Nerve injuries in the throwing elbow

The Physical Examination of the Throwing Elbow

This section is dedicated to the comprehensive evaluation of the overhead throwing athlete's elbow. The elbow provides a unique diagnostic dilemma that requires extensive knowledge and appreciation of elbow anatomy and kinematics, given the extreme forces seen across the elbow during the overhead throwing motion, the superficial nature of the majority of anatomic structures, and the complex interplay among bony, ligamentous, musculotendinous, and neurologic structures. The physical examination of the ulnar collateral ligament, valgus extension overload syndrome, medial and lateral epicondylitis, posterolateral rotatory instability, tendon ruptures, and compressive neuropathies will be covered.

Return to Activity Following Isolated Ulnar Nerve Surgery: A Systematic Review

Ulnar neuropathy is one of the more commonly diagnosed mononeuropathies; despite this, a definitive surgical treatment strategy has not been widely agreed upon. In this study, we systematically review the literature and assess return to play or activity outcomes in patients with neuritis or neuropathy undergoing in situ decompression, subcutaneous transposition, or submuscular transposition of the ulnar nerve. We hypothesized that ulnar nerve transposition or decompression in the absence of concomitant ulnar collateral ligament (UCL) pathology would have a high rate of return to activity. Relevant studies were generated from 1975 to 2023 using PubMed, Academic Search Complete, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and SPORTDiscus. Articles reporting on return to play or activity outcomes following isolated ulnar nerve transposition or decompression for ulnar neuritis were included. Studies evaluating patients with concomitant UCL injury or revision surgery were excluded. A total of 12 studies met the inclusion criteria, ranging from 1977 to 2021. There were a total of 358 patients with a reported return to play or activity status across all studies with an average age of 27.2 years (range, 11-75). Successful return to play, activity, or work was reported in 303 patients (84.6%). Patients undergoing transposition, subcutaneous (n = 232) and submuscular (n = 20), had return rates of 87.9% and 95%, respectively. Patients undergoing in situ decompression (n = 106) had return rates of 75.5%. This systematic review found an 84.6% return to activity rate following ulnar nerve transposition or decompression in the absence of concomitant UCL pathology. Overall, transposition or decompression of the ulnar nerve provides a favorable return to activity rates and with appropriate indications and surgical technique will likely yield a successful return.

Approach to Medial Elbow Pain in the Throwing Athlete

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. 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.

Ultrasonographic reference values for the deep branch of the radial nerve at the arcade of Frohse

PURPOSE

The deep branch of the radial nerve (DBRN) enters the forearm as it passes under the arcade of Frohse. This is the most common entrapment site of the DBRN in the forearm. In this study, we investigated the ultrasonographic reference values for the diameters and cross-sectional area (CSA) of the DBRN at the level of the arcade of Frohse in a healthy sample of the population.

METHODS

Sixty-five healthy Caucasian volunteers (130 nerves) were recruited for this study. The reference range [mean ± 2 standard deviations (SD); 2.5th-97.5th quintiles] and the upper limit of the side-to-side difference were determined. The effects of age, gender, handedness, height, and body mass index were examined.

RESULTS

The mean age was 41.8 ± 11.2 years (range 18-75 years). The mean ± 2SD of the CSA was 0.50-1.42 mm². The upper limit of the normal side-to-side difference was 0.35 mm². The differences between males and females and between the dominant and non-dominant arms were not significant. The mean anteroposterior and transverse diameters were 0.83 ± 0.13 and 1.23 ± 0.29 mm, respectively. A significant correlation between the dominant-side CSA and age (r = 0.41; p < 0.001) was observed. The correlations between CSA and height (r = 0.19; p = 0.12) and body mass index (r = 0.22; p = 0.07) were not significant.

CONCLUSION

The measurements obtained in this study are valuable for examining DBRN pathologies using high-frequency ultrasound. The findings showed that age was associated with the DBRN CSA, while gender, height, and body mass index were not.

