I. Osteochondritis Dissecans
A. Epidemiology/overview
1. Osteochondritis dissecans must be differentiated from Panner disease, which is an osteochondrosis of the capitellum that occurs in children younger than age 10 years.
2. Osteochondritis dissecans is more common in the skeletally immature athlete than in the adult.
B. Pathoanatomy—Osteochondritis dissecans results from repetitive compressive forces generated by large valgus stresses on the elbow during throwing or from compressive forces that are associated with gymnastics.
1. Valgus stress to the elbow results in compression of the radiocapitellar joint in the setting of poor subchondral blood supply to the capitellum.
2. The capitellum is supplied by two end arteries: the radial recurrent and interosseous recurrent arteries.
C. Evaluation
1. History
a. Most patients are involved in repetitive activities, such as throwing or gymnastics, at a young age.
b. Patients report lateral elbow pain and stiffness that is relieved by rest.
c. The symptoms may progress to "locking" or "catching" because of intra-articular loose bodies.
2. Physical examination—Findings include lateral elbow tenderness, crepitus, and, often, a 15° to 20° flexion contracture.
3. Imaging
a. Plain radiographs
i. Plain radiographs often demonstrate fragmented subchondral bone with lucencies and irregular ossification of the capitellum.
ii. Intra-articular loose bodies and abnormalities of the radial head may also be present.
iii. Comparison radiographs of the contralateral elbow can assist in the identification of subtle changes.
b. MRI may further delineate the size of the avascular segment, stability, and the presence of loose bodies (
Figure 1).
D. Classification—Capitellar osteochondritis dissecans lesions have been classified based on the status and stability of the overlying cartilage (
Table 1).
[Figure 1. MRI of the elbow demonstrating a loose body (black arrow) and a displaced osteochondritis dissecans lesion (black arrowhead) along the inferior capitellum (white arrow) adjacent to the radial head (white arrowhead).]
[Table 1. Classification and Surgical Treatment of Osteochondritis Dissecans of the Elbow]
E. Treatment
1. Nonsurgical
a. Initial treatment of stable osteochondritis dissecans lesions includes activity modification, avoidance of throwing or related sports, nonsteroidal anti-inflammatory drugs (NSAIDs), and, occasionally, a short period of bracing for acute symptoms.
b. For patients with lesions that do not demonstrate detachment or frank loose bodies (grades I and II), throwing and sports are restricted for 4 weeks.
c. Physical therapy is instituted for patients with grade I and II lesions. Three to 4 months of therapy and rest is typically required to achieve return to preinjury performance.
d. Younger, skeletally immature patients have a better prognosis with nonsurgical treatment than older patients.
2. Surgical
a. Indications—Surgery is indicated when non-surgical treatment of stable lesions fails. Unstable lesions with gross mechanical symptoms require surgical repair.
b. Contraindications—Surgery is contraindicated for patients with Panner disease and for asymptomatic patients with osteochondritis dissecans lesions.
3. Surgical procedures (Table 1)
F. Complications
1. Complications include nerve injury, arthrofibrosis, and infection.
2. Other longer-term complications include inability to return to previous level of activity, long-term loss of motion, and osteoarthritic changes.
G. Pearls and pitfalls—Treatment requires experience with elbow arthroscopy.
H. Rehabilitation
1. Postsurgical physical therapy is directed at regaining range of motion while avoiding strengthening that may compromise the early healing response after marrow-stimulation drilling.
2. Gentle resistance exercises are initiated 3 months after surgery, with greater resistance at 4 months.
3. For throwing athletes, a throwing program is started at 5 months.
4. Full-effort throwing is achieved at 6 to 7 months.
II. Lateral Epicondylitis
A. Epidemiology/overview
1. Lateral epicondylitis is the most common elbow disorder in patients seeking medical attention for elbow symptoms.
2. Lateral epicondylitis affects 50% of all recreational tennis players.
3. Risk factors for tennis players include a heavy racquet, inappropriate grip size, high string tension, and poor swing technique.
