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Elbow injuries in Sports
The document provides a comprehensive overview of various elbow injuries, such as tennis elbow, golfer's elbow, and radial tunnel syndrome, detailing their causes, pathologies, clinical features, and treatment methods. It emphasizes the significance of proper technique in sports to prevent injuries and outlines treatment protocols including both conservative and surgical options. Key rehabilitation strategies and exercise recommendations are also highlighted for recovery and return to activity.
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Overview of presentation's focus on various elbow injuries like Tennis Elbow, Golfer’s Elbow, and others.
Focus on Tennis Elbow, its pathology, stages, and commonality among tennis players due to overuse.
Discussion on causes of Tennis Elbow, including poor technique, and importance of wrist extensor strength.
Goals of treatment include relieving inflammation and promoting healing, along with therapy modalities.
Exercise protocols focusing on restoration of range and strength for Tennis Elbow rehabilitation.
Strategies for safe return to athletic activities, correcting factors like grip size and technique.
Surgical options for persistent cases and the introduction to Radial Tunnel Syndrome.Discussion on Radial Tunnel Syndrome, presentation similar to Tennis Elbow, and management strategies.
Overview of Medial Epicondylitis, factors leading to it, and clinical presentations related to Golfer's Elbow.Treatment focuses on prevention, restoration, and potential need for surgical intervention.Discussion on Thrower's Elbow focusing on causes, clinical features, and management of MCL injuries.
Pathological changes from repetitive throwing in younger athletes, emphasizing management strategies.
Causes, symptoms, tests for Ulnar Nerve Neuropathy and initial management strategies.
Focus on avulsion fractures, detailed physiotherapy protocols for medial elbow injuries and throwing progression.
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Elbow injuries in Sports
- 1. Dr. Usha (PT) AssistantProfessor Elbow Pain/ Injuries
- 2. Contents Tennis Elbow Radial Tunnel Syndrome Golfer’s Elbow Medial Collateral Ligament Injury (Thrower’s Elbow) Valgus Extension Overload Syndrome Little Leaguer’s Elbow Ulnar Nerve Neuropathy (Cubital Tunnel Syndrome) Avulsion of Medial Epicondyle
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- 4. Tennis Elbow The lesionaffecting the tendinous origin of the wrist extensors (ECRB) characterized by- Local tenderness over the common extensor origin at the lateral epicondyle Exacerbated by continual use and resisted WRIST extension.
- 5. The loosely usedterm, ill defined Common in tennis players- associated with overuse/overstress 45% of tennis player with practice or game experience the problem. This syndrome is also the occupational hazard in individuals carrying out forceful pronation and supination motion, heavy lifting, or repeated hammering type activities.
- 6. Pathology The exactpathology of the tennis is still open to debate 3 major site of pathological changes 1. Common extensor origin , 2. Radio-capitular joint , 3. Radioulnar joint with fibrillation and chondromalacic changes
- 7. Pathology Stage Characteristics Stage IAcute inflammation, No angioblastic invasion, Pain during activity, Minor aching usually after the activity Stage II Chronic inflammation and scar , Some angioblastic invasion, Pain during activity and also during rest Stage III Extensive angioblastic invasion and scar, May be micro rupture of tendon, sometimes partial rupture of the tendon, Pain at rest, sometimes night pain, Numerous activity of the daily living becomes painful
- 8. Etiology Little playingexperience – novice players at risk More stress if consistently miss the sweet spot when hitting the ball. Poor stroke technique- use of arm instead of body Inadequate power, flexibility or endurance Heavier stiffer racquet increases stress Large handle size Too tight stringing Wet / heavy-duty balls Playing surface – cement floor gives more bounce and hence require more work from the wrist extensors .