Treatment of the ulnar nerve for overhead throwing athletes undergoing ulnar collateral ligament reconstruction

Ulnar nerve (UN) injuries are a common complaint amongst overhead athletes. The UN is strained during periods of extreme valgus stress at the elbow, especially in the late-cocking and early acceleration phases of throwing. Although early ulnar collateral ligament (UCL) reconstruction techniques frequently included routine submuscular UN transposition, this is becoming less common with more modern techniques. We review the recent literature on the sites of UN compression, techniques to evaluate the UN nerve, and treatment of UN pathology in the overhead athlete. We also discuss our preferred techniques for selective decompression and anterior transposition of the UN when indicated. More recent studies support the use of UN transpositions only when there are specific preoperative symptoms. Athletes with isolated ulnar neuropathy are increasingly being treated with subcutaneous anterior transposition of the nerve rather than submuscular transposition. When ulnar neuropathy occurs with UCL insufficiency, adoption of the muscle-splitting approach for UCL reconstructions, as well as using a subcutaneous UN transposition have led to fewer postoperative complications and improved outcomes. Prudent handling of the UN in addition to appropriate surgical technique can lead to a high percentage of athletes who return to competitive sports following surgery for ulnar neuropathy.

Elbow Imaging in Sport: Sports Imaging Series

Elbow pain is a frequent presenting symptom in athletes, particularly athletes who throw. The elbow can be injured as a result of acute trauma, such as a direct blow or a fall onto an outstretched hand or from chronic microtrauma. In particular, valgus extension overload during the throwing motion can precipitate a cascade of chronic injuries that can be debilitating for both casual and high-performance athletes. Prompt imaging evaluation facilitates accurate diagnosis and appropriate targeted interventions.

Elbow magnetic resonance imaging: imaging anatomy and evaluation

The elbow is a complex joint. Magnetic resonance imaging (MRI) is often the imaging modality of choice in the workup of elbow pain, especially in sports injuries and younger patients who often have either a history of a chronic repetitive strain such as the throwing athlete or a distinct traumatic injury. Traumatic injuries and alternative musculoskeletal pathologies can affect the ligaments, musculotendinous, cartilaginous, and osseous structures of the elbow as well as the 3 main nerves to the upper limb, and these structures are best assessed with MRI.Knowledge of the complex anatomy of the elbow joint as well as patterns of injury and disease is important for the radiologist to make an accurate diagnosis in the setting of elbow pain. This chapter will outline elbow anatomy, basic imaging parameters, compartmental pathology, and finally applications of some novel MRI techniques.

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.

Nerve injuries about the elbow in the athlete

The athlete's elbow is a remarkable example of motion, strength, and durability. The stress placed on the elbow during sport, including the throwing motion, may lead to soft-tissue ligamentous and nerve injury. The thrower's elbow illustrates one example of possible nerve injury about the elbow in sport, related to chronic repetitive tensile and compressive stresses to the ulnar nerve associated with elbow flexion and valgus position. Besides the throwing athlete, nerve injury from high-energy direct-impact forces may also damage nerves around the elbow in contact sports. Detailed history and physical examination can often make the diagnosis of most upper extremity neuropathies. The clinician must be aware of the possibility of isolated or combined nerve injury as far proximal as the cervical nerve roots, through the brachial plexus, to the peripheral nerve terminal branches. Electrodiagnostic studies are occasionally beneficial for diagnosis with certain nerves. Nonoperative management is often successful in most elbow and upper extremity neuropathies. If conservative treatment fails, then surgical treatment should address all potentially offending structures. In the presence of medial laxity and concurrent ulnar neuritis, the medial ulnar collateral ligament warrants surgical treatment, in addition to transposition of the ulnar nerve. The morbidity of open surgical decompression of nerves in and around the elbow is potentially career threatening in the throwing athlete. This mandates an assessment of the adequacy of the nonsurgical treatment and a thorough preoperative discussion of the risks and benefits of surgery.