B. Pathoanatomy
1. The extensor carpi radialis brevis (ECRB) tendon is most commonly involved.
2. Microtrauma from the repetitive activity results in histopathologic angiofibroblastic hyperplasia.
C. Evaluation
1. History
a. Patients are involved in repetitive activities that require gripping, such as playing tennis.
b. Pain is localized to just below the lateral epicondyle.
2. Physical examination
a. Patients have tenderness over the ECRB tendon insertion, and pain is reproduced with maximum passive wrist flexion, gripping, resisted long-finger extension, and resisted wrist extension while the elbow is fully extended.
b. Grip strength is often decreased compared with the unaffected side.
3. Imaging
a. Radiographs are usually normal.
b. MRI may show increased signal intensity and degeneration at the ECRB tendon origin, but it is not necessary for the diagnosis.
D. Treatment
1. Nonsurgical
a. Nonsurgical treatment includes rest, NSAIDs, counterforce bracing, physical therapy, swing or activity modifications, and corticosteroid injections.
b. Physical therapy is directed at extensor stretching and strengthening.
2. Surgical
a. Indications—Surgery is indicated when pain interferes with the patient's daily activities or when appropriate nonsurgical treatment for up to 6 months fails.
b. Contraindications
i. Surgery is contraindicated when nonsurgical treatment has been inadequate and/or when the patient is noncompliant with treatment recommendations.
ii. Infection and elbow deformity are also contraindications.
3. Surgical procedures
a. Several procedures have been described, including open ECRB tendon release and removal of the degenerated tendon with repair of the remainder of the tendon.
b. More recently, arthroscopic release of the ECRB tendon has been used. Arthroscopic treatment allows for intra-articular evaluation of the capsule and cartilage.
c. The success rate for surgery is as high as 85%.
E. Complications
1. Iatrogenic lateral ulnar collateral ligament injury results in pain and posterolateral rotatory instability. Arthroscopic debridement should be kept anterior to the equator of the radial head, to avoid injury to the lateral ulnar collateral ligament.
2. Other complications include missed concomitant radial nerve entrapment, which may occur in 5% of patients with lateral epicondylitis.
F. Pearls and pitfalls
1. All pathologic tissue must be removed, regardless of the surgical repair technique that is used.
2. Knowledge of the neurovascular anatomy of the elbow and the lateral ulnar collateral ligament can help avoid iatrogenic complications.
G. Rehabilitation—Rehabilitation includes a short period of immobilization followed by wrist and elbow range-of-motion and strengthening exercises.
III. Medial Epicondylitis
A. Epidemiology/overview
1. Medial epicondylitis is less common than lateral epicondylitis; it occurs 4 to 10 times less frequently.
2. Medial epicondylitis affects men and women equally.
3. The dominant extremity is involved 75% of the time.
4. Medial epicondylitis is caused by activities that require repetitive wrist flexion or forearm pronation. It is common in golfers and baseball pitchers, as well as in individuals who participate in racquet sports, football, and weightlifting, and in occupations such as carpentry and plumbing.
B. Pathoanatomy
1. The repetitive activity causes microtrauma to the insertion of the flexor-pronator mass.
2. The pronator teres and the flexor carpi radialis are the most lateral muscles of the flexorpronator mass, and they are the most affected.
3. Because of its close proximity to the affected muscles, the ulnar nerve is often irritated.
C. Evaluation
1. History—Patients are involved in repetitive gripping activities, and they report pain that is localized to the medial epicondyle that increases with resisted forearm pronation or wrist flexion.
2. Physical examination
a. Patients demonstrate tenderness at and distal to the flexor-pronator tendon origin on the medial epicondyle.
b. Pain is reproduced with resisted forearm pronation and wrist flexion.
c. A flexion contracture may be present.
3. Imaging
a. Radiographs are usually normal.
b. MRI may show increased signal intensity and degeneration at the tendon origin, but it is not necessary for the diagnosis.
D. Treatment
1. Nonsurgical treatment includes rest, ice, NSAIDs, ultrasound, counterforce bracing, and corticosteroid injections, followed by guided rehabilitation and return to sports. Throwing, swing, and racquet/equipment modifications should also be considered.
2. Surgical
a. Indications—Surgery is indicated when pain limits function and interferes with the patient's daily activities and occupation, and when appropriate nonsurgical treatment for up to 6 months fails.
b. Contraindications—Surgery is contraindicated when nonsurgical treatment has been inadequate and/or when the patient is noncompliant with treatment recommendations.