- 10. The normalwrist extensor should be about 45-50% of the flexors strength. Among the wrist muscles the strength of various muscle in the descending order is Flexors > Radial deviators > Ulnar deviators > Extensors. Supinators are stronger then pronators. The poor grip strength is factor implicating the genesis of the tennis elbow
- 11. Clinical Features Localtenderness over the outside of the elbow at the common extensor origin with aching and pain at the back of the forearm . aggravated by continual use. Special tests 1. Resisted wrist extension- precipitate pain at the common extensor origin 2. Painful resisted extension of the middle and ring fingers implicates extensor digitorum, whereas painful resistance to wrist extension and radial deviation points to ECRL and ECRB. 3. Hold the elbow in extension and perform passive wrist flexion and pronation. This stretches the tendinous insertion and produces pain .
- 12. Clinical Presentation: TwoType Insidious onset 24-72 hours after unaccustomed activates involving wrist extension Knitting, screwing, brick lying, use of new racquet, wet ball, ground Acute onset Single exertion activity of wrist extensor Lifting heavy objects , hard back hand stroke
- 13. Treatment: Aim Relief ofinflammation, Promotion of healing, Reducing the overload forces (correction of predisposing factors) Increasing upper extremity strength, endurance and flexibility Gradual return to activity
- 14. Treatment: Method Inflammationand healing: Modalities: LASER, phonophoresis with 10% hydrocortisone, IFT, HVGS, TENS, cold therapy. Manual therapy: soft tissue mobilization- transverse friction, restoration of passive range of elbow and forearm Isometric pain free contraction of wrist extensor in non stretched position Counterforce brace Taping
- 16. Post Acute: ExerciseThe Main Stay Restoration of range & strength Active stretching – wrist extensors, triceps Concentric strengthening- all components of extensor complex Eccentric strengthening of– wrist extensor Ensure pain free contraction Buildup endurance (Local, General)
- 18. Specific Exercise Protocol:CURVIN & STANNISH Cryokinetic Eccentric strengthening Warms up with local heat or general exercise Passive stretching to the wrist extensors 3 times each for 30 seconds . Three sets of ten eccentric contraction with the weight of 1- 5 lbs/Surgical tubing . Stretches Ice 20 minute sessions daily for about 3 weeks .
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- 20. Return To Play Practice Thebackhand, forehand, and serve and other specific tasks using surgical tubing or pulley for resistance Correction of deficit of strength and range of motion of shoulder and trunk Overall fitness
- 21. Return To Play Correctionof predisposing factors Grip size Racquet weight and string tightness Technique– use of foot work Counterforce brace
- 22. Other Treatment Options Nitricoxide donor therapy Botulism toxin Extracorporeal shock wave therapy Steroid infiltration
- 23. Surgical Treatment Releaseof fascia and part of common extensor origin Extensive post operative physiotherapy Expected time of recovery 1- 3 months Indication Documented adequate non- operative treatment including injections Adequate time which should be up to a year Severe pain interfering with activities of daily living, employment or competition
- 24. Radial Tunnel Syndrome Compressionof radial nerve (posterior interosseous nerve) in radial tunnel A differential diagnosis of resistant tennis elbow Common in activities requiring supination and pronation
- 25. Presentation: Very SimilarTo Tennis Elbow Pain and tenderness over lateral epicondyle. Stretching of wrist extensors elicit pain. Resisted finger extension elicits pain. Pain radiating up and down the elbow. Weakness of grip. Pain on resisted middle finger extension. Tenderness along radial nerve anterior to radial head, differentiates it from tennis elbow.
- 26. Differential Features Tenderness alongcourse of radial nerve Anterior to radial head Resisted forearm supination with elbow in flexion is painful
- 27. Management Rest Stretch supination andextensor carpi radialis brevis within limits of pain. NSAID’s and massage. Surgical decompression if unresolved for several weeks.
- 28. Medial Epicondylitis Othername are epitrochletitis, golfer’s elbow, medial tennis elbow Acute tear or chronic tendonitis of common flexor origin at medial epicondyle Common in golfers
- 29. It isa tendinopathy of the common flexor origin including the pronator teres. It is an overuse syndrome seen commonly in- Throwing sports – related to repetitive valgus stress along with wrist flexion and pronation . Golf – with excessive driving or by mis-hitting the ground who continually take divots out of hard ground, resulting in overload to the dominant arm’s wrist flexor at the point of impact. The other athlete who require a strong grip (gymnast, water skier) or who grip excessively (tennis, squash) are also prone to this condition.
