Elbow injuries & inner elbow pain in throwing athletes

Anatomy

Your elbow joint is where the upper arm bone (humerus) meets the two bones in your forearm (radius and ulna). The elbow is both a hinge and pivot joint. The hinged part of the joint lets your arm bend and straighten. The lower arm twists and rotates through the pivot function.

Thick ligaments (collateral ligaments) located on the inner and outer sides of the elbow hold the elbow joint together and prevent dislocation. The ulnar collateral ligament (UCL) is on the inside of the elbow and runs from the inner side of the humerus to the inner side of the ulna.

The UCL withstands extreme stress when stabilizing the elbow during overhand throwing.

Several muscles, nerves, and tendons (the connective tissues between muscles and bones) cross each other at the elbow. The muscles of the forearm and wrist begin at the elbow and also stabilize the elbow during throwing.

The ulnar nerve crosses behind the elbow, controlling the muscles of the hand and providing sensation to the small and ring fingers.

The olecranon (the bony point of the elbow that is felt beneath the skin) is located at the upper end of the ulna.

About

Overuse injuries occur gradually over time, unlike acute injuries that result from falls or collisions with other players. Overuse injuries develop when a movement is repeated during a single activity (like games or practices), and when these activities occur so frequently that the body does not have enough time to rest and heal.

Elbow throwing injuries are most common in pitchers but can happen to any athlete who throws overhand repetitively.

To minimize overuse injuries:

• Count the number of pitches
• Learn proper body mechanics
• Don’t pitch through pain or fatigue
• Stay out of play for at least three months every year
• Play sports that don’t stress the elbow and shoulder

Common throwing injuries of the elbow

The repetitive stresses when athletes throw at high speeds can lead to a wide range of overuse injuries. Considerable force is concentrated at the inner elbow during throwing and is where most throwing injuries occur.

Diagnosis of an elbow injury in a throwing athlete begins with a discussion of the patient’s medical history. Your Florida Orthopaedic Institute physician will want to know the general medical health, symptoms (and when they first began), as well as the nature and frequency of athletic participation.

Medical history is followed by a physical examination, where the doctor checks the range of motion, strength, and stability of the elbow. They may also test your shoulder.

The doctor is looking for the range of motion in the elbow, muscle bulk and appearance, and will compare the injured elbow with your opposite elbow. Sometimes sensation and individual muscle strength are evaluated.

The doctor will ask you to identify the area of greatest pain and use direct pressure over several areas to help pinpoint the exact location of the pain.

Your doctor may perform a valgus stress test which recreates the stresses placed on the elbow during throwing. The arm is held still, and pressure applied the side of the elbow to see if the elbow is loose or if the test causes pain. There are other physical examination tests that may be used. Based on the results of the tests, your doctor may recommend additional testing or imaging of the elbow.

Imaging tests include X-rays, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans.

Flexor tendonitis

When repetitive throwing irritates and inflames the flexor/pronator tendons where they attach to the humerus bone on the inner side of the elbow, it results in Flexor Tendinitis. Throwing athletes will have pain on the inside of the elbow. If the Flexor Tendinitis is severe, pain also occurs during rest.

Learn More About Flexor Tendonitis

Ulnar collateral ligament (UCL) injury

The ulnar collateral ligament (UCL) is located on the inside of the elbow and connects the bone of the upper arm to a bone in the forearm. It is the most commonly injured ligament in throwers. Injuries range from minor damage and inflammation to a complete tear of the ligament. Athletes have pain on the inside of the elbow, and often notice a decrease in throwing velocity. Tommy John surgery is commonly used to fix a torn ulnar collateral ligament.

Learn More About UCL Injuries

Valgus extension overload (VEO)

The olecranon and humerus bones are twisted and forced against each other during throwing motions. Repeated over time, this can lead to valgus extension overload (VEO). In valgus extension overload, the protective cartilage on the olecranon wears away, and bone spurs or osteophytes (abnormal overgrowth of bone) develop. There is pain and swelling at the site where there is the greatest contact between the bones.

