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Issue: July 2021
Source: Chauhan A, et al. Am J Sports Med. 2019;doi:10.1177/0363546519876305.
Disclosures: Camp, Chalmers, Ciccotti, Savoie and Wilk report no relevant financial disclosures.
July 15, 2021
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Surgeons explore treatments as elbow injuries increase

Issue: July 2021
Source: Chauhan A, et al. Am J Sports Med. 2019;doi:10.1177/0363546519876305.
Disclosures: Camp, Chalmers, Ciccotti, Savoie and Wilk report no relevant financial disclosures.
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During the past 2 decades, research has shown multiple factors have led to an increase in elbow injuries and surgeries among youth, collegiate and professional overhead-throwing athletes.

“Every year in Major League Baseball ... the number of elbow injuries and surgeries have steadily gone up and the number of shoulder injuries and shoulder surgeries have steadily gone down,” Kevin E. Wilk, PT, DPT, FAPTA, of Champion Sports Medicine in Birmingham, Alabama, told Orthopedics Today. “There are a lot of theories behind that. One is we are getting better at treating shoulders and we are better at training shoulders.”

Michael G. Ciccotti, MD
Michael G. Ciccotti, MD, said stress ultrasound and MRI can map out the extent and location of an athletes ulnar collateral ligament injury and inform decision-making regarding either nonoperative or operative treatment.

Source: Kristina Kaighn

However, Wilk said throwing velocity has also gradually increased in overhead-throwing athletes, causing more stress at the elbow, especially among specialty pitchers. Use of a weighted ball during training has also increased the rate at which elbow injuries occur in professional baseball pitchers, which may lead to an increased elbow injury rate in adolescent players whose training mimics that of professional pitchers, he said.

“We worry about [kids] with these programs because, one, they will do it until they fatigue and, when they fatigue, their mechanics change and it loads [the elbow] even more,” Wilk, an Orthopedics Today Editorial Board Member, said. “Two, they may not be doing it properly. They may be doing too many reps.”

Recreational athlete injuries

The increased number of adolescents and adults who play sports also may contribute to increased elbow injury rates, according to Christopher L. Camp, MD, orthopedic and sports medicine specialist at the Mayo Clinic.

“We are seeing recreational leagues, city leagues pop up for all different types of sports, all different types of ages and different types of activity levels, which is great, and we should continue to do that, but with that some of these injuries are more common,” Camp said.

In addition, single-sport specialization among adolescent athletes has been identified as a cause for increased frequency of sporting injuries, sources who spoke with Orthopedics Today said.

Christopher L. Camp, MD
Christopher L. Camp

“Youth baseball players might be chronologically young, but they have spent years throwing a ball with high force, so their ligaments have gone through a lot of physiologic changes that in the past, when athletes played multiple sports, we did not see until later in life,” Michael G. Ciccotti, MD, Everett J. and Marian Gordon Professor of orthopedic surgery, chief of sports medicine and director of the sports medicine fellowship and research at Rothman Orthopaedic Institute, said.

Adolescent vs adult injuries

Although elbow injuries can occur in any athlete, Peter N. Chalmers, MD, shoulder and elbow surgeon at the University of Utah, said these can vary substantially depending on the sport, level of play and age of the athlete.

Peter N. Chalmers, MD
Peter N. Chalmers

“On average, we see bony injuries more commonly than we see tendon and ligament injuries in youth athletes, but, as athletes age, we tend to see tendon and ligament injuries more frequently and bony injuries less frequently,” Chalmers, an Orthopedics Today Editorial Board Member, said.

Adolescent athletes tend to experience growth plate injuries, such as medial epicondyle apophysitis, according to Ciccotti. He said as overhead-throwing athletes age, they may develop posterior medial impingement or a strain or partial tear of the flexor pronator tendon.

“They can get irritation in their ulnar nerve or ulnar neuritis,” Ciccotti said. “Some of them have some hypermobility of the nerve. They may have some inherent subluxation and then it can become irritated or inflamed.”

Ulnar collateral ligament injury

The most common injury among baseball, softball, volleyball and javelin athletes that requires significant treatment is a medial UCL injury, according to Felix H. “Buddy” Savoie III, MD, FAAOS, FAOA, the Ray Haddad Professor and chair of the department of orthopedic surgery at Tulane University.

