Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Current Reviews in Musculoskeletal Medicine
Published in: Current Reviews in Musculoskeletal Medicine 1/2019

01-03-2019 | Injuries in Overhead Athletes (J Dines and C Camp, section editors)

Approach to Medial Elbow Pain in the Throwing Athlete

Author: L. Pearce McCarty III

Published in: Current Reviews in Musculoskeletal Medicine | Issue 1/2019

Login to get access

Abstract

Purpose of Review

Injury to the ulnar collateral ligament is the most common, significant injury affecting the medial elbow of the overhead athlete. However, there are many other significant sources of pathology that should be considered. This review seeks to present a broad range of conditions that providers should consider when evaluating the overhead athlete with medial elbow pain.

Recent Findings

Recent biomechanical studies have deepened understanding of the anatomy and function of the anterior bundle of the ulnar collateral ligament germane to the overhead athlete. Orthobiologics hold potential for expanding the role of non-operative treatment for ulnar collateral ligament injuries.

Summary

In addition to injury to the ulnar collateral ligament, providers should be prepared to diagnose and treat valgus extension overload, proximal olecranon stress fracture, ulnar nerve pathology, common flexor - pronator mass injury, and, in adolescents, medial epicondylar avulsion, when managing medial elbow pain in the overhead athlete.
Literature
1.
Conte S, Requa RK, Garrick JG. Disability days in major league baseball. Am J Sports Med. 2001;29(4):431–6.CrossRef
2.
Posner M, Cameron KL, Wolf JM, Belmont PJ, Owens BD. Epidemiology of major league baseball injuries. Am J Sports Med. 2011;39(8):1676–80.CrossRef
3.
• Ciccotti MG, Pollack KM, Ciccotti MC, et al. Elbow injuries in professional baseball: epidemiological findings from the major league baseball injury surveillance system. Am J Sports Med. 2017;45(10):2319–28 Excellent, up-to-date review of the epidemiology of elbow injuries in Major League Baseball. CrossRef
4.
Morrey BF. Anatomy of the elbow joint. In: Morrey BF, Sanchez-Sotelo J, editors. The elbow and its disorders. Philadelphia, PA: Saunders Elsevier; 2009. p. 11–38.CrossRef
5.
An KN, Zobitz ME, Morrey BF. Biomechanics of the elbow. In: Morrey BF, Sanchez-Sotelo J, editors. The elbow and its disorders. Philadelphia, PA: Saunders Elsevier; 2009. p. 39–63.CrossRef
6.
Peterson H. Physeal fractures of the elbow. In: Morrey BF, Sanchez-Sotelo J, editors. The elbow and it’s disorders. Philadelphia, PA: Saunders Elsevier; 2009. p. 246–67.CrossRef
7.
Silberstein MJ, Brodeur AE, Graviss ER, Luisiri A. Some vagaries of the medial epicondyle. J Bone Joint Surg Am. 1981;63(4):524–8.CrossRef
8.
• Frangiamore SJ, Moatshe G, Kruckeberg BM, et al. Qualitative and quantitative analyses of the dynamic and static stabilizers of the medial elbow: an anatomic study. Am J Sports Med. 2018;46(3):687–694. Precise, biomechanical analysis of the anterior bundle of the UCLUCL, looking at the clinical significant of injuries to different parts of the complex.
9.
Camp CL, Jahandar H, Sinatro AM, Imhauser CW, Altchek DW, Dines JS. Paper #15—quantitative anatomic analysis of the medial ulnar collateral ligament complex of the elbow with implications for reconstructive surgery. J Shoulder Elb Surg. 2018;27(4):e127.CrossRef
10.
Farrow LD, Mahoney AJ, Stefancin JJ, Taljanovic MS, Sheppard JE, Schickendantz MS. Quantitative analysis of the medial ulnar collateral ligament ulnar footprint and its relationship to the ulnar sublime tubercle. Am J Sports Med. 1936;2011(39):1941.
11.
Lin F, Kohli N, Perlmutter S, Lim D, Nuber GW, Makhsous M. Muscle contribution to elbow joint valgus stability. J Shoulder Elb Surg. 2007;16(6):795–802.CrossRef
12.
Hamilton CD, Glousman RE, Jobe FW, Brault J, Pink M, Perry J. Dynamic stability of the elbow: electromyographic analysis of the flexor pronator group and the extensor group in pitchers with valgus instability. J Shoulder Elb Surg. 1996;5(5):347–54.CrossRef
13.
Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989;14(2 Pt 1):267–71.CrossRef
14.
• Cesmebasi A, O’driscoll SW, Smith J, Skinner JA, Spinner RJ. The snapping medial antebrachial cutaneous nerve. Clin Anat. 2015;28(7):872–7 Interesting report on a novel neurologic source of medial elbow pain. CrossRef
15.
Pribyl CR, Kester MA, Cook SD, Edmunds JO, Brunet ME. The effect of the radial head and prosthetic radial head replacement on resisting valgus stress at the elbow. Orthopedics. 1986;9(5):723–6.PubMed
