Specialist Presentation 25/11/2015 by Dr Lucci Lugee Liyeung Department of Orthopaedics and Traumatology Prince of Wales Hospital Hong Kong

1. Painful elbow in a rising star
Specialist presentation 25/11/2015
Dr. Lucci Lugee Liyeung

2. Let me tell you Pedro’s story…
• 10 years old right handed Pitcher
in a local baseball team
• Prospect for a baseball scholarship
into high school and college
• Keen on a professional career

3. • Noted right medial elbow pain during
mid season
• Did not inform parents and coaches
• Decrease in pitch velocity & distance
• Eventually pain so severe that his
performance deteriorated

4. • Unable to continue playing towards the end of the season

5. • What should have been done to help him?

6. The Kinetic Chain in Overhand Pitching
Shane T Seroyer, MD, et al
The Kinetic Chain in Overhand Pitching
Sports Health. 2010 Mar; 2(2): 135–146.

7. Phases of throwing
• Windup
• Cocking
– Early
– Late
• Acceleration
• Deceleration
• Follow-through

8. Windup
• Gains momentum in forward direction
• Elbow is flexed
• GHJ is slightly internally rotated.
• Lasts 0.5 to 1.0 seconds

9. Cocking
• Begins with front foot
contact
• Ends with shoulder in
maximal external
rotation

10. Cocking
• Elbow flexes between 90–120°
• Forearm pronates 90°
• GHJ in abduction and reaches
maximal external rotation
• Lasts 0.1 to 0.15 seconds

11. Acceleration
• Begins with Maximal
EXTernal rotation
• Ends with Maximal
INTernal rotation
(ball release)

12. Acceleration
• Arm moves to a position of internal
rotation and adduction at the shoulder
and extension at the elbow
• Large valgus and extension forces
generated at the elbow
• Lasts a few 100th of a second

13. Deceleration/Follow-through
• Begins with Maximal
Internal rotation
• Ends with hindfoot
contact

14. Deceleration/Follow-through
• Follow-through is complete when pitcher achieves a
balanced position and is ready to resume play

15. Overhand pitching

16. • Medial elbow is particularly prone to injury at late cocking
and acceleration phases
• Tremendous valgus strain
• Maximum valgus stress occurs at 86°of elbow flexion in adults
and 87° in adolescents, during the late cocking phase
Sabick MB, Torry MR, Lawton RL, Hawkins RJ.
Valgus torque in youth baseball pitchers: A
biomechanical study. J Shoulder Elbow Surg. 2004

17. Little
League
Elbow

18. Little League Elbow
Review article:
Medial elbow injury in young
throwing athletes
Bonnie Gregory et al
Muscles Ligaments Tendons J. 2013
Apr-Jun; 3(2): 91–100. 2013

19. Little League elbow
• Repetitive overhand throwing
• High valgus torque of the throwing motion
• Tensile and shearing stress at the medial elbow
• Apophyseal cartilage at the medial epicondyle
sustains repetitive trauma at hypertrophic zone
• Common in baseball pitchers 9 - 14 y/o

20. The medical epicondyle
• May arise from >1 ossification center
• Commonly the last epiphyseal center to fuse (16+ y/o)
• Attachment site of the flexor muscle origins and UCL
• Apophysis is the area of highest potential for injury

21. The medical epicondyle
Ossification Fusion

22. Ulnar Collateral Ligament

23. Epidemiology
• ~ 30 million children participate in organized sport in USA
• ~ 4.8 million children aged 5-14 participate in baseball/softball
• incidence of elbow pain in young baseball players:
– 20–30% for 8–12 year olds
– approximately 45% for 13–14 year olds
– over 50% for high school, college, and professional athletes
• The true incidence of sports-related injuries is unknown because a
large number of athletes never seek medical care.
Relationship between throwing mechanics and elbow
valgus in professional baseball pitchers.
Werner SL, Murray TA, Hawkins RJ, Gill TJ
J Shoulder Elbow Surg. 2002 Mar-Apr; 11(2):151-5.

