Elbow Pain in Adolescents Kevin deWeber, MD, FAAFP Director, Tri-Service Sports Medicine Fellowship.
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Transcript of Elbow Pain in Adolescents Kevin deWeber, MD, FAAFP Director, Tri-Service Sports Medicine Fellowship.
Elbow Pain in Adolescents
Kevin deWeber, MD, FAAFP
Director, Tri-Service Sports Medicine Fellowship
Goals
• Understand the history/mechanism of injury
• Develop a thorough differential diagnosis for a painful elbow
• Understand the findings to look for on physical exam
• Understand management and return to play criteria
• Know when to refer
Case Study
11 year old Hispanic male complains of right elbow pain for the past 2 weeks. He states that the pain is present but better with rest, but worse when he pitches on his little league baseball team. He has been pitching for 2 years now, and started in a new league about 1 month ago.
Other questions about his history?
Other questions about his history?
Hand Dominance
Other questions about his history?
Hand Dominance
Other sports participation
Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Number of pitches/type of pitches
Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Number of pitches/type of pitchesHow many teams?
Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Number of pitches/type of pitchesHow many teams?
Side arm or overhead pitcher?
DDx
What can cause elbow pain in the young athlete?
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathy
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathy
Ulnar neuritis
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
Medial epicondylitis (“golfer’s elbow”)
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
Medial epicondylitis (“golfer’s elbow”)
Muscle strain/tear (flexor/pronator group)
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
Medial epicondylitis (“golfer’s elbow”)
Muscle strain/tear (flexor/pronator group)
Fascial Compartment Syndrome
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
Medial epicondylitis (“golfer’s elbow”)
Muscle strain/tear (flexor/pronator group)
Fascial Compartment Syndrome
Posteromedial olecranon osteophytosis
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
Medial epicondylitis (“golfer’s elbow”)
Muscle strain/tear (flexor/pronator group)
Fascial Compartment Syndrome
Posteromedial olecranon osteophytosis
Septic arthritis
DDx
What can cause elbow pain in the young athlete?
UCL sprain/tear
Medial epicondyle avulsion fracture
C8-T1 radiculopathyOsteochondrosis of medial epicondyle
Ulnar neuritis
Medial epicondylitis (“golfer’s elbow”)
Muscle strain/tear (flexor/pronator group)
Fascial Compartment Syndrome
Posteromedial olecranon osteophytosis
Septic arthritisTumor
Physical Exam
Appearance
Palpation
Range of Motion
Provocative Tests
• Slight swelling over medial epicondyle and tenderness to palpation. The UCL was also tender to palpation. There was some slight tenderness over the flexor bundle distally. There was no evidence of gross atrophy of the muscle.
• Strength was 5/5 with extension and supination, 4+/5 with pronation and flexion, limited by pain. Normal distal sensation, pulses. Negative Tinel’s with percussion of ulnar groove.
• Pain with valgus stress at 20 degrees, no laxity
• No neck tenderness, crepitus or step off, no gross shoulder pain or instability, nor any wrist/hand pathology noted.
Are radiology studies necessary for diagnosis? Insidious onset: NO
Acute onset: YES
Diagnosis?
Little Leaguer’s Elbow
• Catch-all phrase for elbow pain in young throwing athletes
Medial Epicondyle ApophysitisManagement
• Acute: control pain• “PRICEMM”• Relative rest• Modalities
• Ice, compression
• Brief medication
• Long-term : Rehabilitation• Non-painful ROM ex• Core strength and
shoulder strength• Gradual return to activity
• FROM and ADLs w/o pain• Easy throwing• Assess pitching
mechanics with professional
• Non-pitching position• Return to pitching
• 4-8 weeks
Anatomy Review
•Throwing creates predictable force loads across the elbow
–Medial elbow traction
–Lateral elbow compression
–Translational forces across the humerus and olecranon
Clinical Features
• History• Insidious onset of pain, usually medial• Decreased accuracy or distance
• Physical• Tenderness in the medial, lateral or posterior elbow• +/- mild flexion contracture, esp w/ avulstion fx• Assess ulnar collateral ligament stability at 20° flexn• Distal neuro exam
Medial physis widened
Medial apophyseal avulsion
Osteochondritis of capitellum and
loose bodies
Loose bodies seen arthroscopically
Sports Medicine Referral
Indications
• Unsure of dx or tx
• No improvement with appropriate, compliant therapy
• Lateral lesions
Ortho ReferralIndications
• Hot Joint• Increased joint laxity• Fractures• Avulsed apophysis >5mm• Loose bodies causing ROM
deficits
Prevention• Educate athlete, coaches, and family
• Sports activity no more than 9 months/year
• No sliders or curve balls <13 y/o
Prevention2006 Little League pitching guidelines
• Restriction of pitches per game• Age 10 or under: 75/day• 11-12: 85/day• 13-16: 95/day• 17-18: 105/day
• Mandatory rest days after varying # of pitches• 1-25 pitches: 1 rest day• 26-50 pitches: 2 rest days• 51-75 pitches: 3 rest days• >75 pitches: 4 rest days
• Rest days if soreness develops• Regular strengthening program
Take Home Messages
• Know full athletic history
• Bilateral x-rays
• Emphasize compliance
• EDUCATE EDUCATE EDUCATE
QUESTIONS?