16.
Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11(5):315–9.CrossRef
17.
Sojbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res. 1987;218:186–90.
18.
Callaway GH, Field LD, Deng XH, et al. Biomechanical evaluation of the medial collateral ligament of the elbow. J Bone Joint Surg Am. 1997;79(8):1223–31.CrossRef
19.
Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res. 1980;146:42–52.
20.
O’Driscoll SW, Horii E, Carmichael SW, Morrey BF. The cubital tunnel and ulnar neuropathy. J Bone Joint Surg Br. 1991;73(4):613–7.CrossRef
21.
O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231–9.CrossRef
22.
Magee T. Accuracy of 3-T MR arthrography versus conventional 3-T MRI of elbow tendons and ligaments compared with surgery. AJR Am J Roentgenol. 2015;204(1):70.CrossRef
23.
Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med. 1994;22(1):31 discussion 32, 26.
24.
Schreiber JJ, Potter HG, Warren RF, Hotchkiss RN, Daluiski A. Magnetic resonance imaging findings in acute elbow dislocation: insight into mechanism. J Hand Surg Am. 2014;39(2):199–205.CrossRef
25.
Kim NR, Moon SG, Park J, Choi JW, Oh K. Stress ultrasound in baseball players with ulnar collateral ligament injuries: additional value for predicting rehabilitation outcome. J Shoulder Elb Surg. 2017;26(5):815–23.CrossRef
26.
Ciccotti MC, Hammoud S, Dodson CC, Cohen SB, Nazarian LN, Ciccotti MG. Stress ultrasound evaluation of medial elbow instability in a cadaveric model. Am J Sports Med. 2014;42(10):2463–9.CrossRef
27.
Ciccotti MG, Atanda A, Nazarian LN, Dodson CC, Holmes L, Cohen SB. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med. 2014;42(3):544–51.PubMedCentralCrossRef
28.
Erickson BJ, Bach BR, Cohen MS, et al. Ulnar collateral ligament reconstruction: the rush experience. Orthop J Sports Med. 2016;4(1):2325967115626876 232596711562687.PubMedCentralCrossRef
29.
Savoie FH, Morgan C, Yaste J, Hurt J, Field L. Medial ulnar collateral ligament reconstruction using hamstring allograft in overhead throwing athletes. J Bone Joint Surg Am. 2013;95(12):1062–6.CrossRef
30.
Cain EL, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter JC II, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426–34.CrossRef
31.
Rettig AC, Sherrill C, Snead DS, Mendler JC, Mieling P. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med. 2001;29(1):15–7.CrossRef
32.
• Ford GM, Genuario J, Kinkartz J, Githens T, Noonan T. Return-to-play outcomes in professional baseball players after medial ulnar collateral ligament injuries: comparison of operative versus nonoperative treatment based on magnetic resonance imaging findings. Am J Sports Med. 2016;44(3):723–8 Interesting look at the success/failure of non-operative treatment of varying degrees of UCLUCL injury in professional baseball players. CrossRef
33.
• Dines JS, Williams PN, ElAttrache N, et al. Platelet-rich plasma can be used to successfully treat elbow ulnar collateral ligament insufficiency in high-level throwers. Am J Orthop (Belle Mead NJ). 2016;45(5):296–300 Early data supporting use of orthobiologics in the setting of non-operative treatment of UCLUCL injuries in overhead throwers.
34.
Deal JB, Smith E, Heard W, O’Brien MJ, Savoie FH. Platelet-rich plasma for primary treatment of partial ulnar collateral ligament tears: MRI correlation with results. Orthop J Sports Med. 2017;5(11):2325967117738238 Accessed Sep 29, 2018.PubMedCentralCrossRef
35.
• Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am J Sports Med. 2013;41(7):1689–94 Accessed Sep 29, 2018. Early data supporting use of orthobiologics in the setting of non-operative treatment of UCLUCL injuries in overhead throwers. CrossRef
36.
Savoie FH, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008;36(6):1066–72.CrossRef
37.
Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74(1):67–83.CrossRef
38.
Dugas JR, Walters BL, Beason DP, Fleisig GS, Chronister JE. Biomechanical comparison of ulnar collateral ligament repair with internal bracing versus modified Jobe reconstruction. Am J Sports Med. 2016;44(3):735–41.CrossRef
39.
Wilkins K. Fractures involving the medial epicondylar apophysis. In: Rockwood CJ, Wilkins K, King R, editors. Fractures in children. Phladelphia, PA: JB Lippincott. p. 509–28.
40.
Patel NM, Ganley TJ. Medial epicondyle fractures of the humerus: how to evaluate and when to operate. J Pediatr Orthop. 2012;32(Suppl 1):10.CrossRef
41.
Case SL, Hennrikus WL. Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med. 1997;25(5):682–6.CrossRef
