1. List and describe the types of injuries commonly seen in the athlete’s elbow.

2. Perform a comprehensive physical examination of the athlete’s elbow.

3. Review the differential diagnosis for lateral epicondylitis.

4. Treat lateral epicondylitis by nonoperative management, or percutaneous, arthroscopic, or open surgery.

5. Describe the stages of osteochondritis dissecans, its arthroscopic surgical management, and postoperative care.

Examination of the Athlete’s Elbow
Lewis Yocum, MD, Associate, Kerlan-Jobe Orthopaedic Clinic, Los Angeles, CA

Types of injuries: sport-specific and age-related; in baseball, emphasis on medial aspect of elbow; tension–compression problems of young throwing elbow, with traction on medial aspect and compression forces over lateral aspect; blunt trauma in football, rugby, and similar sports; injuries often related to overuse

Presentation: elbow pain; important to know—whether acute episode occurred during cocking, acceleration, or follow-through phase of throwing; localization of pain; whether pain sudden or came on gradually, as in overuse injury

Anterior injuries: brachialis and distal biceps tendinitis (eg, climber’s elbow)—consistent use of pronated and semi-flexed forearm; distal biceps tendinosis and partial ruptures—cystic degenerative changes; often treated conservatively; be aware of presence during physical examination; understand position of distal biceps and relation to lacertus; use imaging studies to help differentiate partial tears from cystic degenerative changes; differential diagnosis includes posterior interosseous nerve (PIN) syndrome

Other anterior elbow injuries: brachialis and coronoid avulsions; anterior capsular tears; annular ligament tears; pronator teres or lacertus syndrome—rare; seen in weight lifters and others who use repetitive motion; lacertus can compress pronator and put pressure on median nerve; lateral antebrachial cutaneous neuropathies—consider in differential diagnosis of anterolateral elbow pain; finishing throws with forced pronation can compromise or kink anterolateral elbow

Lateral injuries: lateral epicondylitis—tennis elbow, but also seen in baggage handlers and others; insidious onset; symptoms vague and include tenderness to palpation; differential diagnosis includes—radial tunnel syndrome and PIN syndrome (can occur with lateral epicondylitis; do not respond to epicondylar injection); posterolateral instability; radiocapitellar plica and chondromalacia changes also occur

Medial injuries: flexor pronator ruptures—occur in throwing athletes, golfers, and tennis players; check position of flexor muscles and relationship with ulnar collateral ligament (UCL; anterior oblique bundle of UCL frequently involved); medial epicondylar injuries—in adolescents, include apophysitis (with or without fragmentation) and epicondylar avulsions (important to diagnose degree of separation and rotation; cubital tunnel or axial views helpful; computed tomography [CT] may be required); valgus instability—usually related to repetitive valgus stress in throwing athletes; valgus stress test—important to have shoulder maximally rotated externally and locked out; placing thumb at joint line enhances perception; rare to feel significant opening of medial aspect of elbow; O’Brien’s milking test—important to try, but speaker has better results with dynamic stress test or moving valgus stress test; diagnosis possible without magnetic resonance imaging (MRI), but MRI useful for partial tears

Medial epicondylitis: epiphyseal separation possible in adolescents with apophysitis; adaptive changes—include posteromedial osteophytes (sometimes symptomatic); axial or cubital tunnel view helpful for differentiating changes, eg, osteophytes along mediolateral border of olecranon

Valgus extension overload: with mild medial laxity or repetitive throwing, significant stress built up in posteromedial corner of elbow; area tender; in forced valgus position and forced terminal extension, changes and discomfort localized to posteromedial aspect of elbow

Neuropathy: occurs when tunnel size decreases; thickening of cubital tunnel retinaculum; osteophyte formation off sublime tubercle; hypertrophy of medial head of triceps can cause compressive neuropathy; nerve can become tethered, with scarring and chronic inflammation in medial epicondylar region and fibrosis in cubital tunnel; valgus instability may cause traction and nerve problems; translation may occur; ulnar nerve instability—can be related to instability of medial head of triceps; range of motion (ROM) required to demonstrate instability; always compare right and left sides

