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Elbow Pain in Adolescents

Elbow Pain in Adolescents. Kevin deWeber, MD, FAAFP Director, Tri-Service Sports Medicine Fellowship. Goals. Understand the history/mechanism of injury Develop a thorough differential diagnosis for a painful elbow Understand the findings to look for on physical exam

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Elbow Pain in Adolescents

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  1. Elbow Pain in Adolescents Kevin deWeber, MD, FAAFP Director, Tri-Service Sports Medicine Fellowship

  2. Goals • Understand the history/mechanism of injury • Develop a thorough differential diagnosis for a painful elbow • Understand the findings to look for on physical exam • Understand management and return to play criteria • Know when to refer

  3. Case Study 11 year old Hispanic male complains of right elbow pain for the past 2 weeks. He states that the pain is present but better with rest, but worse when he pitches on his little league baseball team. He has been pitching for 2 years now, and started in a new league about 1 month ago.

  4. Other questions about his history?

  5. Other questions about his history? Hand Dominance

  6. Other questions about his history? Hand Dominance Other sports participation

  7. Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history

  8. Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history Number of pitches/type of pitches

  9. Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history Number of pitches/type of pitches How many teams?

  10. Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history Number of pitches/type of pitches How many teams? Side arm or overhead pitcher?

  11. DDx What can cause elbow pain in the young athlete?

  12. DDx UCL sprain/tear What can cause elbow pain in the young athlete?

  13. DDx UCL sprain/tear What can cause elbow pain in the young athlete? Medial epicondyle avulsion fracture

  14. DDx UCL sprain/tear What can cause elbow pain in the young athlete? Medial epicondyle avulsion fracture C8-T1 radiculopathy

  15. DDx UCL sprain/tear What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture C8-T1 radiculopathy

  16. DDx UCL sprain/tear What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle

  17. DDx UCL sprain/tear Medial epicondylitis (“golfer’s elbow”) What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle

  18. DDx UCL sprain/tear Medial epicondylitis (“golfer’s elbow”) What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture Muscle strain/tear (flexor/pronator group) C8-T1 radiculopathy Osteochondrosis of medial epicondyle

  19. DDx UCL sprain/tear Medial epicondylitis (“golfer’s elbow”) What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture Muscle strain/tear (flexor/pronator group) C8-T1 radiculopathy Fascial Compartment Syndrome Osteochondrosis of medial epicondyle

  20. DDx UCL sprain/tear Medial epicondylitis (“golfer’s elbow”) What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture Posteromedial olecranon osteophytosis Muscle strain/tear (flexor/pronator group) C8-T1 radiculopathy Fascial Compartment Syndrome Osteochondrosis of medial epicondyle

  21. DDx Septic arthritis UCL sprain/tear Medial epicondylitis (“golfer’s elbow”) What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture Posteromedial olecranon osteophytosis Muscle strain/tear (flexor/pronator group) C8-T1 radiculopathy Fascial Compartment Syndrome Osteochondrosis of medial epicondyle

  22. DDx Septic arthritis Tumor UCL sprain/tear Medial epicondylitis (“golfer’s elbow”) What can cause elbow pain in the young athlete? Ulnar neuritis Medial epicondyle avulsion fracture Posteromedial olecranon osteophytosis Muscle strain/tear (flexor/pronator group) C8-T1 radiculopathy Fascial Compartment Syndrome Osteochondrosis of medial epicondyle

  23. Physical Exam Appearance Palpation Range of Motion Provocative Tests

  24. Slight swelling over medial epicondyle and tenderness to palpation. The UCL was also tender to palpation. There was some slight tenderness over the flexor bundle distally. There was no evidence of gross atrophy of the muscle. • Strength was 5/5 with extension and supination, 4+/5 with pronation and flexion, limited by pain. Normal distal sensation, pulses. Negative Tinel’s with percussion of ulnar groove. • Pain with valgus stress at 20 degrees, no laxity • No neck tenderness, crepitus or step off, no gross shoulder pain or instability, nor any wrist/hand pathology noted.

  25. Are radiology studies necessary for diagnosis? Insidious onset: NO Acute onset: YES

  26. Diagnosis?

  27. Little Leaguer’s Elbow • Catch-all phrase for elbow pain in young throwing athletes

  28. Acute: control pain “PRICEMM” Relative rest Modalities Ice, compression Brief medication Long-term : Rehabilitation Non-painful ROM ex Core strength and shoulder strength Gradual return to activity FROM and ADLs w/o pain Easy throwing Assess pitching mechanics with professional Non-pitching position Return to pitching 4-8 weeks Medial Epicondyle ApophysitisManagement

  29. Anatomy Review

  30. Throwing creates predictable force loads across the elbow • Medial elbow traction • Lateral elbow compression • Translational forces across the humerus and olecranon

  31. Clinical Features • History • Insidious onset of pain, usually medial • Decreased accuracy or distance • Physical • Tenderness in the medial, lateral or posterior elbow • +/- mild flexion contracture, esp w/ avulstion fx • Assess ulnar collateral ligament stability at 20° flexn • Distal neuro exam

  32. Medial apophyseal avulsion Medial physis widened

  33. Osteochondritis of capitellum and loose bodies Loose bodies seen arthroscopically

  34. Sports Medicine ReferralIndications • Unsure of dx or tx • No improvement with appropriate, compliant therapy • Lateral lesions

  35. Ortho ReferralIndications • Hot Joint • Increased joint laxity • Fractures • Avulsed apophysis >5mm • Loose bodies causing ROM deficits

  36. Prevention • Educate athlete, coaches, and family • Sports activity no more than 9 months/year • No sliders or curve balls <13 y/o

  37. Prevention2006 Little League pitching guidelines • Restriction of pitches per game • Age 10 or under: 75/day • 11-12: 85/day • 13-16: 95/day • 17-18: 105/day • Mandatory rest days after varying # of pitches • 1-25 pitches: 1 rest day • 26-50 pitches: 2 rest days • 51-75 pitches: 3 rest days • >75 pitches: 4 rest days • Rest days if soreness develops • Regular strengthening program

  38. Take Home Messages • Know full athletic history • Bilateral x-rays • Emphasize compliance • EDUCATE EDUCATE EDUCATE

  39. QUESTIONS?

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