PMR PG Teaching

1. Sports Injuries Around
Elbow Joint
Dr Om Prakash
Assistant Professor
SMS Medical College and attached Hospitals, Jaipur

2. Definition of sports-related injury
An injury that has originated during or as a result of sports activities.
An injury that interrupts sports practice.
An injury, which is caused by a sudden event during sports
participation or which originates gradually as a result of sports
participation.
An injury, which originates during physical education and sports
practice is also considered a sports injury.

3. The Problem
Athletic injuries around elbow are common especially in throwing
sports such as baseball and tennis etc.
Common etiology are:
 No/Insufficient warm up
 No/Insufficient cool down
 Insufficient rest after injury
 Poor training and conditioning of the athlete person

4. Injuries to the M/S tissues can be classified as primary
or secondary:
Primary Secondary
Macro-traumatic forces
Acute trauma (F/D,
Sprain, Strain, Contusion)
Microtraumatic forces
(tendinitis, tenosynovitis,
bursitis etc.)
overuse injuries
repetitive overloading
incorrect mechanics
Secondary injuries are
essentially the inflammatory
or hypoxia response that
occurs with the primary injury

5. The Problem
The type of injuries around elbow joint an be roughly grouped
into:
Enthesopathies (lateral and medial epicondylitis and other rarer
similar conditions)
Valgus stress injuries as the result of altered function of the
primary constraint to valgus stress, and the MCL
Posterior impingement
Nerve compression syndromes.
Osteochondritis dissecans (younger athletes).

7. Common Sports related Injuries around
the elbow Joint

8. Lateral Epicondylitis or “tennis elbow”;
Degenerative tears in extensor carpi radialis brevis (ECRB) origin with
pain at lateral epicondyle
Mechanism: Repetitive contraction of wrist extensors leads to
extensor tendon degeneration.
Presentation:
commonely seen in racket sports, poor technique, dominant arm;
Pain with lifting objects; initially pain subsides with rest.
Physical Exam: Tenderness to palpation over lateral epicondyle and
ECRB; pain with resisted wrist and long finger extension; pain with
resisted supination

9. Diagnostics: Clinical diagnosis; MRI may show inflammation of the
ECRB.
Differential Diagnosis: Posterior interosseous nerve entrapment,
radiocapitellar arthrosis, osteochondritis dissecans, cervical
radiculopathy.
Treatment:
Nonoperative management with activity modification, ice, NSAIDs,
physical therapy, and counterforce bracing.
Corticosteroid injection if severely painful or if symptoms persist despite
therapy.
Surgical treatment rare, with excision of ECRB tendon.
Lateral Epicondylitis

10. Medial Epicondylitis or “golfer’s elbow”
Inflammation/ degenerative change of the flexor-pronator mass at
its origin on the medial epicondyle.
Mechanism: Stress/overuse injury of the flexor-pronator mass
that occurs with repetitive wrist flexion or forearm pronation.
Presentation:
Pain at the medial epicondyle
Seen in pitchers, golfers, bowlers, weightlifters and football players
Can be associated with ulnar neuropathy

11. Physical Exam: Pain at the medial epicondyle and overlying the
flexor-pronator mass proximally; discomfort/weakness exacerbated
by resisted wrist flexion and/or pronation performed in full extension
Differential Diagnosis: Ulnar collateral ligament sprain,
flexorpronator tear, ulnar neuritis.

Diagnostics: Clinical and MRI can be used to confirm the diagnosis
in patients with possible conflicting sources of pain
Medial Epicondylitis

12. Treatment:
1. Conservative treatment (activity modification, counterforce elbow
bracing, NSAIDs, icing, and a physical therapy aimed at flexor-
pronator strengthening.
2. Corticosteroid injections can be considered in refractory cases
3. Patients with symptoms lasting more than a year can be offered
operative debridement of the degenerative proximal portions of the
pronator teres and flexor carpi radialis
Prognosis and return to play: Athletes can generally return to
play once asymptomatic (typically after 6- to 12-week)
Medial Epicondylitis

