Tag Archives: Osteochondritis dissecans of capitellum

Painful elbows in throwing athletes

Pitcher elbow

Second only to shoulder pain, elbow pain is one of the most common and dreaded injuries for throwing athletes.  This pain can represent a variety of injuries.  This blog will review some of the most common issues we see with elbow pain in throwers, brief anatomy lesson, and what might be the problem depending on where you hurt.

Basic Elbow Anatomy:

The elbow is a simple joint that allows for flexion, extension and rolling of the forearm (like when you are using a screwdriver).  The joint is made up of the upper arm bone, the humerus, and the radius and ulna forearm bones.  The radius is across from the capitellum (part of the humerus) and is on the outside (lateral) of the elbow and the ulna is across from the trochlea (part of the humerus) and makes up the inside (medial) and pointy back (posterior) parts of the elbow.  There are multiple muscles that cross the elbow, too many to discuss here.  There are also many ligaments that help support the elbow joint, the most important for this discussion is the ulnar collateral ligament (UCL) that supports the inside of the elbow joint.

From Journal of Shoulder and Elbow Surgery, 1996,5:349

Why is the elbow injured when throwing?

There are a lot of components to throwing a ball.  These are broken into several phases: the wind up, early cocking, late cocking, acceleration, deceleration and the follow thru phase (see diagram above).  The late cocking phase starts when the front leg lands and acceleration phase starts when the ball starts to come forward.  These two stages place the most stretch on the medial (inner) elbow tissues while also causing compression of the lateral (outer) elbow tissues.  All of the torque and energy from the pitchers legs is moved up thru the core muscles of the torso and transferred to the shoulder and then elbow.

DIFFERENTIAL DIAGNOSIS

There are two key ways to separate patients with elbow pain clinically, by the location of the pain and by their skeletal maturity (age).

ANTERIOR (FRONT) ELBOW SYMPTOMS

  • Biceps tendonitis, tear or bursitis
    • Pain may be worst during follow thru phase.
  • Flexor/pronator muscle injury
  • Nerve entrapment (Lateral antebrachial cutaneous, posterior interosseous or anterior interosseous nerves) and C5 radiculopathy (pinched nerve in neck)
    • Pain plus numbness/tingling or certain muscle weakness.  Need EMG/NCV test to diagnose the problem.

MEDIAL (INNER) ELBOW SYMPTOMS

  • Age <15yo then possibly Little Leaguer Elbow Syndrome (LLES) (aka medial epicondylar apophysitis or traction apophysitis and epicondylitis.
    • Symptoms of progressive pain with throwing, decrease accuracy/speed
    • Can lead to medial epicondyle avulsion fracture (see below), which requires surgery, if continued throwing despite pain.
    • Rehab- Stop throwing, restore motion and when appropriate begin strengthening dynamic stabilizers of medial elbow amongst other treatments.
  • Medial epicondyle avulsion fracture
    • Can result from continued throwing despite pain from LLES.
    • Symptoms of pain and swelling, usually unable to fully straighten elbow.
  • Age >15yo then possibly Ulnar Collateral Ligament (UCL) sprain or tear
  • C8-T1 radiculopathy (pinched nerve in neck) or ulnar nerve injury at elbow (aka cubital tunnel).
    • Need EMG/NCV test to diagnose.
  • Medial epicondylitis (aka golfer’s elbow) or epicondylalgia

LATERAL (OUTER) ELBOW SYMPTOMS

  • Age 7-12yo than possibly Panner’s Disease, (aka osteochondrosis of capitellum)
    • Symptoms: dull, achy activity related lateral pain.  Sometimes swelling, clicking and decreased range of motion.
    • Usually resolves on its own if complete rest (no weight bearing on arm and no throwing)
  • Age 13-17yo than possibly Osteochondritis Dissecans (OCD) lesion of the capitellum (part of the humerus bone that makes up the outer elbow joint)
    • Just below the joint surface a bone injury occurs from repeated compression during throwing.
    • Symptoms: dull pain worse with activity.  Unable to fully straighten elbow and perhaps catching/locking elbow symptoms.
    • If untreated it may lead to pieces of bone floating around in the joint, joint surface deformity and early elbow degenerative arthritis.
    • Needs MRI to detail severity of OCD lesion.
    • Type 1 = no displacement, no articular cartilage fracture.
    • Type 2 = partialy displaced, articular cartilage fracture.
    • Type 3 = completely displaced, boney loose body in joint.

