Sports Medicine – Forearm and Elbow

Among the most common type of fracture, the distal radius fracture affects the distal end (end towards the wrist) of the radius bone in the forearm – generally when the arm is used to break a fall.

A distal radius fracture is also called Colles Fracture – named after the surgeon who initially described it, Abraham Colles.

The radius is a forearm bone that runs between the wrist and the elbow. It becomes rigid when it is extended in order to break a sudden fall and subjected to extreme compression and twisting force that generally results in a fracture at the wrist. This type of injury can also result from a direct trauma.

A fracture may be either displaced (out of proper alignment) or non displaced.

When it occurs, the pain is immediate and there is an obvious deformity of the wrist. This may be followed by pain, stiffness, swelling and loss motion in the affected area. Bruising may also be present.

Those at Risk
While distal radius fractures can happen to anyone involved in a trauma such as a car accident, as well as the weekend roller bladder or skater boarder, it most frequently occurs in athletes involved in action sports such as motocross racing and cycling.

Distal radius fractures are also common in patients over the age of 60 as a result of osteoporosis. A relatively minor fall in these patients can result in a fracture because of the decreased bone density.

Diagnosis
Patient history, nature of the incident that resulted in the fracture, and a physical examination will assist in the diagnosis. The outward appearance, while varied depending on severity, is also a strong indicator of this type of fracture. An X-ray will confirm the diagnosis.

Treatment
The primary goal of treatment is to ensure that the bones heal in the correct alignment. For fractures that are not displaced a simple brace and anti-inflammatory medication may be all that is necessary. For fractures that are displaced, or not properly aligned, surgery may be indicated in order to ensure that the dislocated bones are replaced in their normal anatomic positions. This is called reduction. Reduction may be done either closed (without making an incision) or open (with an incision). The type of fixation used to hold the bone in the correct position is determined based on the condition of the patient, lifestyle, and severity of the injury.

Common injuries among athletes, contusions often involve the muscles of the forearm and portion of the bony prominence of the elbow. In athletes, the forearm often absorbs the greatest portion of the impact – particularly in contact sports. This repeated force to the muscles can result in bruising and possibly bleeding, which produces stiffness during active range of motion activities. Occasionally a contusion is accompanied by a fracture, depending on the severity of the force.

Depending on the area impacted by the force, a contusion can also produce an actute hemorrhagic bursitis or a common chronic olecranon bursitis. A contusion to the ulnar nerve (an area often referred to as the “funny bone”) can be very painful and send burning sensations down the ulnar side of the forearm to the ring and little fingers.

Those at Risk
Athletes involved in high impact contact sports such as football, baseball and basketball are most likely to be affected by this condition, though contusions can also result from an accident or fall.

Diagnosis
Patient history, combined with a thorough physical examination that includes range of motion tests, are used in diagnosing elbow trauma. An X-ray may be taken to identify a possible fracture, which sometimes accompanies a trauma resulting in a contusion.

Treatment
Once any accompanying fracture is addressed, a period of rest followed by a series of range of motion exercises may be all that is necessary in the treatment of contusions to the elbow or forearm.

Elbow Instability
Elbow instability is the detachment or thinning of an elbow ligament often caused by throwing activities or sports, or a trauma that resulted in a dislocation. Instability can affect either the outer (lateral) or inner (medial) portion of the elbow.

Elbow instability is classified according to five criteria, which help in identifying the severity of the condition – acute, chronic, or recurrent, as well as the area of irritation, the direction of displacement, the degree of displacement, and any associated fractures.

This condition is symptomatically similar and sometimes confused with arthritis and tendonitis.

Those at Risk
Athletes involved in throwing sports generally develop medial elbow instability. And those experiencing trauma or earlier surgery to repair a dislocated elbow most often develop lateral elbow instability.

Diagnosis
In order to accurately diagnose elbow instability, a physical examination with patient history is obtained – along with X-rays and magnetic resonance imaging (MRI) enhanced with an arthrogram. An arthrogram is the process of injecting the elbow with a small amount of dye in order to enhance the clarity of the MRI, which aids in the capturing of ligament disruption.

