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Dr. Andrew's Corner #4 - Elbow Injuries

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From Dr. Andrew Gutierrez, DC, CCSP

Dr. Gutierrez has been in practice since 2009 after graduating with his doctorate of chiropractic from Southern California University of Health Sciences. He earned his Bachelor of Arts degree from Occidental College where he was a 4-year letterman in football. He furthered his education in sports chiropractic and earned his certification as a Certified Chiropractic Sports Practitioner® (CCSP®) from the American Chiropractic Board of Sports Physicians. As a sports chiropractor, he specializes in the diagnosis and treatment of extremity injuries in addition to his expertise in treating the spine. 


Summary:

Elbow injuries are common in sports such as
baseball, tennis, volleyball and golf.

Most injuries can be diagnosed in-office without
the use of expensive diagnostic imaging.

Most injuries can be treated conservatively with
chiropractic, physiotherapy and acupuncture.

Some persistent injuries will require diagnostic imaging
and may require regenerative or surgical interventions.


 

Elbow injuries are common amongst athletes of all ages and ability levels, especially those in sports involving overhead arm motions. Although throwing injuries in the elbow most commonly occur in baseball pitchers, they can be seen in any athlete who participates in repetitive overhand throwing. Overhand throwing places extremely high stresses on the elbow, and when these stresses are repeated many times they can lead to serious overuse injury. Unlike an acute traumatic injury that results from a fall or collision with another player, an overuse injury occurs gradually over time. In many cases, overuse injuries develop when an athletic movement is repeated often during single periods of play, and when these periods of play (games or practices) are so frequent that the body does not have enough time to rest and heal. Common examples of these types of injuries are: lateral and medial epicondylitis, ulnar collateral ligament injury, olecranon bursitis, ulnar neuritis and stress fracture. overhead arm motions. Elbow injuries are common amongst athletes of all ages and ability levels, especially those in sports involving


ELBOW ANATOMY
Your elbow 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, while 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.

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LATERAL EPICONDYLITIS
Lateral epicondylitis is the most common type of tendinopathy that affects the elbow and occurs in over 50% of athletes using overhead arm motions. Lateral epicondylitis, more commonly known as Tennis Elbow, is characterised by pain on the lateral (outside) part of the elbow where the common extensor muscles meet the lateral humeral epicondyle. The onset of this pathological condition begins with the excessive use of the wrist extensor musculature. Repetitive microtraumatic or stress injuries can lead to tendinosis of the extensor origin, which is a series of microtears in the connective tissue in or around the tendon and can lead to subsequent failure of the tendon. This injury most commonly occurs during sports, such as tennis, swimming, golf, and sports involving throwing. These injuries can also occur in occupations such as carpentry or plumbing and/or daily activities, such as lifting objects or gardening.

MEDIAL EPICONDYLITIS
Medial epicondylitis, also known as Golfer’s Elbow, is characterised by pain and tenderness at the flexor-pronator tendons where they attach to the humerus bone on the medial (inner side) of the elbow. The pathology is commonly located at the interface between the pronator teres and flexor carpi radialis muscle origins. This injury is basically identical to Tennis Elbow, just on the opposite side of the joint. Golfers and tennis players often develop this condition because of the repetitive valgus stress placed on the medial elbow soft tissues. In children who participate in sports that involve throwing, the same elbow pain is often referred to as Little Leaguer's elbow. Careful evaluation is important to differentiate this condition from other causes of medial elbow pain.

ULNAR COLLATERAL LIGAMENT INJURY
A less frequent cause of medial elbow pain is ulnar collateral ligament injury (UCL). The UCL is the most commonly injured ligament in throwing athletes and can range from minor damage and inflammation to a complete tear of the ligament. These athletes will have pain on the inside of the elbow, and frequently notice decreased throwing velocity. Repetitive valgus stress placed on the elbow joint can lead to microtraumatic injury and valgus instability. When this ligament is disrupted, abnormal stress is placed on the articular (joint) surfaces that can lead to degenerative changes with osteophyte (bone spur) formation.

As with other elbow injuries, a strict rehabilitation regimen is first employed, and ligament reconstruction is only recommended if the injury fails to improve and only in athletes requiring a high level of performance. Baseball fans are likely aware of the procedure referred to as “Tommy John surgery” named after Major League Baseball pitcher Tommy John who was the first to undergo the surgery in 1974. This procedure involves harvesting a ligament from elsewhere in the body or from a cadaver to substitute the injured UCL ligament.

OLECRANON BURSITIS
There are many bursae located throughout the body that act as cushions between bones and soft tissues, such as skin. They contain a small amount of lubricating fluid that allows the soft tissues to move freely over the underlying bone. The olecranon bursa is a thin, fluid-filled sac that is located at the boney tip of the elbow (the olecranon). If it becomes irritated or inflamed, more fluid will accumulate in the bursa and olecranon bursitis will develop, also referred to as “Popeye elbow”. This bursitis can occur for a number of reasons, aside from a direct traumatic blow to the tip of the elbow. Prolonged pressure from leaning on the tip of the elbow for long periods of time on hard surfaces, such as a tabletop, may cause the bursa to swell. People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows. Certain athletic activities may also prompt the development of olecranon bursitis, such as long holds of the plank position. Those suffering from gout or rheumatoid arthritis are far more likely to develop this condition.

ULNAR NEURITIS
When the elbow is bent, the ulnar nerve stretches around the bony bump at the end of the humerus (upper arm). In throwing athletes, the ulnar nerve is stretched repeatedly, and can even slip out of place, causing painful snapping. This stretching or snapping leads to irritation of the nerve, a condition called ulnar neuritis. Throwers with this injury will notice pain that resembles electric shocks starting at the inner elbow (often called the "funny bone") and running along the nerve as it passes into the forearm. Numbness, tingling, or pain in the small and ring fingers may occur during or immediately after throwing, and may also persist during periods of rest. Ulnar neuritis can also occur in non-throwers, who frequently notice these same symptoms when first waking up in the morning, or when holding the elbow in a bent position for prolonged periods.

STRESS FRACTURE
When an activity or sport is repeated too much or too frequently with inadequate rest, our muscles become fatigued and are unable to absorb added shock. Eventually, the fatigued muscle transfers the overload of stress to the bone, causing a tiny crack called a stress fracture. It can take months or even years for the bone to weaken enough for the stress fracture to occur. Stress fractures are generally smaller and cause less pain than acute injury fractures, so they often go undetected for quite some time.The olecranon (tip of the elbow) is the most common location for stress fractures in throwing athletes. Athletes will notice aching pain over the surface of the olecranon on the underside of the elbow. This pain is worse during throwing or other strenuous activity, but occasionally occurs during rest.

DIAGNOSIS AND TREATMENT
A history and examination is usually sufficient to diagnose most of these conditions but an X-ray or MRI may be obtained to view for more significant damage.
All the conditions above can be managed conservatively in our office with activity modification, rehabilitative exercises, chiropractic manipulative therapy, myofascial release, class IV laser therapy, and kinesiology taping. In severe cases that do not respond to conservative treatment, more aggressive treatment is warranted such as steroid injections, platelet-rich-plasma (PRP) injections, stem cell injections, and/or possibly surgical interventions.

If you have any questions about elbow or any other type of sports injury please don't hesitate to contact our office and set up an appointment.

Dr. Andrew Gutierrez DC, CCSP

Santa Monica Chiropractor

310-993-8482

 

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