- 30. Racquet sportsdue to repeated wrist action Acute tear or ruptures of the common flexor origin may develop- When an opponent or hard object unexpectedly block the forceful flexion of the wrist or Due to sudden excessive contraction of the flexors of the wrist and fingers . The chronic involvement is often due to repetitive activity that leads to damage to the collagen fibers.
- 31. Clinical Presentation Medialelbow pain. Tenderness around or just distal to common flexor origin. Painful resisted wrist and finger flexion. Passive elbow and wrist extension in supination also elicits pain Stretching of wrist and finger flexor together elicit pain. Acute tear may present with palpable defect, ecchymosis This condition is often coexist with MCL instability as excessive valgus overload during forceful contraction places increased strain on the medial elbow.
- 32. Management Main aimis prevention and restoration of lost range of motion. 1. In acute stage- ice, pulsed ultrasound, and other modalities may be used in conjunction with NSAIDs. The exercises later on constitute the main stay of the treatment. The stretching and strengthening routine of tennis elbow should be used but the direction of movement is reversed. 2. In recalcitrant cases, the injection of steroid may be given into the area and 3. If failed release of the common origin may be considered.
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- 34. Medial Collateral LigamentInjury (Thrower’s Elbow) Acute inflammation of medial collateral ligament may be caused by repetitive valgus stress in pitchers and javeline throwers or by one single episode of trauma can also cause partial or complete tear of the ligament.
- 35. Causes Micro trauma dueto tensile valgus stress placed on medial aspect of elbow during acceleration phase of throwing Macro trauma: single vigorous valgus stress
- 36. Features Point tendernessover medial joint line and effusion. Tenderness distal to medial epicondyle. Valgus stress test- demonstrates pain and instability, stress need to be applied with elbow flexed to 15-30 degree Differential diagnosis Medial epicondylitis Medial epicondyle fracture avulsion Ulnar nerve entrapment Medial olecranon fossa impingement
- 37. Differential Diagnosis Medial epicondylitis-painful wrist flexor contraction Medial epicondyle fracture/avulsion- acute injury history of trauma, limitation of elbow range of motion Ulnar nerve entrapment- motor sensory deficit Medial olecranon fossa impingement syndrome- dull aching pain, negative valgus stress test
- 38. Line of Management Acutephase- reducing inflammation- PRICE & NSAIDs Promote healing and repair- use of modalities Within 1-2 weeks- all active and passive movement should be within pain free limit only in order to prevent stretch on the ligament, as the all the three bands of the ligaments gets taut in different part of the elbow range.
- 39. Return to activity Tapingduring return to play In disruption of ligament (Grade 3), orthopaedic referral as untreated instability of the MCL can be a source of ulnar nerve injury and can lead to the cessation of throwing career.
