Elbow Pain in Young Athletes and Tommy John Surgery
With more widespread and high-level participation of young children and teenagers in sports in recent times, elbow injuries are becoming more common. The sport’s most likely to cause elbow injury are gymnastics and baseball (particularly pitchers and catchers) although athletes of all types and skill level are prone to elbow injury. Learn more about some of these causes of elbow pain in young athletes.
- Osteochondritis Dissecans (OCD) of the Capitellum
- Panner’s Disease
- Medial Ulnar Collateral Ligament Injury and “Tommy John” Surgery
- Valgus-Extension Overload Syndrome
Osteochondritis Dissecans (OCD) of the Capitellum
The capitellum is a bony structure inside of the elbow joint, forming one half of the end of the humerus. In teenage athletes who chronically apply compressive loads to the elbow (gymnasts and overhead throwing athletes), osteochondritis dissecans (OCD) may occur in the capitellum. This is a disorder in which a portion of the cartilage overlying the capitellum may soften, fray, and even separate. A small amount of the underlying bone may separate along with it, resulting in a loose body floating within the elbow joint. No one is entirely sure why this happens but it is thought to occur due to interruption of the blood supply to the separated portion of bone as well as the chronic compressive loads to the joint. This condition may be thought of as a “stress fracture” of the joint. The pain from an OCD lesion is dull and aching and feel as if it is coming from deep within the elbow. Very often there is great difficulty straightening the arm. There may also be clicking, clunking, snapping, or other mechanical symptoms with attempts at elbow motion if a loose body has formed. Diagnosis is obtained by a physical exam and history, as well as X-rays and in many cases an MRI scan of the elbow.
In its early stages (i.e. before separation and formation of a loose body) this condition is best treated by at least a month of complete rest from the offending sport, possibly even application of a long-arm cast to immobilize the elbow during that time. Physical/occupational therapy may be required following the period of rest, with a gentle and gradual return to play only if pain has improved.
In the late stages (lesion has separated, loose bodies have formed) or if symptoms have not improved after a long period of rest and physical/occupational therapy, surgery may need to be performed. Arthroscopic surgery is now the standard treatment for this condition and usually consist of drilling holes in the bone beneath the lesion (to increase blood supply), removing loose bodies, and microfracture (removing the loose lesion and abrading the bone beneath it to stimulate a healing reaction). In extremely rare cases with very large lesions, the loose fragment may actually be fixable using screws, pins, staples or suture.
Video of Arthroscopic Treatment Of OCD Lesion of the Capitellum
Panner’s Disease is similar in almost every way to osteochondritis dissecans of the capitellum. However, unlike OCD of the capitellum (which occurs in teenagers) Panner’s Disease almost always occurs in boys younger than age 10. The prognosis is excellent and, with a period of rest and immobilization (i.e. a brace or cast) the condition almost always resolves on its own.
Medial Ulnar Collateral Ligament Injury and “Tommy John” Surgery
The medial ulnar collateral ligament (MCL) is a ligament at the medial (“inside”) elbow, which stabilizes the elbow during overhead throwing motion, particularly during late cocking and acceleration phases. These are the phases during which a pitcher will experience inner elbow pain with a MCL tear. Other types of overhead throwing athletes (quarterbacks, javelin throwers) may also experience MCL injury. Underhand throwers (softball pitchers) are at low risk of this type of injury.
The most common symptoms an athlete experiences is loss of throwing endurance and speed, with gradual onset of throwing-related pain. Sometimes, the MCL may rupture with a “pop” and sudden pain, followed by swelling and bruising of the inner arm. Generally, athletes with MCL injuries do not experience inner elbow pain with regular daily activities. The pain occurs only during overhead throwing, and there will be an accompanying loss of throwing speed and endurance.
For the athlete who is likely to make a career out of pitching, early evaluation by an orthopedic surgeon is best in order to avoid prolonged “down time” and to maximize the odds of return to pre-injury levels of competition. This usually begins with a history, physical examination and often includes X-rays and possibly MRI of the elbow.
Figure: X-ray of the right elbow of a 20-year-old college baseball pitcher with an ulnar collateral ligament rupture
Initial treatment should consist of ice, elevation, compression and anti-inflammatory medication. In cases of mild injury or when MRI confirms that no complete ligament rupture has occurred, conservative treatment is highly effective. This consists of avoidance of throwing for 4-6 weeks followed by physical therapy and a graduated throwing program to slowly return to competition, which may take an additional 6-8 weeks. If there is a complete MCL rupture and the athlete is likely to make a career out of throwing (collegiate or professional), consideration should be given towards reconstruction of the ligament, widely known as “Tommy John Surgery.”
As with any chronic injury, prevention is the best treatment. A serious pitcher should work with a qualified pitching coach to ensure safe pitching mechanics and good general conditioning, particularly of the hips, back, and shoulder. Pitch counts, limitations on days of throwing per week, and a 2-3 month yearly “break” from pitching should all be observed. An excellent summary of these recommendations can be found in the ASMI Position Statement for Youth Baseball Pitchers
Valgus Extension Overload Syndrome
Valgus Extension Overload Syndrome describes the formation of bone spurs in the back of the elbow. These spurs may cause dull aching pain in the back of the elbow during the follow-through motion of throwing. Treatment consists initially of several weeks of rest to reduce inflammation, followed by gradual return to throwing using a graduated throwing program. In patients in whom conservative treatment fails to relieve pain, arthroscopy of the elbow to remove bones spurs in the posterior elbow is highly effective.