24. Risk Factors
• Age
• >80 pitches per month
• > 8 months per year
• Position played (Pitchers > catchers >
infielders > outfielders)
• involve in multiple baseball leagues
• Dominant arm
• Family history of osteochondrosis.

25. Diagnosis
• Age and skeletal maturation
– injury profile changes with fusion of elbow ossification centers.
• Overuse vs acute injuries
– Acute: sudden onset or a "pop" may indicate an avulsion
– Chronic: decrease strength, active mobility, and endurance
• Relationship of the pain with throwing phases
– exacerbated during early acceleration/ late cocking

26. Diagnosis
• Tenderness/swelling/hypertrophy over the medial epicondyle
• Carrying angle >20: chronic pathology
• ecchymosis / flexion contracture > 15° - avulsion fracture
• UCL integrity :
– Anterior band: valgus stress at 20° elbow flexion
– Posterior band: valgus torque when the forearm is supinated and the
elbow is flexed > 90° (Milking maneuvre)
• Neurological exam: ulnar nerve injury.

27. Diagnosis
Milking Maneuvre: UCL integrity

28. Diagnostic Imaging
• Confirm diagnoses based on
history and physical examination
• Aid in treatment planning.

29. Diagnostic imaging
• Plain X-Ray
– medial epicondyle avulsion fractures, loose bodies, osteochondritis,
bone spurs, ligament calcification, HO
• Stress radiographs
– Confirm elbow valgus instability with joint opening > 3 mm
Imaging of sports injuries of the upper extremity in children.
Emery KH
Clin Sports Med. 2006 Jul; 25(3):543-68, viii

30. Diagnostic imaging
• widening of the growth plate or irregularity
of the medial epicondyle ossification center
• avulsed epicondylar fragment
• anterior and posterior fat pads
("sail sign"): effusion

31. Diagnostic imaging
• Magnetic Resonance Imaging
– Marrow edema in the medial epicondyle
– UCL injuries:
– 100% specificity, 100% sensitivity in identifying full-thickness tears
– 100% specificity, 57% sensitivity for partial-thickness tears
Tuite MJ, Kijowski R. Sports-related injuries of the elbow:
an approach to MRI interpretation. Clin Sports Med.
2006;25(3):387–408.

32. Diagnostic imaging
• Marrow edema in the medial
epicondyle and adjacent bone

33. Diagnostic Imaging
• Partial thickness tear: Increased T2-
weighted signal within the anterior
bundle of UCL ligament
• Edema-like signal changes in the
proximal pronator muscle strain
• Edema in the sublime tubercle

34. Diagnostic Imaging
• Osteochondritis Dissecans
– Junior high school > high school and collegiate players
• MCL injuries
– High school and collegiate > junior high school players
– Pitchers and outfielders > infielders.
The effect of physical characteristics and field position on
the shoulder and elbow injuries of 490 baseball players:
confirmation of diagnosis by magnetic resonance imaging.
Han KJ, Kim YK, Lim SK, Park JY, Oh KS
Clin J Sport Med. 2009 Jul; 19(4):271-6.

35. Diagnostic Imaging
• Dynamic ultrasonography
– UCL injury
– operator-dependent
• CT arthrography
– 86% sensitive and 91% specific for UCL injury

36. Treatment
• REST: 4-6 weeks
• restriction from throwing
• Wrist and Elbow strengthening exercises
• Gradual return to throwing if asymptomatic
• Avoid aggravating pitches, restrict pitch counts
• Change position that involves less throwing,
such as first base
• Conservative treatment:
– full recovery rates in 40–50% of overhead throwing
athletes, 100% in non-throwing athletes
Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball
players: a variant of Little League elbow.
Osbahr DC, Chalmers PN, Frank JS, Williams RJ 3rd, Widmann RF, Green DW
J Shoulder Elbow Surg. 2010 Oct; 19(7):951-7

