Thrower’s Elbow

THE CLINICAL SYNDROME

• Thrower's elbow is a type of valgus stress overload syndrome that is brought on by persistent microtrauma to the medial and lateral elbows brought on by repeated throwing motions.
• The pathophysiology of thrower's elbow, which is also known as little leaguer's elbow, begins with damage that occurs as a result of significant valgus stress being placed in the medial structures of the elbow and compression of the lateral structures of the elbow when throwing activities are performed.
• Because of this repetitive stress, the medial epicondyle, the medial collateral ligaments, and the medial epicondylar apophysis are especially prone to injury.
• Ongoing tissue damage frequently exceeds the capacity of the athlete's body to repair the damage caused by the repetitive stress.
• When this happens, the result is severe pain in the medial aspect of the elbow, which is accompanied by a reduction in both the accuracy and the distance of the throw.
• Thrower's elbow is the name given to the cluster of symptoms, rather than a single pathologic process, that results from repetitive microtrauma to the elbow.
• This microtrauma can be caused by activities such as throwing a ball or hitting a baseball.
• Medial epicondylitis, also known as golfer's elbow, growth abnormalities of the medial epicondyle (medial epicondylar apophysitis), medial epicondylar fragmentation, stress fractures involving the medial epicondylar epiphysis, and avulsion fractures of the medial epicondyle are all factors that contribute to this symptom complex.
• Additionally, the findings of osteochondrosis of the humeral capitellum, osteochondritis dissecans of the humeral capitellum, osteochondritis of the radial head, hypertrophy of the ulna, traction apophysitis of the olecranon, triceps tendinitis, and mild instability of the ulnar collateral ligament complex may be observed alone or in combination with the pathologic processes Nerve entrapment syndromes and subluxation of the ulnar nerve can also sometimes occur, though they are much less common.

SIGNS AND SYMPTOMS

• In a manner comparable to golfer's elbow, the pain associated with thrower's elbow almost always includes discomfort in the region of the medial epicondyle.
• The patient might mention that they are unable to use a hammer or hold a coffee cup, and the examiner might note that the patient has reduced grip strength.
• It is common to experience problems sleeping.
• The presence of other symptoms indicates the presence of other specific pathologic processes that were active at the time of the examination.
• Patients with thrower's elbow may experience mild instability of the ulnar collateral ligament complex, which is brought on by repetitive stretch injuries, in addition to a diminished capacity to fully extend the elbow.
• Both of these symptoms are brought on by overuse.
• Both active compression across the radiocapitellar joint from muscular forces and an active radiocapitellar compression test, which is performed by having the patient pronate and supinate the forearm in full extension, have the potential to reproduce the patient's pain.
• Active compression across the radiocapitellar joint from muscular forces also has the potential to reproduce the patient's pain.

TESTING

• Plain radiographs need to be taken of every patient who comes in complaining of elbow pain in order to rule out joint mice and other occult bony pathologic processes like avulsion fractures of the olecranon.
• Due to the clinical presentation of the patient, it is possible that additional testing is required.
• These tests could include a complete blood count, uric acid level, erythrocyte sedimentation rate, and testing for antinuclear antibodies.
• Imaging tests, such as magnetic resonance and ultrasound, should be performed on the elbow if joint instability is suspected or if the symptoms of thrower's elbow continue to be present.
• In order to diagnose entrapment neuropathy at the elbow and to rule out cervical radiculopathy, electromyography, also known as an EMG, is typically performed.
• The injection technique that will be described later can be utilized both as a diagnostic tool and a treatment strategy.

DIFFERENTIAL DIAGNOSIS

• Thrower's elbow can occasionally be mistaken for cervical radiculopathy; however, patients suffering from cervical radiculopathy typically experience pain in the neck and the proximal upper extremity in addition to symptoms below the elbow.
• As was mentioned earlier, an EMG can differentiate between thrower's elbow and radiculopathy.
• Bursitis, arthritis, and gout are three additional conditions that can cause symptoms similar to those of thrower's elbow and lead to a misdiagnosis.
• It is possible for the olecranon bursa, which is located in the posterior aspect of the elbow joint, to become inflamed as a result of direct trauma to the joint or from excessive use of the joint.
• Bursae in the antecubital and cubital regions, in addition to those located between the insertion of the biceps and the head of the radius, can also become inflamed and develop bursitis if they are not properly maintained.

TREATMENT

• Thrower's elbow is typically treated with a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors and physical therapy at first.
  • This is done in order to alleviate the pain and functional disability associated with the condition.
• The application of heat and cold to specific areas of the body may also be beneficial.
• Avoid engaging in any activity that requires a repetitive motion and has the potential to make the patient's symptoms worse.
• Patients who do not respond to these treatment modalities may benefit from an injection that combines a steroid and a local anesthetic.
  • This is a reasonable next step.
• When administering an injection for thrower's elbow, the patient is positioned in the supine position with the affected arm fully adducted at the patient's side, the elbow fully extended, and the dorsum of the hand resting on a towel that has been folded in half in order to relax the tendons that are being treated.
• A sterile syringe with a capacity of 5 milliliters is used to draw up a total of 1 milliliter of local anesthetic and 40 milligrams of methylprednisolone.
• The medial epicondyle is located after the sterile preparation of the skin that lies over the medial aspect of the joint.
• A needle measuring 1 inch in length and 25 gauges in diameter is inserted through the patient's skin, perpendicular to the medial epicondyle, and into the subcutaneous tissue that lies over the affected tendon.
  • This procedure is performed in accordance with strict aseptic technique.
• If bone is found, the needle is retracted into the subcutaneous tissue and the procedure is repeated.
• After that, a gentle injection of the contents of the syringe is performed.
• After receiving an injection for elbow pain, the patient should wait several days before beginning physical therapy treatments.
• These treatments should include gentle range-of-motion exercises and local heat therapy.
• The symptoms can also be alleviated by wrapping a Velcro band around the flexor tendons in the affected area.
• Occupational therapy that educates patients on how to perform activities of daily living may also be beneficial.
• A return to play should not take place until the patient's symptoms have been completely alleviated.
• Vigorous exercises should be avoided because they will make the patient's symptoms worse, and vigorous exercises should not be avoided.

COMPLICATIONS AND PITFALLS

• If an inflamed tendon that has already been damaged is injected directly, this technique can cause the tendon to rupture due to the associated trauma.
  • This is one of the most significant risks associated with this injection method.
• Therefore, before the clinician continues with the injection, they should make sure that the needle position is confirmed to be outside of the tendon.
• Infection is yet another potential risk associated with the injection method; however, this should be an extremely remote possibility if the aseptic technique is strictly adhered to.
• It is possible to avoid injury during injection by paying close attention to the anatomical features that are clinically significant; in particular, the ulnar nerve is vulnerable to injury at the elbow.
• After receiving this type of injection, approximately one quarter of patients experience an increase in the pain for a brief period of time. Patients should be informed that this is a possibility.