3. Surgical procedures—The surgical technique involves excision of the pathologic portion of the tendon, enhancement of the vascular environment, and reattachment of the origin of the flexor-pronator muscle group to the medial epicondyle.
E. Complications
1. Neuropathy may result from avulsion, traction, or transection of the medial antebrachial cutaneous nerve.
2. If an injury to the medial antebrachial cutaneous nerve is recognized intraoperatively, the nerve should be transposed into the brachialis muscle.
F. Pearls and pitfalls
1. Knowledge of elbow neurovascular anatomy helps avoid iatrogenic injury.
2. Differentiating medial collateral ligament (MCL) injuries from medial epicondylitis is essential for implementing proper treatment.
3. Surgical success rates are 80% to 95%.
G. Rehabilitation—Rehabilitation includes a short period of immobilization followed by range-of-motion exercises. Volar flexion of the wrist is avoided until soft-tissue inflammation subsides.
IV. Medial Collateral Ligament Injuries
A. Epidemiology/overview
1. The MCL complex comprises three ligaments: The anterior oblique, the posterior oblique, and the transverse ligaments.
a. The anterior oblique ligament is the strongest and is the primary stabilizer to valgus stress. It is functionally composed of anterior and posterior bands that provide a reciprocal function in resisting valgus stress through the range of flexion-extension motion.
b. The anterior band is taut in extension, and the posterior band is tight in flexion.
2. MCL injuries occur in overhead athletes who subject their elbows to tremendous valgus forces.
3. Valgus torque generated at the elbow during throwing maneuvers is highest in the acceleration phase.
4. The olecranon also stabilizes valgus stress to the elbow, and excessive resection places the MCL at risk.
5. The surrounding elbow musculature provides a dynamic stabilizing force.
B. Evaluation
1. History
a. Patients with MCL injuries report medial elbow pain during the acceleration phase of throwing; pain may occur only when throwing at >50% to 75% of maximal effort.
b. Acute injuries may present suddenly with a pop, sharp pain, and inability to continue throwing.
2. Physical examination
a. Point tenderness can be noted at the MCL or toward its insertion sites.
b. Valgus instability is tested with the patient's elbow flexed between 20° and 30° to unlock the olecranon from its fossa as valgus stress is applied.
i. The milking maneuver is performed by either the patient or the examiner pulling on the patient's thumb to create valgus stress while the patient's forearm is supinated and the elbow is flexed beyond 90°. A subjective feeling of apprehension, instability, or localized pain at the MCL indicates MCL injury.
ii. The moving valgus stress test is a modification of the milking maneuver, whereby valgus stress is applied while the elbow is moved through an arc of flexion or extension. As with the milking maneuver, a subjective feeling of apprehension, instability, or localized pain at the MCL indicates MCL injury.
3. Imaging
a. Radiographs
i. AP, lateral, and axillary views should be obtained to assess for joint space narrowing, osteophytes, and loose bodies.
[
Figure 2. MRI of the elbow demonstrating a MCL tear (arrow).]
ii. Valgus stress radiographs may be used to measure medial joint-line opening (>3 mm has been considered diagnostic for valgus instability).
b. Conventional MRI can help identify thickening within the ligament from chronic injury or more obvious full-thickness tears (Figure 2).
c. Magnetic resonance arthrography enhanced with intra-articular gadolinium improves the diagnosis of partial undersurface tears.
d. Dynamic ultrasonography can help detect increased laxity with valgus stress; however, diagnostic quality of the results is operator dependent.
C. Treatment
1. Nonsurgical treatment includes a period of rest from throwing. Flexor-pronator strengthening and optimization of throwing mechanics is followed by a progressive throwing program or decreasing throwing demands.
[
Figure 3. Drawings showing the surgical techniques for MCL reconstruction. A, Modified Jobe technique with muscle-splitting approach, figure-of-8 reconstruction, and ulnar nerve in situ. B, Docking technique with graft limbs tensioned into the humeral docking tunnel. C, Hybrid reconstruction technique with interference screw fixation on the ulna and docking fixation on the humerus.]