 Felix H. “Buddy” Savoie III, MD, FAAOS, FAOA
Felix H. “Buddy” Savoie III

“It could be a sprain, it could be a partial tear, it could be a complete tear. Sometimes it is an acute injury and sometimes an overuse injury,” Savoie told Orthopedics Today. “Other athletes will get [a medial UCL injury] from a hyperextension of the elbow in a gymnast or a football player, but those are less significant for those athletes.”

Recreational athletes who are 30 to 50 years old may experience traumatic biceps tendon ruptures, according to Camp.

“After that, the most common [injury] would be epicondylitis, which, if it is on the lateral side of the elbow, is often called tennis elbow and, if it is on the medial side, it is often called golfer’s elbow,” he said. “That happens more commonly in a slightly older age group.”

Identify the injury

In addition to athlete age, sporting level and the athlete’s goals, timing of the injury relative to the season is among the factors to consider when deciding the best treatment method for athletic elbow injuries, according to Chalmers.

“The way we would treat a high school senior who has 1 week before their season is different than the high school sophomore when it is the fall and their season is in the spring,” Chalmers told Orthopedics Today.

When an athlete presents with an elbow injury, physicians should do a thorough exam of the elbow and compare the injured side with the contralateral side. After history and thorough physical examination, patients undergo X-rays and sometimes MRI, depending on the nature of the injury, Chalmers said.

He said MRI can be helpful in youth athletes because early awareness of the status of the ligament or soft tissue can set the treatment course.

“Once we have confirmed the diagnosis, then we can determine how to treat it and, in the vast majority of youth athletes, we first start with nonoperative treatment, which often involves a period of rest and can involve some structured physical therapy,” he said.

Laxity, vascularity

Physicians can use stress ultrasound to determine whether an athlete with a UCL injury can be treated operatively or nonoperatively based on the amount of laxity the imaging reveals is present in their ligament, according to Ciccotti.

“We use [stress ultrasound] in addition to MRI to map out the degree of injury, the location, whether it is partial or full thickness and then all of those pieces of the puzzle help us to determine should we treat this athlete nonoperatively or should we treat them operatively,” Ciccotti told Orthopedics Today.

The area of the elbow in which the injury occurs can help determine the treatment method, he said, noting nonoperative treatment tends to provide better healing in the more vascular areas of the elbow compared with areas with poor vascularity.

An athlete with a partial proximal injury is “inherently more stable there and they have a better blood supply, so they are more likely to be well treated nonoperatively whereas the athlete that has an injury that is distal — so they are more unstable and they do not have a good blood supply — they are not likely to heal nonoperatively, so they would require surgical treatment,” Ciccotti said.

Operative, nonoperative treatment

When caught early, some elbow injuries, such as osteochondritis dissecans (OCD) of the capitellum, can readily heal with nonoperative treatment, according to Camp. Older athletes with medial and lateral epicondylitis can also be treated nonoperatively through strengthening and stretching exercises or, potentially, platelet-rich plasma, he said.

“The downside is it takes a lot longer than any of us like and it can often be up to 6 months or even a year before symptoms resolve,” Camp said.

However, surgery may be needed in younger athletes with growth plate displacement, a torn ligament or elbow dislocation, according to Savoie.

Similarly, Camp said adolescent athletes generally undergo surgery when OCD of the capitellum is caught late and presents with cartilage disruption, fragmentation or loose bodies in the elbow.

“For those athletes [with osteochondritis dissecans of the capitellum], the goal is to catch them early, shut them down, let them heal,” Camp told Orthopedics Today. “If we catch them late and they have already progressed to the point where they are unstable, causing mechanical symptoms in the elbow, we will have to operate on those [patients]. The goal is to operate early before it causes any additional damage to the elbow.”

When surgery is required, Savoie tries to perform arthroscopic surgery or use the smallest incision possible to reduce any associated damage and aid the recovery process.

“If you have to open it, though, the key is to get a good, secure stable repair of whatever structure you are operating on,” Savoie said.

Whether performing open or arthroscopic surgery, Savoie said surgeons “want to preserve [the original anatomy] as best as they can.”

Reconstruction vs repair

Although reconstruction is the traditional surgical option for UCL injuries, sources who spoke with Orthopedics Today said there has recently been renewed interest in repairing the UCL with supplementation from an internal brace.

“[The internal brace is] a collagen-coated heavy suture that lays over the repaired ligament that helps to support it while the ligament is healing,” Ciccotti said. “The early and intermediate results are promising for repair with an internal brace.”

