sure you get a good exam before and after if you’re doing dislocation. Reduce immediately, immobilization. The nice thing about elbow dislocations is that a lot of people think that if you dislocate your elbow, you need surgery immediately, but if you don’t have a fracture, the majority of these actually in three weeks unstabilized, and then you put them in a brace and the ligaments heal up beautifully. I had a wrestler that had this happen to her. Complete, bad pull dislocation, and we popped it back into place, put her in a hinge brace, and she ended up going back to wrestling and got a scholarship and did great. So it’s amazing how much the body can actually heal, and like I said, we can probably add a lot of this stuff into the talk regarding PRP, and how much of a play this is going to have on some of these things with the elbow. Range of motion and strengthening at six to 12 weeks, and return to the sport in about four to six months.
[Dislocation of the elbow 3] This is the brace I usually use. Actually it’s a little bit lower profile than this, but this is a hinged brace, and this is what we use for ulnar collateral partial tears as well if we’re going to protect them for a period of time. They’re able to move their elbow, but it keeps them from stressing the medial aspect of the elbow.
If you have any questions about the information provided in this presentation or about any issue related to orthopedics or sports medicine, please call Dr. Bennett’s office at 281-633-8600.
