We are the Orthopedic Sports Medicine Institute Virginia Beach trusts! We offer proven treatments for Sports Injuries, and the latest surgical techniques for the thrower’s elbow and shoulder. Read on to learn more.
Pitching and other forms of overhand throwing, places extremely high stresses on the elbow, with the repetitive nature of the activity leading to serious overuse injury, as the body does not have enough time to rest and heal.
The elbow joint is made up of three bones, including the upper arm bone (humerus) and the two bones in your forearm (radius and ulna). It is a combination hinge and pivot joint that allows the elbow to bend and straighten, and twist and rotate. Ligaments hold the elbow joint together and prevent dislocation: the medial (or ulnar) collateral ligament (UCL) is on the inside, and the later (or radial collateral ligament on the outside of the joint.
At the upper end of the ulna is the olecranon, the bony point on the back of the elbow that can easily be felt beneath the skin.Several muscles, nerves, and tendons cross at the elbow. The flexor/pronator muscles of the forearm and wrist begin at the elbow, and are also important stabilizers of the elbow during throwing. The ulnar nerve crosses behind the elbow. It controls the muscles of the hand and provides sensation to the small and ring fingers.
With repetitive throwing, the stresses can lead to a wide range of overuse injuries. Problems most often occur at the inside of the elbow because considerable force is concentrated over the inner elbow during throwing.
Ulnar Collateral Ligament (UCL) Injury
The ulnar collateral ligament (UCL) is the most commonly injured ligament in throwers. Injuries of the UCL can range from minor damage and inflammation to a complete tear of the ligament. Athletes will have pain on the inside of the elbow, and frequently notice decreased throwing velocity and increased fatigue. Sometimes the repetitive stretching forces imparted on the ligament, cause micro-tears and weaken it. As a result the athlete can develop a sense of
subtle instability in addition to the pain, and often a complete tear of the UCL can occur if throwing continues.
Valgus Extension Overload (VEO)
During the release and follow-through stages of the throwing motion, the olecranon and humerus bones are twisted and forced against each other on the back of the elbow. Over time, this can lead to valgus extension overload (VEO), a condition in which the protective cartilage on the olecranon is worn away and abnormal overgrowth of bone — called bone spurs or osteophytes — develop. Athletes with VEO experience swelling and pain at the site of maximum contact between the bones along the back of the elbow.
Olecranon Stress Fractures
Stress fractures occur when muscles become fatigued and are unable to absorb added shock. Eventually, the fatigued muscle transfers the overload of stress to the bone, causing a tiny crack called a stress fracture.The olecranon is the most common location for stress fractures in throwers. Athletes will notice aching pain over the surface of the olecranon on the underside of the elbow. This pain is worst
during throwing or other strenuous activity, and occasionally occurs during rest.
Repetitive throwing can irritate and inflame the flexor/pronator tendons where they attach to the humerus bone on the inner side of the elbow. Athletes will have pain on the inside of the elbow when throwing, and if the tendinitis is severe, pain will also occur during rest.
When the elbow is bent, the ulnar nerve stretches around the bony bump at the end of the humerus, called the medial epicondyle. In throwing athletes, the ulnar nerve is stretched repeatedly, and can even slip out of place, causing painful snapping called “subluxation”. This stretching or snapping leads to irritation of the nerve, a condition called ulnar neuritis.
Throwers with ulnar neuritis will notice pain that resembles electric shocks starting at the inner elbow (often called the “funny bone”) and running along the nerve as it passes into the forearm. Numbness, tingling, or pain in the small and ring fingers may occur during or immediately after throwing, and may also persist during periods of rest.
Ulnar neuritis can also occur in non-throwers, who frequently notice these same symptoms when first waking up in the morning, or when holding the elbow in a bent position for prolonged periods.
As these injuries correlate with the frequency and intensity of throwing, in most cases, pain will resolve when the athlete stops throwing. In baseball pitchers, rate of injury is highly related to the number of pitches thrown, the number of innings pitched, and the number of months spent pitching each year. Taller and heavier pitchers, pitchers who throw with higher velocity, and those who participate in showcases are also at higher risk of injury. Pitchers who throw with arm pain or while fatigued have the highest rate of injury.
Most of these conditions initially cause pain during or after throwing. They will often limit the ability to throw or decrease throwing velocity. In the case of ulnar neuritis, the athlete will frequently experience numbness and tingling of the elbow, forearm, or hand as described above.
The diagnosis of elbow conditions in the throwing athlete is typically made by a combination of the patient’s history, the findings on physical examination. Ax x-ray is often helpful in identifying aberrant bony anatomy or bone spurs, but commonly advanced imaging like an MRI and/or a CT scan are needed.
The treatment approach for elbow conditions in the throwing athlete usually starts with a conservative approach including refraining from throwing activities, icing, anti-inflammatory medications, and a six week course of physical therapy. After this time, a throwing protocol that focuses on establishing proper throwing mechanics in the shoulder and elbow, is recommended. In addition, a comprehensive strengthening and conditioning program, to include the lower extremities, core and shoulder girdle is important, as the athlete attempts to return to their sport.
If the above regimen is unsuccessful, and a repeat period of rest does not allow return to sport surgical options can be explored.
In VEO, elbow arthroscopy can be used to remove bone spurs on the olecranon and the olecranon fossa of the humerus, as well as loose fragments of bone or cartilage within the elbow joint. This minimally invasive approach allows for quick recovery and return to play.
Athletes who have an unstable or torn UCL, and who do not respond to nonsurgical treatment, are candidates for surgical ligament reconstruction. In most cases, tears cannot be sutured (stitched) back together, and a reconstructive procedure is necessary to fully restore the elbow’s stability and strength. This involves replacing the torn ligament with a tissue graft, usually a tendon harvested from the patient’s forearm or knee, or a sterile tendon from a donor.
This surgical procedure is referred to as “Tommy John surgery” by the general public, named after the former major league pitcher who had the first successful surgery in 1974. Today, UCL reconstruction has become a common procedure, helping professional and college athletes continue to compete in a range of sports.
Ulnar nerve anterior transposition
In cases of ulnar neuritis, the nerve can be moved, or transposed, to the front of the elbow to prevent stretching or snapping. This is called an anterior transposition of the ulnar nerve.
At Oceana Sports Medicine and Orthopaedic Center, Dr. Aboka brings added expertise in the management of condition of the throwing athlete, including elbow arthroscopy and minimally invasive UCL reconstruction, facilitating your return to pain-free function. These procedure are outpatient/same-day surgery, and lead to less pain and scarring and quicker recovery and return to normal function.