38. Fixation of medial epicondyle
• Significantly displaced medial epicondyle avulsion fractures
• Younger children: K-wires
• Near Skeletal maturation: Screw fixation
• Operative treatment affords a significantly higher union rate over
the non-operative management
• There was no difference in pain at final follow-up
Operative versus non-operative management of pediatric
medial epicondyle fractures: a systematic review
Atul K Kamath, et al
J Child Orthop. 2009 Oct; 3(5): 345–357

39. Fixation of medial epicondyle

40. Fixation of medial epicondyle
• Great care is needed to ensure a smooth surface over which
the ulnar nerve will lie

41. UCL reconstruction
• favored over primary surgical repair
(only yield 50% return to previous level)
• Tommy John Surgery
– first baseball player to undergo the surgery,
MLB pitcher Tommy John
• UCL disruption and insufficiency
• Restore medial stability of the elbow

42. UCL reconstruction
Common site of donar tendon graft:
• Palmaris Longus
• Hamstring
• Toe extensor
• Allograft

43. UCL Reconstruction
Review article:
Elbow medial collateral
ligament injuries
Ra’Kerry K. Rahman, et al
Curr Rev Musculoskelet Med
(2008) 1:197–204

44. UCL reconstruction
Jobe’s Technique
• Detachment of the flexor-pronator mass
• Transposition of the ulnar nerve
• Bone tunnels directed posterior on the
humeral epicondyle
• Graft in a figure of 8
✕Technically demanding
✕High complication rate, ulnar nerve palsy in 21%

45. UCL reconstruction
Docking Technique
• Graft is passed through the proximal ulnar
bone tunnel and medial epicondyle
• Graft is tensioned with the elbow flexed with
an applied varus stress
• The proximal limb of the graft is sutured to the
medial intermuscular septum outside the drill
hole on the superior surface of the epicondyle

46. UCL reconstruction
• The native ligament repaired over the graft
with simple sutures
• Graft fashioned to an exact length to fit
inside the humeral tunnel
• The free ends of the graft are controlled with
sutures that are passed through the two
exiting tunnels and tied over a bony bridge.

47. Rehabilitation
• Immediate post-op: elbow immobilized in a
splint to allow skin and soft tissues healing.
• At 10 days: active wrist, elbow and shoulder
range of motion exercises
• At 4–6 weeks: strengthening exercises,
avoiding valgus stress
• At 4 months: begin throwing program with
gradual increase in pitch count
• 18 months may be needed to regain pre-op
level with accurate ball control

48. Platelet-rich plasma injection
• Peripheral blood from the patient is centrifuged
• Autologous activated platelets retained in fibrin matrices
– Source of molecular signals to control cell growth + differentiation
– synthesis of functional proteins.
• PRP injected to the injured ligament to stimulate healing
• Widely in treatment in different sports injuries
– ACL repair and tendon surgery
– No report of usage in Little League elbow
– lack of good evidence

49. Prevention
• Warm up properly by stretching, running, and gradual throwing
• Develop skills that are age appropriate
• Don’t pitch with elbow or shoulder pain
• Don’t pitch on consecutive days
• Adhere to pitch count guidelines
• Rotate playing different positions
• Don’t play year-round

50. Prevention
Pitches in a game (Ages < 14) Pitches in a game (Ages 15-18) Required rest days after game
66+ 76+ 4 days
51-65 61-75 3 days
36-50 46-60 2 days
21-35 31-45 1 day
1-20 1-30 none
Source : Little League Baseball
Required Rest days after a game

51. Prevention
Pitch limit 9-10 y/o 11-12 y/o 13-14 y/o
Per game 50 75 75
Per week 75 100 125
Per season 1000 1000 1000
Per year 2000 3000 3000
Pitch Count Recommendations by Age
The American Sports Medicine Institute 2006
http://www.asmi.org/asmiweb/usabaseball.htm#Counts

52. Thank you!