Anterior translation and morphologic changes of the ulnar nerve at the elbow in adolescent baseball players

The effect of repetitive throwing on the ulnar nerve is not clear. There are no published imaging studies regarding this issue in adolescent baseball players. The purpose of this cross-sectional ultrasonographic study was to use 5- to 10-MHz frequency ultrasonography to define the anterior translation and flattening of the ulnar nerve in different elbow positions. We divided 39 adolescent baseball players into two groups, 19 pitchers and 20 fielders, according to the amount of throwing. Twenty-four non-athlete junior high school students were also included as controls. We ultrasonographically examined each participant's ulnar nerve in the cubital tunnel with the elbow extended and at 45°, 90° and 120° of flexion. Anterior translation and flattening of the ulnar nerve occurred in all groups. Pitchers had larger-scale anterior translation than did controls. In pitchers, the ulnar nerve exhibited more anterior movement on the dominant side than on the non-dominant side. The anterior subluxation of the ulnar nerve occurred in players without ulnar nerve palsy and was not correlated with elbow pain. In addition to the known musculoskeletal adaptations of pitchers' elbows, ultrasonography revealed new changes in the ulnar nerve, anterior translation and subluxation, after repetitive throwing. These changes might also be physiologic adaptations of throwing elbows.

Magnetic resonance imaging of the elbow in athletes

Acute and chronic elbow pain is common, particularly in athletes. Although plain radiographs, ultrasound, and computed tomography all have a role to play in the investigation of elbow pain, magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for diagnosis of soft tissue disease and osteochondral injury around the elbow. The high spatial resolution, excellent soft-tissue contrast, and multiplanar imaging capabilities of MRI make it ideal for evaluating the complex joint anatomy of the elbow. This article reviews imaging of common disease conditions occurring around the elbow in athletes, with an emphasis on MRI.

The emerging role of elbow arthroscopy in chronic use injuries and fracture care

Arthroscopy is emerging as an invaluable tool for diagnosing and treating elbow pathology. In addition to the advantages of less scarring, decreased risk of infection, less postoperative pain, and a more thorough visualization of the elbow joint, arthroscopy is particularly well suited to the treatment of athletes trying to minimize rehabilitation and inactivity. Indications for elbow arthroscopy now extend well beyond diagnosis and loose body removal, and include the treatment of impingement, arthritis, contractures, fragment stabilization for osteochondritis dessicans, and treatment of certain fractures. This article reviews the basic principles and techniques of elbow arthroscopy and their application to common sports-related conditions, such as valgus overload syndrome, medial collateral ligament insufficiency, and the various causes of lateral elbow pain. Newer applications of elbow arthroscopy in fracture care are addressed as well.

Customized dynamic splinting: orthoses that promote optimal function and recovery after radial nerve injury: a case report

Radial nerve injury is a relatively common occurrence and recovery depends on the level of injury and extent of connective tissue damage. Orthoses (splints) are often provided to compensate for lost motor power. This article chronicles the recovery, over 27 months, of a 76-year-old woman who sustained a high radial nerve injury of her dominant arm during surgery for total shoulder replacement (Delta Reverse). Customized, low-profile dynamic splints, unlike any previously published design, were developed to address her goals for functional independence and the biological needs of the tissues. Dynamic power was provided to the wrist, fingers, and thumb by elastic cords and thin, flexible thermoplastic, without the need of an outrigger, thus avoiding the need for wire bending and cutting. At the outset, the splint was forearm-based and when wrist extension power was recovered, a hand-based splint was designed. Eventually, a circumferential hand-based thumb-stabilizing splint fulfilled most of the remaining orthotic requirements.

Baseball and softball injuries

Baseball and softball injuries can be a result of both acute and overuse injuries. Soft tissue injuries include contusions, abrasions, and lacerations. Return to play is allowed when risk of further injury is minimized. Common shoulder injuries include those to the rotator cuff, biceps tendon, and glenoid labrum. Elbow injuries are common in baseball and softball and include medial epicondylitis, ulnar collateral ligament injury, and osteochondritis dissecans. Typically conservative treatment with relative rest, medication, and a rehabilitation program will allow return to play. Surgical intervention may be needed for certain injuries or conservative treatment failure.