13. Distal Biceps Raptures
 Traumatic avulsion of distal biceps tendon from bicipital tuberosity of the
proximal radius
 Mechanism: Eccentric extension load applied to flexed, supinated forearm
 Presentation: 97% of biceps raptures are proximal, only 3% are distal;
thought to be associated with pre-existing tendon injury/degeneration or
steroid use
 Physical Exam: Tenderness in antecubital fossa, regional ecchymosis,
palpable tendon defect in complete tears, tendon retraction if lacertus
fibrosis torn; weakness with supination/elbow flexion

14. Differential Diagnosis: Biceps tendonitis, cubital bursitis,
lateral antebrachial cutaneous nerve entrapment
Diagnostics: Mostly a clinical diagnosis, ultrasound or MRI to
confirm
Treatment: Acute injury surgically repair considered superior to
non-operative treatment
Prognosis and return to play: Usually a season-ending injury;
patients treated early can be expected to have full return of
power and function
Distal Biceps Raptures

15. Triceps Tendonitis
Inflammation of the triceps tendon at its insertion at olecranon
process of the ulna.
Mechanism: Overuse injury from repetitive extension/
hyperextension of the elbow.
Presentation:
Most commonly seen in baseball players and weightlifters
Patients report pain focal to the triceps insertion on the olecranon.
Physical Exam: Triceps tendon is tender to palpation at, or just
proximal to, its insertion site; focal pain with resisted elbow
extension.

16. Differential diagnosis: Partial tendon tear; olecranon bursitis;
olecranon stress fracture; fracture of olecranon osteophyte.
Diagnostics: Plain x-ray can reveal traction osteophytes; MRI can
be useful to distinguish between inflammation and partial triceps
tendon tear.
Treatment:
Almost all respond to rest, ice, NSAIDs, and/or rehabilitation with
graduated stretching and strengthening
steroid injection can also be considered in refractory cases
Prognosis and return to play: Most athletes can continue to play
with this disorder with initiation of rest and focused rehabilitation in
the off-season
Triceps Tendonitis

17. Triceps Rupture/Olecranon Avulsion
Traumatic avulsion of the triceps tendon from its insertion on the
olecranon process of the ulna, or avulsion of the olecranon process
from the ulna with triceps tendon attached.
Mechanism:
Most commonly occurs from fall on outstretched hand with
deceleration load applied to an actively contracting triceps
also reported in weightlifters and in direct trauma.
Presentation: Rare injury; can be associated with steroid use,
metabolic bone disorders, and renal osteodystrophy.

18. Physical Exam: Tenderness to palpation along olecranon and
distal triceps; regional ecchymosis and edema; palpable defect
of triceps tendon or step-off at olecranon; weak elbow extension
Differential diagnosis: Triceps tendonitis, olecranon bursitis,
olecranon stress fracture, posterior elbow impingement.
Diagnostics: Largely a clinical diagnosis; “flake sign” (small
bony avulsion fragment from olecranon process) noted in 80% of
these injuries; can use MRI or ultrasound to aid in diagnosis if
unclear.
Triceps Rupture/Olecranon Avulsion

19. Treatment:
Conservative treatment consists of splint immobilization with
elbow in 30° of flexion for 4 weeks is indicated only in the elderly
or in partial tears
Treatment of choice is surgical repair within 2 weeks of injury in
young patients and complete tear
Prognosis and return to play: Usually a season-ending
injury with at least 6 months of recovery time expected
Triceps Rupture/Olecranon Avulsion

20. Olecranon Impingement Syndrome or hyperextension valgus
overload syndrome or “boxer’s elbow
Mechanical abutment of olecranon process against posterior soft
tissues or the olecranon fossa that occurs with terminal extension of
the elbow.
Mechanism:
Overuse syndrome caused by repetitive extension overloading
Can seen in a stable elbow (football linemen, gymnasts, weightlifters)