Although both the traditional, gold standard UCL reconstruction and recently developed repair of the UCL with an internal brace provide good outcomes for athletes, UCL repair has one-half to two-thirds of the recovery time of a reconstruction, Ciccotti said. However, not every UCL injury is amenable to repair with an internal brace, according to Ciccotti, who said athletes with acute-on-chronic UCL injuries with extensive damage would be better served with a UCL reconstruction while athletes with a UCL tear who have an otherwise healthy ligament could undergo a UCL repair supplemented with an internal brace.

“Those two techniques vary on recovery. They are important for us, they are both part of our armamentarium and, as we have learned more through research, we can get more granular and precisely determine what is going to be best for any individual athlete,” Ciccotti said.

Use of biologics

One area that shows promise regarding treatment of elbow injuries is the use of biologic treatments, according to Savoie.

“The whole stem cell issue for these types of injuries shows incredible promise. The elbow is vascular and so some biologic supplementation would be good,” Savoie said. “The problem with stem cells is that if you are going to use them, they need to be autologous. It needs to be from your body, either your bone marrow or your adipose cells, to truly be effective. Off-the-shelf stuff does not seem to help the elbow.”

Although published research has shown success with the use of PRP or growth factor injections for tendon and ligament tears, a 2019 study by Aakash Chauhan, MD, MBA, and colleagues in the American Journal of Sports Medicine showed PRP used in conjunction with nonoperative treatment for UCL injuries in MLB pitchers did not improve return to play outcomes or ligament survivorship compared with nonoperative treatment alone.

Similarly, a database study by Ciccotti and his colleagues showed MLB players with UCL tears who received PRP injections in addition to nonoperative treatment had a significantly longer time to return to a throwing program, as well as a significantly lower return to play rate vs. athletes who received nonoperative treatment alone. The researchers also found the proportion of athletes who required UCL reconstruction and the time to surgery did not significantly differ between the two groups.

Limitations of the study included the use of different types of biologics and different rehabilitation regimens, Ciccotti said.

Pitch count graphic

“The theory [of the use of biologics] is brilliant, but the reality is we just have not figured this out yet,” he said. “We have not figured out what combination of biologics, what ratio of each, how often to give it and what the post-biologic treatment rehabilitation should be like. Ultimately, I believe that this will be something that will help speed up our healing.”

Recondition the kinetic chain

Regardless of whether athletes undergo operative or nonoperative treatment, Savoie said they should take time to recondition their body before and after any treatment.

“What we usually see is that the reason they hurt the elbow is because the rest of the body has deconditioned some or it is fatigued, and so their shoulder is weak, their posture is poor, their core strength is down, their hip strength is not good [and] their flexibility for the rest of the body is not good,” Savoie said.

Ciccotti said this reconditioning can be done by optimizing the kinetic chain and correcting any deficiencies when the athlete is not throwing and pain free on physical exam.

“Often they need a structured program because a lot of these athletes are not even aware of the concept of the kinetic chain,” Ciccotti said. “You cannot give them a sheet of paper and say: just do these. They deserve to go to someone.”

Once an athlete’s kinetic chain is improved, the athlete should be enrolled in a throwing program that starts with a short toss at 30 feet and gradually increases to 180 feet for position players, while pitchers continue with an additional mound-throwing program to work on fastball and off-speed pitches.

“The idea is they gradually progress,” Ciccotti said. “You have 6 weeks of not throwing when you are optimizing the kinetic chain and then the throwing program takes roughly 4 to 6 weeks.”

Education is key

Physicians can help reduce the risk of elbow fatigue and overuse injuries in athletes by educating athletes on proper mechanics, appropriate training and, for youth athletes, not allowing them to specialize in a single sport, according to Wilk.

Kevin E. Wilk
Kevin E. Wilk

Physicians should also educate coaches on the risk of elbow injuries and provide an off-season program to help keep their athletes in shape, he said.

“If [physicians] can somehow educate coaches to not have [athletes] pitch too much, give them some exercises to do beforehand, maybe before practice everybody goes through an exercise routine for 10 minutes, ... that would be beneficial for these kids,” Wilk said.

Physicians should be familiar with age-based workload recommendations in young athletes and advise them that elbow pain is never normal, Camp said.

“There is a misconception out there that elbow pain is common and is normal and it is OK, and that is not the case,” Camp said. “Elbow pain should be investigated. Particularly, elbow pain that lasts more than a couple of days is something that is worth looking into and investigating.”

Click here to read the Point/Counter to this Cover Story.