Posterior injuries: triceps rupture—if small amount of tendon still present, patient may be able to extend elbow; palpate tendon defect (difficult due to swelling); associated avulsion fractures and stress fractures possible (MRI helpful for differentiating inflammation of bone from fracture); triceps tendinitis—may involve spurring; avulsion and fragmentation may occur; capitellar osteochondritis dissecans (OCD) lesions—may cause some posterior and posterolateral problems of radiocapitellar joint

Physical examination: ROM—check valgus carrying angle, pronation and supination, and difference between dominant and nondominant sides; anterior aspect—check lacertus position; palpate median nerve area, medial antebrachial cutaneous nerve, and medial intermuscular septum; resisted pronation and supination to identify biceps lesions; lateral aspect—palpate extensor carpi radialis brevis (ECRB) and PIN; feel for resistance in extensor muscles; palpate for crepitus over radiocapitellar joint; posterolateral instability—tabletop test; MRI; difficult diagnosis; clinical presentation; may require examination under anesthesia; condition can explain problems with vague lateral pain, “catching,” slipping, and loss of strength; reduction of radial head and radiocapitellar joint, usually by 40 to 70 degrees of flexion; medial aspect—patient’s hand placed under speaker’s arm while speaker rotates shoulder maximally; index finger or thumb over joint as valgus stress applied; perceive position of ulnar nerve; milking test; manual stress x-ray (test until point of most pain found, then apply valgus stress and obtain x-ray); posterior aspect—bounce test while applying valgus stress to elbow; neurologic examination—address possibility of cervical problems

Arthroscopic Treatment of Lateral Epicondylitis
Felix H. Savoie III, MD, Professor of Orthopaedic Surgery, Lee C. Schlesinger Chair, Chief, Division of Sports Medicine, and Vice-Chair, Department of Orthopaedics, Tulane University School of Medicine; Medical Director, Tulane Institute for Sports Medicine, New Orleans, LA

Lateral epicondylitis: angiofibrotic dysplasia in or near origin of ECRB; tendinosis, not inflammation (no inflammatory cells at attachment, just disorganized matrix); etiology—usually overuse, but can be traumatic due to sudden resisted extension or blow to elbow that produces local necrosis; differential diagnosis—plica syndrome; radial tunnel syndrome; radiocapitellar degenerative joint disease (DJD); osteochondral lesions around radiocapitellar joint; posterolateral rotatory instability (PLRI; can coexist with lateral epicondylitis); surgery for tennis elbow will fail if PLRI present; physical examination—point tenderness over epicondyle; pain with resisted wrist extension; best to test with elbow extended; symptoms—pain, weakness, night pain, decrease in grip strength; pain on initiation of movement

Treatment: goals—improve blood supply to area; protect from reinjury; excise Nirschl lesion or allow it to heal

Nonoperative management: nonsteroidal anti-inflammatory drugs (NSAIDs)—make patients feel better; speaker prefers topical therapy, eg, ketoprofen cream from compounding pharmacy; massage during application therapeutic; injections—locate origin; scraping epicondyle to cause bleeding helpful; goal to change local milieu; injection of bupivacaine (eg, Marcaine), lidocaine (eg, Xylocaine) or saline as effective as prednisone; braces— cock-up wrist splint; elbow sleeves preferable to counterforce braces (difficult to keep pressure exactly at epicondyle; can cause posterior interosseous or radial tunnel syndrome); wrist brace excellent (takes pressure off ECRB); physical therapy—includes patches, deep tissue massage, and exercises (done with elbow straight); shockwave therapy—works well if targeted correctly, but not covered by insurance, so not used