2. Surgical
a. Indications—Surgery is indicated when non-surgical treatment fails. Patients must be willing to undergo the extensive postoperative rehabilitation program.
b. Contraindications—Surgery is contraindicated for asymptomatic athletes with low valgus demands on the elbow and for patients who are unable or unwilling to undergo the extensive postoperative rehabilitation program.
3. Surgical procedures
a. Several surgical techniques are currently used for MCL reconstruction, including the modified Jobe technique (Figure 3, A), docking technique (Figure 3, B), and hybrid interference-screw technique (Figure 3, C).
b. A muscle-splitting approach is preferred, to limit morbidity to the flexor-pronator mass.
c. Ulnar nerve transposition is reserved for patients with subluxating nerves or motor weakness.
D. Complications include ulnar nerve or medial antebrachial cutaneous nerve injury, ulnar or epicondylar fracture, elbow stiffness, and failure to achieve preinjury level of throwing ability.
E. Pearls and pitfalls
1. Ulnar nerve complications can occur.
2. The medial antebrachial cutaneous nerve lies at the distal aspect of the incision.
F. Rehabilitation
1. Active wrist, elbow, and shoulder range-of-motion exercises should be initiated early in the postoperative period.
2. Strengthening exercises should begin 4 to 6 weeks postoperatively, but valgus stress should be avoided until 4 months after surgery.
3. A progressive throwing program is initiated 4 months postoperatively.
4. A return to competitive throwing is permitted 1 year after surgery if the shoulder, elbow, and forearm are pain free and full range of motion has returned.
V. Distal Biceps Tendon Rupture
A. Epidemiology/overview
1. Distal biceps tendon rupture occurs most commonly in men between the fourth and sixth decades of life (average age of occurrence = 50 years) and usually involves the dominant extremity.
2. The mechanism of injury is usually a single traumatic event in which an unexpected extension force is applied to an elbow flexed to 90°.
B. Pathoanatomy
1. The distal biceps tendon avulses from the radial tuberosity, although ruptures within the tendon substance or at the musculotendinous junction also can occur.
2. Risk factors for rupture include hypovascularity of the tendon, mechanical impingement in the space available for the biceps tendon between the radius and the ulna, and intrinsic degeneration of the tendon.
C. Evaluation
1. History—Patients report an unexpected extension force applied to the flexed elbow followed by subjective weakness, especially during activities that require supination (eg, turning doorknobs or opening jars).
2. Physical examination
a. Ecchymosis and tenderness are present in the antecubital fossa.
b. The distal biceps tendon is absent from its normal anatomic position in the antecubital fossa.
c. Proximal retraction of the biceps muscle is apparent.
d. Weakness is noted, primarily during supination of the forearm.
3. Imaging—MRI may discern the integrity of the distal biceps tendon and any intrasubstance degeneration.
D. Treatment
1. Nonsurgical—Nonsurgical management is considered only for elderly, sedentary patients who do not require strength and endurance in forearm flexion and supination.
2. Surgical
a. Indications
i. Surgical repair is indicated for the patient with a confirmed distal biceps tendon rupture and a medical history that does not pose a high risk for surgical complications.
ii. Partial tears that fail to respond to nonsurgical treatment are treated surgically.
b. Contraindications
i. Chronic ruptures are a relative contraindication; they may require a grafting procedure.
ii. Asymptomatic tears—Patients with lower demands and no symptoms may forgo surgery.
iii. Unacceptable surgical risk
3. Surgical procedures
a. For partial tears, the remaining portion of the biceps tendon is released from the tuberosity, the frayed tendon end is debrided, and the tendon is reattached anatomically to the radial tuberosity.
b. Complete distal biceps tendon ruptures are repaired with either a single-incision or two-incision technique.
i. Single-incision technique—The approach uses the interval between the brachioradialis laterally and the pronator teres medially. (The lateral antebrachial cutaneous nerve is at risk.) The forearm is supinated to expose the radial tuberosity and to protect the posterior interosseous nerve. To avoid the risk of heterotopic ossification, do not expose the periosteum of the ulna. The tendon is attached with suture anchors or a transosseous fixation device.
ii. Two-incision technique—The surgical interval is the same as that used for the single-incision technique. After surgical dissection to the radial tuberosity, a blunt hemostat is advanced along the medial border of the radial tuberosity toward the dorsolateral proximal forearm (
Figure 4). The hemostat pierces the anconeus and tents the skin. A small dorsolateral incision is made in the skin over the hemostat. Sutures are placed in the tendon, passed through the dorsolateral incision. The forearm is pronated, exposing the radial tuberosity. The tendon is repaired to the tuberosity in a small trough. To avoid the risk of heterotropic ossification, contact with the ulna should be avoided.