21. Presentation: Posterior elbow pain, crepitus, and locking or
catching; overhead throwers often complain of premature fatigue,
loss of velocity, or loss of control.
Physical exam: Some loss of terminal extension; posterior
elbow pain with valgus stress in terminal extension; possible laxity
of UCL with valgus stress.
Differential Diagnosis: Olecranon bursitis, olecranon stress
fracture, triceps tendonitis.
Diagnostics: Plain x-rays can reveal loose bodies, hypertrophic
bone formation, calcification of the UCL; MRI can help to further
assess the status of the articular cartilage
Olecranon Impingement Syndrome

22. Treatment:
PRICE and a physical therapy regimen aimed at improving
flexibility and elbow strength focused on wrist flexor and extensor
strengthening;
Athletes that fail to respond are candidates for arthroscopic
debridement of the posterior fossa with or without concomitant
UCL reconstruction.
Olecranon Impingement Syndrome

23. Olecranon Stress Fracture
Microfracture of the proximal portion of the ulna.
Mechanism: Overuse injury that results from repeated tension on
the proximal ulna with throwing
Presentation:
Common seen in adolescents and children throwers
Patients usually report gradual onset of pain in the posterior or
lateral elbow that occurs during the acceleration phase of throwing.
Physical Exam: Focal point tenderness at olecranon process

24. Differential Diagnosis: Triceps tendonitis, olecranon bursitis,
posterior impingement syndrome.
Diagnostics: CT scan or MRI or bone scan to confirm the
diagnosis
Treatment:
Immediate cessation of throwing with non–weight bearing status in
the affected arm till tenderness subsided with gradual
rehabilitation thereafter;
If patients become symptomatic again with rehab, percutaneous,
cannulated screw fixation of the fracture can be considered.
Olecranon Stress Fracture

25. Olecranon Bursitis or miner’s elbow,” or “student’s elbow”;
Inflammation of the bursa overlying the olecranon process
Can be acute or chronic, septic or aseptic
Mechanism: Typically occurs because of mild direct trauma to the
posterior elbow; may be secondary to a single direct blow, or to
repetitive trauma to the superficial tissues
Presentation:
Acute or gradual onset of swelling; acute/septic cases can be painful,
whereas chronic cases are often painless;
Most common in football and hockey players; high association with
play on artificial turf.

26. Physical Exam: Focal posterior elbow swelling; mobile, fluctuant mass
that can wax and wane in size
Differential Diagnosis: Gouty tophus, calcium pyrophosphate
deposition.
Diagnostics: X-rays occasionally will show calcification of the bursa or
olecranon spur; aspiration can be performed in acute and chronic
cases; fluid should be sent for cell count and differential, Gram
stain/culture, and crystal analysis
Olecranon Bursitis

27. Treatment:
Acute cases PRICE and NSAIDs
Chronic cases can be treated with aspiration and injection of
corticosteroid
Septic bursitis should be drained/excised with administration of
intravenous and or oral antibiotics
Chronic aseptic cases can also be treated with excision of the bursal
sac
Olecranon Bursitis

28. Ulnar Collateral Ligament Sprain
Microtears or complete ruptures of the ulnar collateral ligament
Mechanism: Repetitive valgus stress (pitching, throwing, racket sports)
causes tensile loading of ulnar collateral ligament, resulting in microtears
or complete rupture.
Presentation: Insidious medial elbow pain, provoked by valgus
stresses and relieved by rest.
Physical Exam: Swelling, pain, tenderness 2 cm distal to medial
epicondyle; pain increased by manual valgus stress, Tinel’s
(associated ulnar neuritis)

29. Differential Diagnosis: Ulnar neuritis, medial epicondylitis, flexor-
pronator muscle rupture/strain.
Diagnostics:
X-rays may show avulsion fracture (acute); medial collateral ligament
ossification, loose bodies, marginal osteophytes (chronic); manual or
gravity valgus stress views to confirm (2 mm gapping).
MRI useful for tear evaluation
Treatment:
Rest, NSAIDs, physical therapy, correction of throwing mechanics; limit
pitch count.
Complete medial collateral ligament tear (acute or chronic) may require
surgical reconstruction.
Ulnar Collateral Ligament Sprain

