Elbow Injuries in the Throwing Athlete
Overhand throwing places extremely high stresses on the elbow. In Cricket pitchers and other throwing athletes, these high stresses are repeated many times, leading to serious overuse injury.
Unlike an acute injury resulting from a fall or collision with another player, an overuse injury occurs gradually. In many cases, overuse injuries develop when an athletic movement is repeated, often during single periods of play; when these periods of play (including games and practices) are so frequent, the body does not have enough time to rest and heal.
Although throwing injuries in the elbow most commonly occur in pitchers, they can be seen in any athlete who participates in repetitive overhand throwing.
When athletes repeatedly throw at high speed, the repetitive stresses can lead to a wide range of overuse injuries. Problems most often occur at the inside of the elbow because considerable force is concentrated over the inner elbow during throwing.
Common Throwing Injuries of the Elbow
Common Throwing Injuries of the Elbow
Repetitive throwing can irritate and inflame the flexor/pronator tendons, where they attach to the humerus bone on the inner side of the elbow. Athletes will have pain on the inside of the elbow when throwing, and if the tendinitis is severe, they will also experience pain during rest.
Ulnar Collateral Ligament Injury
The ulnar collateral ligament (UCL) is the most commonly injured ligament in throwers. Injuries of the UCL can range from minor damage and inflammation to a complete tear of the ligament. Athletes will have pain on the inside of the elbow and frequently notice decreased throwing velocity.
Valgus Extension Overload
During the throwing motion, the olecranon and humerus bones are twisted and forced against each other. Over time, this can lead to valgus extension overload (VEO), a condition in which the protective cartilage on the olecranon is worn away and abnormal overgrowth of bone called bone spurs, or osteophytes, develop. Athletes with VEO experience swelling and pain at the site of maximum contact between the bones in the back part of the elbow.
The abnormal bone growth of VEO is apparent in these illustrations of the back of the elbow and the inner side of the elbow.
Olecranon Stress Fracture
Stress fractures occur when muscles become fatigued and are unable to absorb added shock. Eventually, the fatigued muscle transfers the overload of stress to the bone, causing a tiny crack called a stress fracture.
The olecranon is the most common location for stress fractures in throwers. Athletes will notice aching pain over the surface of the olecranon on the underside of the elbow. This pain is worst during throwing or other strenuous activity and occasionally occurs during rest.
Ulnar Neuritis (Cubital Tunnel Syndrome)
When the elbow is bent, the ulnar nerve stretches around the bony bump at the inner end of the humerus. In throwing athletes, the ulnar nerve is stretched repeatedly and can even slip out of place, causing painful snapping. This stretching or snapping leads to irritation of the nerve, a condition called ulnar neuritis.
Throwers with ulnar neuritis will notice pain that resembles electric shocks starting at the inner elbow (often called the “funny bone”) and running along the nerve as it passes into the forearm. They may have numbness, tingling, or pain in the small and ring fingers during or immediately after throwing, and these symptoms may also persist during periods of rest.
Ulnar neuritis can also occur in non-throwers who frequently notice these same symptoms when first waking up in the morning or holding the elbow in a bent position for prolonged periods.
In most cases, treatment for throwing injuries in the elbow begins with a short period of rest.
Additional treatment options may include:
Specific exercises can restore flexibility and strength. A rehabilitation program directed by the doctor or a physical therapist will include a gradual return to throwing.
Change of position
Throwing mechanics can be evaluated in order 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.
Drugs like ibuprofen and naproxen reduce pain and swelling and can be provided in the prescription-strength form.
If symptoms persist, the athlete may need a prolonged period of rest.
In some cases, an injection of platelet-rich plasma (PRP) can be beneficial in patients with partial tearing of the UCL. There is growing evidence in the literature to support the use of PRP, which involves using the patient’s own platelets to stimulate healing. For this procedure, a small amount of blood is drawn from the patient. The platelets are then separated from other blood cells using a centrifuge and injected into the area of the injury.
If painful symptoms are not relieved by non-surgical methods and the athlete desires to continue throwing, surgical treatment may be considered.
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 rather than the larger incision needed for standard, open surgery.
Athletes who have an unstable or torn UCL and who do not respond to non-surgical treatment are candidates for surgical ligament reconstruction.
In some cases, if the ligament is in good condition but is torn at the bony attachment, it can be reattached to the arm, eliminating the need for a graft. Sometimes, the ligament is reinforced with a high-strength suture to add to the strength of the construct and potentially allow for a quicker return to play.
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.
If non-surgical treatment is effective, the athlete can often return to throwing in 6 to 9 weeks.
If surgery is required, however, recovery may take much longer, depending upon the procedure performed. For example, it may take the athlete 6 to 9 months or more to return to competitive throwing after ligament reconstruction.
Recent research has focused on identifying risk factors for an elbow injury and strategies for injury prevention.
Proper conditioning, technique, and recovery time can help to prevent throwing injuries in the elbow.
In the case of younger athletes, pitching guidelines — including pitch count limits and required rest recommendations — have been developed to protect children from injury.