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Forms of elbow injuries, diagnosis and treatment

21 March 2022
Dr. Elviz Qasımov

General information on elbow injuries

Excessive strain on the elbow during athletic activities such as baseball, shot put and discus throwing, and other sports can result in stress fractures. During a fall or a collision with other players, chronic injuries can occur over time, as opposed to acute (momentary) injuries. Similar elbow injuries can occur in other professions. For example, lateral epicondylitis at the elbow joint is most common in plumbers and automotive locksmiths.

Anatomical structure of the elbow joint

The elbow joint is formed by three bones: the bones of the shoulder – the humerus, and the bones of the forearm – the ulna and radius. Many muscles, nerves, and tendons (connective tissue between muscles and bones) pass through the elbow joint. The flexors and extensors of the wrist and hand start at the elbow joint and are also important stabilizers when making a throw. The ulnar nerve runs through the posterior-inner part of the joint, is under the skin and we can easily palpate it. This nerve controls the muscles of the hand and the sensitivity of the fourth and fifth fingers.

This picture shows the bones that make up the elbow joint and other structures

Golfer’s elbow and tennis player’s elbow

This is the name given to the condition that occurs when the muscles of the forearm that attach to the elbow joint become inflamed. A golfer’s elbow pain is felt on the inner surface, while a tennis player’s pain is localized on the anterior surface. In both cases, too much grueling training causes problems.

The golfer’s elbow is flexor tendonitis – medial epicondylitis:

Repeated throws lead to the development of damage to the flexor muscles, which are attached to the bone on the inner surface of the elbow joint. This condition is called tendinitis. For this reason, the athlete has pain on the inside surface of the elbow joint during a throw. When tendinitis is severe, pain may also occur at rest.

Tennis player’s elbow – extensor tendinitis – lateral epicondylitis:

It is common for tennis players who hold the wrist radius joint in an extensor position to have pain in the area of the outer surface of the elbow joint as a result of repetitive trauma.

Damage to the ulnar collateral ligament (UCL)

The ulnar collateral ligament is the ligament most commonly injured in people who throw. The severity of injury to the ulnar collateral ligament can range from mild injury and inflammation to complete rupture of the ligament. There is pain and decreased throwing speed.

Excessive stress on the valgus extension of the elbow joint

During a throw, the humerus and olecranon bend and friction occurs between them. Over time, this can lead to an excessive load on the valgus extension. And this in turn can cause the elbow cartilage to thin and to develop bone spikes (osteophytes – abnormal bones). Athletes with this pathology may experience pain and swelling during maximal contact between the bones.

The figure shows abnormal bone outgrowths (bone spurs) during excessive valgus elbow extension stress

Stress fractures of the olecranon

Stress fractures occur during muscle fatigue and when additional impulses can’t be received. Fatigued muscles transmit additional stress loads to the bones, resulting in what are known as stress fractures in the form of small fractures.

The most common stress fracture of the olecranon occurs in athletes who throw. Athletes with this condition may indicate m pain points on the surface of the olecranon, which is located on the lower surface of the elbow joint. This pain becomes very severe during throws and other heavy exertion, and sometimes even continues during rest.

Neuritis of the ulnar nerve

The ulnar nerve extends along the posterior surface of the distal end of the humerus. During disc throwing by athletes, the ulnar nerve lengthens several times and can lead to dislocation, or even cause painful fissures – fibrosis. This condition causes nerve irritation and leads to what is known as neuritis, an inflammatory nerve disease. Athletes suffering from ulnar nerve neuritis feel pain that is similar in sensation to an electric shock. It extends from the inner surface of the elbow joint to the surface of the rib cage. There is numbness in the area of the IV and V fingers, and pain during or immediately after a throw.

What causes elbow injuries?

Most elbow injuries occur in throwing athletes due to very high and repetitive loads. The pain usually goes away when the athlete pauses the throw. A number of these problems are rarely seen among people who do not throw. Elbow pain can also be seen in mechanics, plumbers, golfers, and some housewives.

Clinical manifestations of elbow injuries

  • Pain
  • Restriction of range of motion
  • Numbness
  • Swelling

How is the examination performed?

During the examination, a medical history, information about the patient’s health, clinical complaints, and information about the sport the patient plays and when he or she started. Next, physical tests are performed and the movements in which pain occurs are identified. The doctor checks the amount of movement in the elbow joint, its stability by performing very important physical examination tests, such as valgus and varus stress tests. During the examination, you should assess the angle of motion, the number and condition of the muscles, and make a comparison between the healthy and the injured elbow joint. It is mandatory to measure muscle strength and degree of sensitivity.

In order to assess and determine the exact location of pain, palpation should be performed. Note the anatomical point, in the localization of which the pain is determined.

The valgus stress test is used to assess the condition of the medial collateral ligament. The doctor holds the patient’s hand and performs traction (load) to the opposite side on the lateral surface of the elbow joint. The test result is considered positive if the elbow joint wobbles or the test contributes to pain.

The varus stress test is used to evaluate the condition of the lateral collateral ligament. The results of these tests help the doctor decide on the tactics for further evaluation of the patient, the need for additional tests and imaging of the elbow joint.

Diagnosis

X-Ray is an examination that is performed to evaluate the condition of the bone attachments.

A computer tomography (CT) scan is a study that provides a three-dimensional (3D) image of bones. The CT scan can be used to detect bone growths that restrict range of motion or cause pain, as well as to clarify other bone abnormalities.

Magnetic resonance imaging (MRI) is a study that provides a clear image of the soft tissues of the elbow joint, and helps the doctor match symptoms and physical test results to the ligaments and tendons that cause them. With an MRI exam, minimal ligament damage or complete ligament rupture can be detected. MRI can detect stress fractures that can’t be detected by radiological examination.

Treatment options for elbow injuries

Conservative treatment

In most cases, treatment begins with short-term rest.

Physical therapy – if the patient’s complaints do not go away, the patient should be given special exercises to restore strength and dexterity of movement.

Anti-inflammatory drugs – drugs such as ibuprofen and naproxen can be used to reduce pain symptoms and swelling in the joint area.

Surgical treatment

If the pain symptoms do not go away with conservative treatment and the athlete wants to continue discus throwing, then the patient is recommended to undergo surgical treatment.

Arthroscopy – Bony protrusions on the surface of the elbow joint (olecranon), loose bone fragments and pieces of cartilage are removed arthroscopically. During arthroscopy, a small camera called an arthroscope is inserted into the joint cavity. The surgeon uses small incisions instead of the large incision used in open surgeries because the instruments for the surgery are very small.

Reconstruction of the ulnar collateral ligament – Athletes who have instability and rupture of the ulnar collateral ligament are treated by surgery to restore the integrity of the ligament. Most torn ligaments cannot be repaired. To repair the ulnar collateral ligament, the ligament must be re-formed. During the procedure, the doctor restores the integrity of the ligament by using a crepe from another tendon. For this purpose, the doctor uses a tendon from the upper or lower extremity.

Transposition of the ulnar nerve to the anterior surface of the elbow joint – When the ulnar nerve is inflamed and the nerve is compressed in the ulnar tunnel, the nerve is transplanted to the anterior surface of the elbow joint. This surgery is called anterior transposition of the ulnar nerve.

After conservative treatment, the athlete can return to sports activities after 6-9 weeks. Depending on the method of surgical treatment, the recovery time may vary. If the ulnar collateral ligament has been reconstructed, it may take 6-9 months to recover and return to sports.

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