30. Medial Epicondyle Stress Lesions or “little leaguer’s elbow”
Medial sided pain in the throwing elbow of adolescents.
Mechanism: Repetitive tensile stress on the medial epicondyle
apophysis from the flexor-pronator mass and the ulnar collateral
ligament. Results from transient weakness of the apophysis in the
adolescent
Presentation: Triad of symptoms: Medial elbow pain with throwing,
loss of throwing speed, and diminished throwing effectiveness.
Physical Exam: Point tenderness at medial epicondyle; pain with
valgus stressing, but not frank instability

31. Differential Diagnosis: Ulnar collateral ligament injury, ulnar
neuropathy, medial epicondyle fracture, flexor-pronator strain.
Diagnostics: X-rays show widening of apophyseal line or less
commonly fragmentation.
Treatment: 6 weeks cessation of throwing; ice, NSAIDs, and brief
immobilization; gradual return to throwing only after pain free with
emphasis of proper throwing mechanics.
Medial Epicondyle Stress Lesions or “little leaguer’s elbow”

32. Pronator Teres Syndrome (Median Nerve Entrapment)
Compression of the median nerve at the level of the elbow with
resultant nerve irritation
Mechanism: Common in throwing sports, racquet sports weight
lifting sports. Four possible sites of compression have been
identified:
Tendinous arch of the flexor digitorum superficialis (“sublimis bridge”)
An aberrant band of fibrous tissue that connects the sublimis bridge to the
deep head of the pronator
Beneath the ligament of Struthers
At the lacertus fibrosis at the level of the elbow joint

33. Presentation:
Patients often present with insidious onset of vague anterior elbow pain
that increases with activity;
Associated activities include weightlifting, competitive driving, and
underarm pitching
Diagnostics: EMG and NCS are an appropriate diagnostic step
Treatment: Conservative treatment measures are generally not
effective, sites of compression must be released operatively
Pronator Teres Syndrome (Median Nerve Entrapment)

34. Ulnar Nerve Compression Syndrome (Cubital tunnel
syndrome);
Compression of the ulnar nerve as it crosses the elbow joint.
Presentation: Insidious onset of aching medial elbow/forearm pain,
numbness at ring/small fingers, and grip weakness
Physical Exam: Positive Tinel’s sign over cubital tunnel; positive ulnar
nerve compression test; grip weakness; weak FDP to small finger.
Differential Diagnosis: Cervical radiculopathy, thoracic outlet
syndrome, ulnar nerve compression at wrist
Treatment:
NSAIDs, modification of training, night-time splinting, elbow pads
anterior transposition if poor response to nonoperative management.

35. DISLOCATIONS AND FRACTUREDISLOCATIONS
 Fracture of the radius, ulna, or humerus, with or without dislocation or
subluxation of the elbow joint
 Mechanism: High-energy traumatic event, usually a fall onto outstretched
arm.
 Presentation: History of trauma; severe pain, exacerbated by subtle
movement; instability.
 Physical Exam: Tenderness, deformity, swelling, ecchymosis; limited and
severely painful motion, crepitus; possible neurologic or vascular compromise;
varus/ valgus instability.
 Diagnostics: X-ray, CT and MRI to assess bone and ligamentous damage.

36. Principles of sport injuries treatment
The basic principles of treatment of all sporting injuries are
that
The injuries are speedily and effectively treated with the aim
of returning the patient to their sport at the same level as
previously as soon as possible.

37. Prevention
A. Warm-up, stretching and cool down
Proper warm-up before all training and competition is a prerequisite for
peak performance and for injury avoidance
General warm up and sports specific warm up with stretching
Should last 10-15 minutes resulting in effects that will last 45 minutes
Prevent unnecessary musculoskeletal injury and soreness
Stimulates cardiorespiratory system, enhancing circulation and blood
flow to muscles and enhance performance
Increases metabolic processes, core temperature, and muscle
elasticity

39. Cool Down
Essential component of workout
Bring body back to resting state
5-10 minutes in duration
Often ignored
Decreased muscle soreness following training if time used to
stretch after workout

40. B. Proper progression of training
One of the most important risk factors for overuse injuries is
increasing the training load too rapidly
Training must be in a progressive increasing load during the sports
activities
10% rule: Don’t increase activity by more than 10% per week