Surgery: percutaneous—simple release; depends on body’s ability to heal; knowledge of anatomy key, ie, must know location of origin; penetrate fascia, get tip of knife on origin of ECRB, and pivot knife to release; place hand on bottom to avoid going too far distally; patient must be awake (have patient bend wrist after procedure); done in office; arthroscopic—Nirschl’s lesion seen; can abrade epicondyle; can add stitches; hints—place portal in front of epicondyle; because tendon extra-articular, must release some of capsule; if worried about tendon collapse, use retractor portal; remove gray part of tendon, leave white part in place; if part of lateral collateral ligament involved, place anchor in front of epicondyle and repair ligament and tendon back to one spot; must be posterior to lateral intermuscular septum when retriever placed; side-to-side closure; open—standard Nirschl technique

Results: only 1 in 10 patients treated operatively; 95% of surgical patients have good to excellent results; over 4-yr follow-up, Andrews-Carson score went from 160 to 195; associated pathology found in 41% of arthroscopic group; no significant difference in results between methods; ≈95% success with open surgery, 98% with arthroscopic, and 88% with percutaneous

Arthroscopic Treatment of the Athlete’s Elbow
Dr. Savoie

Indications: loose body removal (look for source); osteophyte excision (remove bone only; address concomitant instability); OCD (capitellum most common, but can occur anywhere in elbow); plica removal; release of adhesions; rotatory instability

Osteochondritis dissecans: Panner’s disease similar in appearance but self-limited and does not require surgery; true OCD related to overuse and involves loss of motion and increasing symptoms with activity; important to determine whether “shoulder” of capitellum involved (if lateral cortex of humerus good, prognosis better); on MRI—if OCD involves lateral cortex, instability likely present, and patient has increased risk for arthritis and decreased chance of successful result (with or without surgery); determine whether cartilage cap intact and look for fluid behind fragment

Stages of OCD: stage 1—nondisplaced and cartilage cap intact; decrease patient’s activity or put in offloading brace; prognosis good; stage 2—separated and cap disrupted; choice of fixation or debridement; speaker favors debridement; stage 3—full displacement, sometimes microfracture; if shoulder involved, consider grafting; debridement to remove loose fragments

Surgical management: look down posterolateral gutter, switch to 70° scope, leaving soft spot, proximal and distal portals surrounding posterior aspect of radiocapitellar joint; can flex elbow more for better view; osteochondral grafting rare, but necessary if lateral cortex lost (no shoulder for stability); speaker prefers to take osteochondral plug from tip of olecranon; contour to fit radial head

Postoperative care: early ROM; if patient not stable enough for continuous passive motion (CPM) apparatus, use offloading brace; follow with serial x-rays and MRIs; look at other elbow for bilateral disease

Plica syndrome: plica becomes swollen and catches on elbow, gradually increasing in size; surgery rarely needed; injections and anti-inflammatory creams usually work

Release of adhesions: postinjury stiffness common, especially in young athletes; arthroscopic removal via synovectomy and radiation therapy when patient first experiences loss of motion preferable to waiting

Injury to medial ulnar collateral ligament: check instability arthroscopically; look for associated posterolateral damage (1 in 4 have looseness and laxity on lateral side; slip in stitch); remove spur with grabber and shaver

Posterolateral rotatory instability: commonly associated with lateral epicondylitis; symptoms seen more frequently in right-handed people; common after dislocated elbow, more common after repetitive stress; perform pivot-shift examination with patient prone (easier to feel dislocation and reduction); arthroscopic repair and plication

Triceps repair: done arthroscopically, double- or single-row; clean out fossa posteriorly; clean and free muscle; prepare bed on tip of olecranon and around corner; place rigid anchor (single- or double-loaded); use retrograde retriever proximal to edge of tendon and pull it back down

Question and answer: surgery for medial epicondylitis—open procedure used because of closeness of ulnar nerve; obtain MRI to determine whether medial conjoined tendon involved (if so, anchor necessary); place anchor on anterior aspect of epicondyle and sew closed