E. Complications
1. Complications of the single-incision technique include radial nerve or lateral antebrachial cutaneous nerve injury; however, when these injuries occur, they typically resolve completely.
2. Use of the two-incision technique decreases the incidence of radial nerve injury; however, proximal radioulnar synostosis is a concern.
3. Use of a muscle-splitting approach, instead of the original technique of subperiosteal ulnar dissection, reduces the incidence of radioulnar synostosis.
F. Pearls and pitfalls
1. Avoid nerve injury.
2. Contact or dissection between the radius and the ulna increases the risk of heterotopic bone and/or radioulnar synostosis.
G. Rehabilitation—Rehabilitation includes a short period of immobilization followed by progressive range-of-motion exercises.
[Figure 4. Course of the hemostat relative to the anatomic structures of the forearm in repair of a distal biceps tendon rupture with the two-incision technique. Cross-section illustration of the forearm at the level of the biceps tuberosity shows the hemostat passed from anterior to posterior with the curve facing radially. It is passed on the ulnar side of the radius, curving away from the ulna.]
VI. Valgus Extension Overload Syndrome and Posterior Impingement
A. Epidemiology/overview
1. During throwing, the olecranon is repeatedly and forcefully driven into the olecranon fossa, exerting shear forces on the medial aspect of the olecranon tip and the olecranon fossa. This may cause cartilage injury and the development of osteophytes.
2. Medial ligamentous laxity commonly exacerbates the condition.
3. This constellation of injuries is called valgus extension overload syndrome.
B. Pathoanatomy
1. The pathoanatomy of valgus extension overload syndrome includes chondrosis, osteophyte development on the posteromedial olecranon and humerus, and loose bodies.
2. The ulnohumeral articulation contributes to elbow stability. Olecranon resection increases valgus angulation and MCL strain during valgus stress.
C. Evaluation
1. History
a. Patients report posteromedial elbow pain that occurs during the deceleration phase of throwing as the elbow reaches terminal extension. They may have pain during acceleration as well.
b. Loss of extension may occur.
2. Physical examination
a. Crepitus and tenderness over the posteromedial olecranon may be noted.
b. Pain is reproduced when the elbow is forced into extension.
3. Imaging
a. AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies.
b. In addition to MRI, CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology.
D. Treatment
1. Nonsurgical
a. Treatment consists of activity modification with a period of rest from throwing, intra-articular corticosteroid injections, and NSAIDs.
b. Pitching instruction should be instituted to correct flaws in pitching technique that may be contributing to the injury.
2. Surgical
a. Indications—Surgery is indicated for patients who continue to have symptoms in spite of nonsurgical treatment.
b. Contraindications—MCL insufficiency is a relative contraindication for isolated olecranon debridement.
3. Surgical procedures
a. Surgical procedures include diagnostic elbow arthroscopy, removal of osteophytes on the posteromedial aspect of the olecranon, removal of loose bodies, and debridement of chondromalacia.
b. To prevent increased strain on the MCL, it is important to remove only the osteophyte and not normal olecranon.
4. Complications—Overaggressive olecranon resection may result in valgus instability of the elbow.
VII. Triceps Tendon Rupture
A. Epidemiology/overview
1. Rupture of the triceps tendon is rare and is seen in body builders, middle-aged males, or debilitated patients.
2. Risks include corticosteroid injections for olecranon bursitis, use of anabolic steroids, inflammatory or systemic conditions, and previous triceps surgery.
B. Pathoanatomy
1. Ruptures occur most commonly at the insertion of the medial or lateral head of the triceps, and less often through the triceps muscle belly or musculotendinous junction.