41. C. Protective gear (devises):
Protective gear is one of the most
well-documented injury prevention
measures in sports．
D. Physical exams:
Individuals with a known disease or injury should be examined to
assess the potential risk and make the necessary adjustment in
their training program.
E. Education:
Athletes must educate and trained for his sports
Athletes must provide a list of possible injury and their preventive
methods for his particular sports activity

42. Sports Injuries Treatment
and Rehabilitation

43. Healing process is a continuum
Stages of injury recovery
Injury Day 4 Week 6 2-3 Years
Inflammatory-Response Phase
Fibroblastic-Repair Phase
Maturation-Remodeling Phase

44. Treatment Plans
 When in doubt keep the athlete out
 Thorough history & physical exam
 Report all injuries
 X-rays, MRI might be needed
 Specialists in sports medicine can be particularly helpful

45. 1. Treatment of Acute Sporting Injuries
Keep aids:
In the sport ground keep all aids available ready to use
Backboard
Splints
Stretcher
Stretcher is not a sign of weakness

46. 1. Treatment of Acute Sporting Injuries
In Acute injury Inflammation leads to edema, bleeding
and additional trauma
Controlling inflammation is essential
Injury causes Inflammation
Inflammation delay Healing
Inflammation reduces tensile strength
Immobile Loose connective turned into dense
connective tissue

47. 1. Treatment of Acute Sporting Injuries
Immediate First Aid - PRICE
Protection
Rest
Ice
Compression
Elevation
Immediate first aid management of injury minimize the early effects
of excessive inflammation
By decreasing swelling, bleeding, muscle spasm, provides analgesia
and also facilitating healing

48. 1. Treatment of Acute Sporting Injuries
Immediate First Aid - PRICE (MM)
Pain of the inflammatory phage may be control by:
NSAID’s and pain killers
Cryotherapy
Electrical stimulating currents
Low-power laser
Specific ROM exercises are instituted in first 48 hours to
maintain ranges and prevent contracture around the joint

49. 2. Recovery phase/ Intermediate stage
Criteria:
1. Pain/Inflammation under control
2. Pain-free Full ROM
 Restoration of flexibility
 Strengthening of affected limb
 Proprioceptive training
 Correct maladaptive movement patterns and muscle
substitutions
 Aerobic and endurance exercises

50. 2. Recovery phase/ Intermediate stage
Modalities :
US Therapy
Electrical stimulation, SWD etc
Applying heat
If swelling, bruising and pain
Relieve muscle tension, promoting relaxation
NSAID:
Initially for a short period
Help ROM and flexibility

51. 3. Functional phase/Advanced stage
Return to practice
Progression is the key principle :
Start with little but often
Gradually increase the amount of load
Avoid painful activities
Stretch muscle group 2-3 times every hour
One-two longer stretchings
Build up 3 sets of 10 repetitions
Exercises to improve function of injured part

52. 3. Functional phase/Advanced stage
Principles of progression:
If pain on doing exercise or soreness the next morning, drop back to easier
exercise
If no pain or swelling, feels the same next day, stay at that same level of
exercise
If no pain during or after or upon waking the next morning, injured area feels
better in ADL the next day, increase intensity of exercises/move to next
stage

53. 3. Functional phase/Advanced stage
 Regain motions:
 Active-assisted pulley or wand exercise
 Pendulum exercises
 Passive joint mobilization and stretching
 Muscle strengthening:
 Start with closed-kinetic chain exercises (Supine position)
 Sub-maximal isometric strengthening exercises around the joint
 Proprioceptive neuromuscular Facilitation (PNF) exercises
 Progression to open-kinetic chain exercises
 Resistive bands, tubings
 Medicine ball or free weights
 Progression to plyometric exercises (in functional phase)

54. Neuromuscular control and Dynamic stability exercises

55. Plyometrics Exercises

56. Before return
Do not return to sport until player can stress the injured tissues
without reaction of
Pain
Swelling
Limitation of movement
Ensure before return
Full ROM
Strength
Balance
Co-ordination