- 40. Valgus Extension OverloadSyndrome Throwing generated extreme valgus stress on elbow Repeated throwing with inadequate rest can give rise to a spectrum of pathological changes within joint leading to chronic pain and disability In growing athlete, the term little leaguers elbow is used to describe these varying presentations
- 41. Impact of Throwing Distractiveforce of medial structure Compressive force at lateral and posterior structure In growing athlete affect the growth plate and ossification centers If unrecognized may lead to non reversible changes in the joint forcing premature retirement
- 42. Long Term Consequencesof Throwing Overuse Medial compartment: Strain flexor origin, MCL stress, spur on ulnar coronoid, ulnar nerve traction, avulsion of medial ossification center Lateral compartment: Lateral epicondylitis, radial head compression, Capitular osteochondral injury, deformity of radial head, loose body formation Posterior compartment: triceps strain, synovial impingement, olecranon fracture, degenerative changes
- 43. Little Leaguer’s Elbow Theterm encompass all the stress changes involved in baseball pitching (throwing) that occurs in immature athlete Original pathology- stress on medial epicondylar epiphysis
- 44. Presentation Vague symptoms Pain– insidiousonset. Swelling following game, later on for long periods. Stiffness after prolonged period of throwing Progressive reduction of rom due to fibrosis of soft tissue Tenderness over involved area. Test– radiograph
- 45. Line of Management Earlyrecognition Adequate rest from repeated stress Symptomatic conservative treatment of lesions in early stages Correction of technique Fitness Education of coach, players Established cases Surgical exploration and repair Prolonged physiotherapy Return to sports doubtful
- 46. Early Management Rest alongwith icing, NSAIDs, TENS. Avulsion fracture (medial epicondyle)- Splinting and rest
- 47. Ulnar Nerve Neuropathy(Cubital Tunnel Syndrome) Compression of ulnar nerve during its course around elbow
- 48. Cause Direct Dislocation ofelbow Fracture humeral condyle Mal-union, secondary valgus deformity due to epiphyseal injury Irregularity in ulnar groove Indirect Inflammation and adhesion following repeated throwing stress Overdevelopment of FCU Recurrent subluxation of nerve due to attenuation of UCL
- 49. Presentation Postero-medial elbow Pain. Sensorysymptoms: pins and needle or numbness along ulnar nerve distribution, Clumsiness and heaviness of hand. (ulnar aspect of forearm and hand). Positive tinnel sign Weakness of introssie and 3rd and 4th lumbricals
- 50. Special Tests Palpation ofulnar nerve at medial elbow elicits tenderness. Position of fully flexed elbow and wrist extension for 3 minutes elicits pain and paranesthesia along ulnar aspect of forearm.
- 51. Differential Diagnosis Nerveentrapment at Guyton canal Thoracic outlet syndrome Carcinoma of apex of lung Systemic conditions (DM, Alcoholism) Referred from neck Glioma/ lipoma at medial elbow
- 52. Line of Management Initial: treatment of neuritis Rest, NSAID, soft tissue mobilization, electrotherapy, stretching , Later: removal of compressing factor Surgical exploration and decompression
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- 54. Avulsion of MedialEpicondyle Cause Massive contraction of forearm flexors, posterior elbow dislocation, fall on hand, repeated valgus stress at elbow. Presentation Pain, swelling and tenderness at medial aspect of elbow. Limited elbow and wrist flexion and extension. Valgus instability. X-ray Gravity stress test – opens the medial aspect of elbow joint.
- 55. Treatment Displace fracture requiresinternal fixation. Post operative physiotherapy Active mobilization of wrist and elbow in pain free range. Wrist extension accompanied with finger flexion to avoid stress on medial epicondyle. Gradually resisted exercise within pain free range at 4 weeks.
- 56. General Physiotherapy ProtocolFor Medial Elbow Injuries Phased process 1. Phase1- 0 to 2 weeks 2. Phase2- 2 to 4 weeks 3. Phase3- 4 to 6 weeks 4. Phase4- 6 to 10 weeks
- 57. Phase 1- Week0 To 2 Ice and compression. Brace, tape to restrict movement if required Passive and active assisted non painful ROM for wrist and elbow. Strengthening- all within pain free range Isometrics- wrist and elbow muscles Isotonic strengthening of shoulder muscle except external rotators
- 58. Phase 2- Week2 To 4 Increase motion to 0 to 135 degrees. (10 degrees/ week) Initiate isotonic strengthening Wrist – flexors and extensors Elbow – flexors and extensors Pronation and supination Shoulder muscles with external rotators.
- 59. Phase 3- Week4 To 6 Eccentric exercises for wrist and elbow muscle. Continue concentric strengthening. Continue shoulder muscle strengthening.
- 60. Phase 4- Week6 To 10. Plyometrics Practice throwing.
- 61. Progression of Throwing High lob, light toss, 15 to 20 m throwing, 50% of maximum velocity, one set of 10 reps, gradually progress to five sets. Gradually increase by 10 m until competitive distance is reached. Throw straight and flat instead of high lob. First 15 to 20 m at 75% of maximum velocity. Gradually progress as above, Then throw 15 to 20 m at maximum velocity. Gradually progress to competitive distance.
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