Repetitive stresses can lead to overuse injuries in the throwing athlete

May 27, 2021

Overhand throwing places extremely high stresses on the elbow. In baseball pitchers and other throwing athletes, these high stresses are repeated many times and can lead to serious overuse injury.

When athletes throw repeatedly at high speed, the repetitive stresses can lead to a wide range of overuse injuries. Common problems include:

·Flexor Tendinitis

·Ulnar Collateral Ligament (UCL) Injury

·Valgus Extension Overload (VEO)

·Olecranon Stress Fracture

·Ulnar Neuritis

Doctor Examination

During the physical examination, the doctor will check the range of motion, strength, and stability of the elbow. He or she may also evaluate the athlete's shoulder. The doctor will ask the athlete to identify the area of greatest pain and will frequently use direct pressure over several distinct areas to try to pinpoint the exact location of the pain.

To recreate the stresses placed on the elbow during throwing, the doctor will perform the valgus stress test. During this test, the doctor holds the arm still and applies pressure against the side of the elbow. If the elbow is loose or if this test causes pain, it is considered a positive test.

The results of these tests help the doctor decide if additional testing or imaging of the elbow is necessary.

X-rays will often show stress fractures, bone spurs, and other abnormalities.

MRI scans provide a view of the soft tissues of the elbow and can help your doctor distinguish between ligament and tendon disorders that often cause the same symptoms and physical examination findings. MRI scans can also help determine the severity of an injury, such as whether a ligament is mildly damaged or completely torn. MRI is also useful in identifying a stress fracture that is not visible in an x-ray image.

Treatment

Nonsurgical Treatment

In most cases, treatment for throwing injuries in the elbow begins with a short period of rest. If symptoms persist, a prolonged period of rest may be necessary.

Additional treatment options may include:

  • Anti-inflammatory medications. Drugs like ibuprofen and naproxen reduce pain and swelling and can be provided in prescription-strength form.
  • Physical therapy. Specific exercises can restore flexibility and strength. A rehabilitation program directed by your doctor or physical therapist will include a gradual return to throwing.
  • Change of position. Throwing mechanics can be evaluated to correct body positioning that puts excessive stress on the elbow.

Although a change of position or even a change in sport can eliminate repetitive stresses on the elbow and provide lasting relief, this is often undesirable, especially in high-level athletes.

Surgical Treatment

If painful symptoms are not relieved by nonsurgical methods, and the athlete desires to continue throwing, surgical treatment may be considered.

Arthroscopy. Bone spurs on the olecranon and any loose fragments of bone or cartilage within the elbow joint can be removed arthroscopically.

During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the elbow joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

UCL reconstruction. Athletes who have an unstable or torn UCL, and who do not respond to nonsurgical treatment, are candidates for surgical ligament reconstruction.

Most ligament tears cannot be sutured (stitched) back together. To surgically repair the UCL and restore elbow strength and stability, the ligament must be reconstructed. During the procedure, the doctor replaces the torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on. In most cases of UCL injury, the ligament can be reconstructed using one of the patient's own tendons.

This surgical procedure is referred to as "Tommy John surgery" named after the former major league pitcher who had the first successful surgery in 1974. Today, UCL reconstruction has become a common procedure, helping professional and college athletes continue to compete in a range of sports.

Ulnar nerve anterior transposition. In cases of ulnar neuritis, the nerve can be moved to the front of the elbow to prevent stretching or snapping. This is called an anterior transposition of the ulnar nerve.

Recovery

If nonsurgical treatment is effective, the athlete can often return to throwing in 6 to 9 weeks. If surgery is required, recovery will be very different depending upon the procedure performed. If UCL reconstruction is performed, it may take 6 to 9 months or more to return to competitive throwing.