Throwing Injuries

Your elbow joint  or shoulder joint is where three bones in your arm meet: your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). It is a combination hinge and pivot joint. The hinge part of the joint lets the arm bend and straighten; the pivot part lets the lower arm twist and rotate.

At the upper end of the ulna is the olecranon, the bony point of the elbow that can easily be felt beneath the skin.

On the inner and outer sides of the elbow, thicker ligaments (collateral ligaments) hold the elbow joint together and prevent dislocation. The ligament on the inside of the elbow is the ulnar collateral ligament (UCL).

It runs from the inner side of the humerus to the inner side of the ulna, and must withstand extreme stresses as it stabilizes the elbow during overhand throwing.

Several muscles, nerves, and tendons (connective tissues between muscles and bones) 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.

Cause

Elbow and shoulder injuries in throwers are usually the result of overuse and repetitive high stresses. In many cases, pain will resolve when the athlete stops throwing. It is uncommon for many of these injuries to occur in non-throwers.

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.

Symptoms

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.

Diagnosis

Medical History

The medical history portion of the initial doctor visit includes discussion about the athlete’s general medical health, symptoms and when they first began, and the nature and frequency of athletic participation.

Physical Examination

During the physical examination, the doctor will check the range of motion, strength, and stability of the elbow. He or she may also evaluate the athlete’s shoulder.

The doctor will assess elbow range of motion, muscle bulk, and appearance, and will compare the injured elbow with the opposite side. In some cases, sensation and individual muscle strength will be assessed.

The doctor will ask the athlete to identify the area of greatest pain, and will frequently use direct pressure over several distinct areas to try to pinpoint the exact location of the pain.

To recreate the stresses placed on the elbow during throwing, the doctor will perform the valgus stress test. During this test, the doctor holds the arm still and applies pressure against the side of the elbow. If the elbow is loose or if this test causes pain, it is considered a positive test. Other specialized physical examination maneuvers may be necessary, as well.

The results of these tests help the WBJ physician decide if additional testing or imaging of the elbow is necessary.

Imaging Tests

X-rays. This imaging test creates clear pictures of dense structures, like bone. X-rays will often show stress fractures, bone spurs, and other abnormalities.

Computed tomography (CT) scans. These scans are not typically used to help diagnose problems in throwers’ elbows. CT scans provide a three-dimensional image of bony structures, and can be very helpful in defining bone spurs or other bony disorders that may limit motion or cause pain.

Magnetic resonance imaging (MRI) scans. This test provides an excellent view of the soft tissues of the elbow, and can help your doctor distinguish between ligament and tendon disorders that often cause the same symptoms and physical examination findings. MRI scans can also help determine the severity of an injury, such as whether a ligament is mildly damaged or completely torn. MRI is also useful in identifying a stress fracture that is not visible in an x-ray image.

Nonsurgical Treatment

In most cases, treatment for throwing injuries in the elbow begins with a short period of rest.

Additional treatment options may include:

Physical therapy. Specific exercises can restore flexibility and strength. A rehabilitation program directed by your doctor or physical therapist will include a gradual return to throwing.

Change of position. Throwing mechanics can be evaluated in order to correct body positioning that puts excessive stress on the elbow.

Although a change of position or even a change in sport can eliminate repetitive stresses on the elbow and provide lasting relief, this is often undesirable, especially in high level athletes.

Anti-inflammatory medications. Drugs like ibuprofen and naproxen reduce pain and swelling, and can be provided in prescription-strength form.

If symptoms persist, a prolonged period of rest may be necessary.

Surgical Treatment

If painful symptoms are not relieved by nonsurgical methods, and the athlete desires to continue throwing, surgical treatment may be considered.

Arthroscopy. Bone spurs on the olecranon and any loose fragments of bone or cartilage within the elbow joint can be removed arthroscopically.

During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the elbow joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

UCL reconstruction. Athletes who have an unstable or torn UCL, and who do not respond to nonsurgical treatment, are candidates for surgical ligament reconstruction.

Most ligament tears cannot be sutured (stitched) back together. To surgically repair the UCL and restore elbow strength and stability, the ligament must be reconstructed. During the procedure, the doctor replaces the torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on. In most cases of UCL injury, the ligament can be reconstructed using one of the patient’s own tendons.

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 to the front of the elbow to prevent stretching or snapping. This is called an anterior transposition of the ulnar nerve.