42.
Lawrence JTR, Patel NM, Macknin J, Flynn JM, Cameron D, Wolfgruber HC, et al. Return to competitive sports after medial epicondyle fractures in adolescent athletes. Am J Sports Med. 2013;41(5):1152–7.CrossRef
43.
Wilson FD, Andrews JR, Blackburn TA, McCluskey G. Valgus extension overload in the pitching elbow. Am J Sports Med. 1983;11(2):83–8.CrossRef
44.
Osbahr DC, Dines JS, Breazeale NM, Deng XH, Altchek DW. Ulnohumeral chondral and ligamentous overload: biomechanical correlation for posteromedial chondromalacia of the elbow in throwing athletes. Am J Sports Med. 2010;38(12):2535–41.CrossRef
45.
Ahmad CS, Park MC, Elattrache NS. Elbow medial ulnar collateral ligament insufficiency alters posteromedial olecranon contact. Am J Sports Med. 2004;32(7):1607–12.CrossRef
46.
Park JY, Yoo HY, Chung SW, Lee SJ, Kim NR, Ki SY, et al. Valgus extension overload syndrome in adolescent baseball players: clinical characteristics and surgical outcomes. J Shoulder Elb Surg. 2016;25(12):2048–56.CrossRef
47.
Cohen SB, Valko C, Zoga A, Dodson CC, Ciccotti MG. Posteromedial elbow impingement: magnetic resonance imaging findings in overhead throwing athletes and results of arthroscopic treatment. Arthroscopy. 2011;27(10):1364–70.CrossRef
48.
Ahmad CS, ElAttrache NS. Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med. 2004;23(4):76 x.CrossRef
49.
Waris W. Elbow injuries of javelin-throwers. Acta Chir Scand. 1946;93(6):563–75.PubMed
50.
Suzuki K, Minami A, Suenaga N, Kondoh M. Oblique stress fracture of the olecranon in baseball pitchers. J Shoulder Elb Surg. 1997;6(5):491–4.CrossRef
51.
Paci JM, Dugas JR, Guy JA, Cain EL Jr, Fleisig GS, Hurst C, et al. Cannulated screw fixation of refractory olecranon stress fractures with and without associated injuries allows a return to baseball. Am J Sports Med. 2013;41(2):306–12.CrossRef
52.
Schickendantz MS, Ho CP, Koh J. Stress injury of the proximal ulna in professional baseball players. Am J Sports Med. 2002;30(5):737–41.CrossRef
53.
Furushima K, Itoh Y, Iwabu S, Yamamoto Y, Koga R, Shimizu M. Classification of olecranon stress fractures in baseball players. Am J Sports Med. 2014;42(6):1343–51.CrossRef
54.
Treihaft MM. Neurologic injuries in baseball players. Semin Neurol. 2000;20(2):187–93.CrossRef
55.
Keefe DT, Lintner DM. Nerve injuries in the throwing elbow. Clin Sports Med. 2004;23(4):42 xi.CrossRef
56.
Spinner RJ, O’Driscoll SW, Jupiter JB, Goldner RD. Unrecognized dislocation of the medial portion of the triceps: another cause of failed ulnar nerve transposition. J Neurosurg. 2000;92(1):52–7.CrossRef
57.
Conti MS, Camp CL, Elattrache NS, Altchek DW, Dines JS. Treatment of the ulnar nerve for overhead throwing athletes undergoing ulnar collateral ligament reconstruction. World J Orthop. 2016;7(10):650–6.PubMedCentralCrossRef
58.
Childress HM. Recurrent ulnar-nerve dislocation at the elbow. Clin Orthop Relat Res. 1975;108:168–73.CrossRef
59.
Zemel NP. Ulnar neuropathy with and without elbow instability. Hand Clin. 2000;16(3):95 x.
60.
Del Pizzo W, Jobe FW, Norwood L. Ulnar nerve entrapment syndrome in baseball players. Am J Sports Med. 1977;5(5):182–5.CrossRef
61.
Rettig AC, Ebben JR. Anterior subcutaneous transfer of the ulnar nerve in the athlete. Am J Sports Med. 1993;21(6):40.CrossRef
Metadata
Title
Approach to Medial Elbow Pain in the Throwing Athlete
Author
L. Pearce McCarty III
Publication date
01-03-2019
Publisher
Springer US
Published in
Current Reviews in Musculoskeletal Medicine / Issue 1/2019
Electronic ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-019-09534-w

Other articles of this Issue 1/2019

Current Reviews in Musculoskeletal Medicine 1/2019 Go to the issue

Injuries in Overhead Athletes (J Dines and C Camp, section editors)

Approach to Latissimus Dorsi and Teres Minor Injuries in the Baseball Pitcher

Outcomes Research in Orthopedics (O Ayeni, section editor)

The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury

Concussion (C Senter and M Kapadia, Section Editors)

Review of the Management of Pediatric Post-Concussion Syndrome—a Multi-Disciplinary, Individualized Approach

Injuries in Overhead Athletes (J Dines and C Camp, section editors)

Osteochondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm

Distal Radius and Wrist Fractures (E Shin, section editor)

Considerations in the Treatment of Osteoporotic Distal Radius Fractures in Elderly Patients

Injuries in Overhead Athletes (J Dines and C Camp, section editors)

Shoulder and Elbow Fractures in Athletes