Learn More About Valgus Extension Overload

Olecranon stress fracture

When muscles become fatigued and are unable to absorb added shock, stress fractures can occur. Muscles eventually transfer the stress overload to the bone, causing a tiny crack or stress fracture. The olecranon is the most common location for stress fractures in throwers.

Athletes get an aching pain over the surface of the olecranon on the underside of the elbow. Pain is worst during throwing and other energetic activities and sometimes occurs at rest.

Learn More About Olecranon Stress Fracture

Ulnar neuritis

The ulnar nerve stretches around the bony bump at the end of the humerus when the elbow is bent. When throwing, the ulnar nerve is stretched repeatedly. It can even slip out of place and cause painful snapping. Ulnar nerve stretching or snapping leads to irritation of the nerve, a condition called ulnar neuritis.

Symptoms of ulnar neuritis include pain that resembles electric shocks. The pain starts at the inner elbow (the “funny bone”) and runs along the nerve as it passes into the forearm. Numbness, tingling, or pain in the small and ring fingers can also occur while throwing, immediately after and during periods of rest.

Ulnar neuritis also occurs in non-throwers. They may have the same symptoms when holding the elbow in a bent position for a prolonged period or when first waking up in the morning.

Learn More About Ulnar Neuritis Injuries

Tommy John elbow surgery

A recent study found that nearly 60 percent of Tommy John surgeries were performed on teens between 15 and 19. The study showed that the ulnar collateral ligament (UCL) repairs are rising every year among teenagers, especially baseball pitchers. According to another study, 60% of professional pitchers had a minor injury to their UCL when they were in youth baseball.

Sports medicine experts theorize that the increase in surgeries is caused by teens playing sports year-round and specializing in a single sport. Because of these factors, they throw more pitches, and faster pitches, putting them at increased risk for an elbow injury. When they throw harder and more often they put more stress on their arm. Teens used to play different sports depending on the season, rotating sports can help prevent overuse injury to the elbow.

The rate of injury in baseball pitchers relates to:

• The number of pitches thrown
• The number of innings pitched
• The number of months spent pitching each year
• Taller and heavier pitchers
• Pitchers who throw with higher velocity

Pitchers who throw with arm pain or while fatigued have the highest rate of injury.

Many surgeons are urging parents to help prevent elbow ligament tears, rather than relying on Tommy John surgery for repair. Parents and coaches can count the number of pitches to make sure they aren’t throwing the ball too often. To avoid this injury, players are also being taught proper body mechanics and encouraged not to pitch through pain or fatigue. Some parents are holding children out of play for at least three months every year or letting them play sports that don’t stress the elbow and shoulder, like soccer or track.

Sometimes the ligament can be repaired with suture augmentation rather than needing a full reconstruction.

Baseball players, especially pitchers, are one of the largest groups to have UCL or Tommy John surgeries. It is named after major league pitcher Tommy John, the first professional baseball player to have the surgery in 1974.

In Tommy John surgery the injured UCL is replaced with a tendon taken from the player’s own body, usually either the forearm or the knee, but also from the hamstring, hip, or foot.

Tommy John surgery returns many major league baseball pitchers to play. 80% of pitchers in the major leagues who undergo Tommy John surgery eventually return to pitch as well as they did before surgery.

Nonsurgical treatment

Treatment for throwing injuries in the elbow usually begins with a short period of rest. Other treatment options may include:

• Physical therapy
• Change of position
• Anti-inflammatory medications
• Longer periods of rest
• Stem cell therapy
• Platelet rich plasma (PRP) therapy is also being used as a nonsurgical treatment and adjunct at time of surgery

The Florida Orthopaedic Institute’s philosophy is to first try all appropriate nonsurgical methods to increase mobility and function. If these methods do not achieve the desired results then, and only then, is surgery suggested.

If you or someone in your family has suffered an elbow injury, Florida Orthopaedic Institute has the largest and most advanced sports medicine program in the region. Physicians use a multi-disciplinary approach to ensure the most innovative treatment for all sports-related injuries.