POSTERIOR (BACK) ELBOW SYMPTOMS

  • Loose bodies in posterior elbow recess
    • Pain, clicking and lack of full elbow extension during follow-thru phase
  • Olecranon non-union, fracture or osteophyte formation
    • May require surgery
  • Triceps tendinopathy or tear

GENERAL WORKUP INFO

In younger throwers (<18 years old) it is important to know that there are multiple growth plates that fuse at fairly predictable times in our development.  Therefore, it is crucial to compare the painful elbow to the opposite elbow when looking at x-rays in young throwers.  The arrows in the x-rays below are pointing to normal looking growth plates, but these can look like fractures or may be appear too far apart.  So looking at the other side for comparison is cruicial.

-X-rays of both elbows is usually needed to evaluate bones/joints.

-Ultrasound can identify muscle trauma, tendonitis, tendinopathy, tendon tears, ligament tears.

Normal appearing Ulnar Collateral Ligament (UCL) with Ultrasound

-Nerve testing (aka NCV/EMG) can look into any nerve like symptoms (tingling, numbness, weakness).
-MRI is needed for OCD of capitellum (to know what Type it is and for surgical planning).

General treatment ideals

DISCLAIMER: In no way should the content of this Website or blog be considered as medical advice.  The information here is provided for educational and informational purposes only and is NOT a substitute for the advice of an appropriately qualified medical practitioner or other health care provider. Please consult a physician if you suspect you are ill or injured

1)      SEEK MEDICAL CARE FROM A QUALIFIED SPORTS MEDICAL PROFESSIONAL.  YOU NEED TO HAVE A PROPER WORK-UP COMPLETED BECAUSE TREATMENT IS DETERMINED BY FIRST GETTING A CORECT DIAGNOSIS!!!

a.      For more information about setting up an evaluation call Stark Sports Medicine at 949-722-7070.

2)      In the meantime, it is crucial that you stop throwing until you are evaluated!!!

3)      It is also fine to begin the “PRICE” principles (Protect, Rest, Ice, Compress, Elevate).

a.       Only immobilize the elbow if sore, however try to limit immobilization as much as possible so you don’t lose your range of motion.

4)      Depending on the diagnosis you may be referred for Physical Therapy, Surgical evaluation or be offered a pain relieving procedure (injection).

a.       SURGICAL INDICATIONS
-Medial epicondyle fracture or other fractures.
-Type 2 OCD lesion with locking/catching symptoms or all Type 3 OCD lesions

How do I prevent serious injury in my little leaguer?

If you want your little leaguer to be the next Nolan Ryan you have to take it upon yourself to keep them healthy.  There have been many good medical articles that looked into the risk factors for elbow pain in little leaguers.  Many leagues took this information and have implemented pitch counts and have limited the use of certain pitches that were known to increase the risk to the young athlete’s elbow.  Here are some general guidelines to follow.

1.      Make sure your athlete does a proper warm-up and stretch before each game and practice.

2.      It is recommended that you limit your athlete’s pitches by the following guidelines.   Studies have shown a significantly increased risk if an athlete pitches >9 months per year or more than 100 innings per year.  Also consider how much he/she is throwing in practice.

Athlete’s age

Pitches per game

Pitches per week

Pitches per season

Pitches per year

Pitches to be used/taught

<10

50

75

1000

2000

Fastballs only

11-12

75

100

1000

3000

Add changeup

13-14

75

125

1000

3000

Add curveball

15-16

90

-

-

-

Add slider, forkball, splitter, knuckleball

17-18

105

-

-

-

Add screwball

3.      Also, you may consider having a professional pitching coach evaluate the pitcher’s biomechanics.  This could be done if an athlete is pitching close to recommended limits above, has a history of injury and/or early in a little league career to educate and enforce good pitching mechanics from day one.  List of Instructors in California.

I hope you found this information helpful.  If you are having probems with elbow pain contact the medical experts at Stark Sports Medicine to schedule your thorough evaluation and depending on the problem we can offer you a broad range of non-surgical options to get you back to throwing pain free and better than ever.

Mike Gruba, MD
Rehab Director
Stark Sports Medicine
17524 Von Karman
Irvine, CA 92614
949-722-7070

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