2. The anconeus expansion is usually intact.
C. Evaluation
1. History—The mechanism of injury is an eccentric load to a contracting triceps, similar to the mechanism of injury reported in weight lifters performing a bench press.
2. Physical examination
a. Patients present acutely with swelling, ecchymosis, and pain.
b. Once swelling subsides, a palpable gap and extensor weakness are observed.
3. Imaging—MRI is used to identify partial tears and muscle or musculotendinous junction tears.
D. Treatment
1. Nonsurgical—Nonsurgical management is considered only for older, sedentary patients who do not require extension strength and who are too ill to undergo surgery.
2. Surgical procedures
a. Acute repair is performed via a straight posterior incision.
b. Locking sutures in the tendon are passed through drill holes in the olecranon.
3. Complications include failure of the repair, elbow stiffness, and ulnar nerve injury.
E. Rehabilitation—Rehabilitation includes a short period of immobilization followed by progressive range-of-motion exercises.
Top Testing Facts
Osteochondritis Dissecans
1. Osteochondritis dissecans must be differentiated from Panner disease.
2. Osteochondritis dissecans is more common in skeletally immature athletes than in adults.
3. Most patients with osteochondritis dissecans are involved in repetitive activities, such as throwing or gymnastics, at a young age.
4. Physical examination findings include lateral elbow tenderness, crepitus, and, often, a 15° to 20° flexion contracture.
5. Initial treatment of stable osteochondritis dissecans lesions includes activity modification, avoidance of throwing or related sports, NSAIDs, and, occasionally, a short period of bracing for acute symptoms.
6. Unstable osteochondritis dissecans lesions with gross mechanical symptoms require surgical repair.
Lateral Epicondylitis
1. Patients with lateral epicondylitis are involved in repetitive activities that require gripping, such as playing tennis.
2. The microtrauma from the repetitive activity results in histopathologic angiofibroblastic hyperplasia.
3. Radiographs are usually normal.
Medial Epicondylitis
1. Patients with medial epicondylitis are involved in repetitive gripping activities, and they report pain that is localized to the medial epicondyle that increases with resisted forearm pronation or wrist flexion.
2. Surgical complications include neuropathy resulting from avulsion, traction, or transection of the medial antebrachial cutaneous nerve.
Medial Collateral Ligament Injuries
1. Patients with MCL injuries report medial elbow pain during the acceleration phase of throwing; pain may occur only when throwing at >50% to 75% of maximal effort.
2. Several surgical techniques are currently used for MCL reconstruction, including the modified Jobe technique, the docking technique, and the hybrid interference screw technique.
3. A muscle-splitting approach is preferred, to limit morbidity to the flexor-pronator mass.
4. Ulnar nerve transposition is reserved for patients with subluxating nerves or motor weakness.
5. A return to competitive throwing is permitted 1 year after surgery if the shoulder, elbow, and forearm are pain free and full range of motion has returned.
Distal Biceps Tendon Rupture
1. The mechanism of injury for a distal biceps tendon rupture is usually a single traumatic event in which an unexpected extension force is applied to an elbow flexed to 90°.
2. The distal biceps tendon avulses from the radial tuberosity, although ruptures within the tendon substance or at the musculotendinous junction can also occur.
3. Weakness is noted, primarily during supination of the forearm.
4. Complete distal biceps tendon ruptures are repaired with either a single-incision or two-incision technique.
5. Complications include radial nerve or lateral antebrachial cutaneous nerve injury (more common with the single-incision technique) and proximal radioulnar synostosis (more common with the two-incision technique).
Valgus Extension Overload Syndrome and Posterior Impingement
1. The ulnohumeral articulation contributes to elbow stability.
2. Patients report posteromedial elbow pain that occurs during the deceleration phase of throwing as the elbow reaches terminal extension. They may have pain during acceleration as well.
3. Olecranon resection should be limited to osteophytes only, to avoid increased elbow valgus laxity and strain on the MCL.
Triceps Tendon Rupture
1. Triceps tendon ruptures are rare.
2. The mechanism of injury is an eccentric load to a contracting triceps, similar to the mechanism of injury reported in weight lifters performing a bench press.
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