Treatment
The conservative treatment plan indicated for elbow instability includes anti-inflammatory medication – possibly combined with a period of immobilization.

In cases nonresponsive to conservative treatment, surgery is performed to reconstruct the biomechanics of the joint and repair the ligaments. Surgery is indicated only when the risk of long-term arthritis from prolonged friction is present.

Medial collateral ligament (MCL) injuries most often occur when the elbow is subjected to the high velocity pitches attained by amateur and professional pitchers, who may throw balls reaching speeds between 70 and 100 miles an hour. This level of throwing places a significant amount of force on the elbow joint that over time can lead to irritation, inflammation, cartilage tears, formation of bone spurs and eventually tearing of the MCL.

The MCL is part of a network of ligaments and tendons that attach and help stabilize at the elbow the bones of the lower (ulna and radius) and upper (humerus) arm.

When the MCL is torn, athletes usually maintain full range of motion and the ability to throw, but with significantly reduced force. While often times a “pop” is reported with the ligament tears, it can also be a gradual process and go undetected for a period of time.

Those at Risk
Baseball players, particularly pitchers, are most often diagnosed with this injury as a result of the frequent and irregular force exerted on their elbow joint.

Diagnosis
Patient history and physical examination are followed by a radiologic exam. Those patients experiencing extended periods of performance disruption may have an X-ray, while those experiencing a sharp “pop” – particularly during a throw – may require magnetic resonance imaging (MRI).

Treatment
A change in activity is recommended initially in order to remove the stress from the elbow. This may mean a temporary change in field position for an athlete, while the damage is assessed. A course of conservative treatment followed by rehabilitation is generally the first phase of addressing an injury or condition.

When a tear requires surgery, an exploratory arthroscopy is generally performed to confirm no other damage. And a surgery popularized by a former major league pitcher, Tommy John, called the Tommy John surgery may be indicated. The procedure – known to doctors as medial collateral ligament reconstruction – takes only an hour and returns full strength to the elbow by replacing a ligament in the medial elbow with a tendon from another area of the body (generally taken from the forearm, hamstring or foot).

Also known as Golfer’s Elbow, medial epicondylitis is similar in nature to lateral epicondylitis or Tennis Elbow – though one affects the outer (lateral) portion of the elbow and the other affects the inner (medial) portion.

Medial epicondylitis affects the inner portion of the elbow and is caused by the excessive and repeated force used to bend the wrist toward the palm. This occurs in such activity as pitching a baseball, swinging a golf club or serving a tennis ball. The force causes damage to the tendons responsible for this bending action and causes a pain that generates from the elbow to the wrist, on the palmar side of the forearm.

While the condition may also result from a number of other activities such as carrying a heavy suitcase, chopping wood with an ax, throwing a javelin and frequently using other hand tools, it has become popularized by golfers and is most often referred to as Golfer’s Elbow.

Those at Risk
Those adults subjecting repeated force on the wrist are likely to experience medial epicondylitis. It is often diagnosed in those actively involved in a sporting activity or manual labor – generally between the ages of 20 and 40.

Diagnosis
Diagnosis of medial epicondylitis usually consists of patient history and a physical examination of the arm and wrist in various positions of resistance.

Treatment
Unless chronic and severe, most cases are treated with conservative nonsurgical treatment plans that may include: cold compression, anti-inflammatory medications, and strengthening exercises.

When the condition is nonresponsive to conservative treatment, surgery is indicated to repair the ligament.

Known by physicians as lateral epicondylitis, Tennis Elbow affects the lateral, or outer, portion of the elbow and results when the elbow is overstressed or repetitively overused.

The forearm muscles that bend the wrist back (the extensors) attach at the lateral epicondyle (bony bump at the outer portion of the elbow) and are connected by a single tendon. Lateral epicondylitis is the irritation and subsequent inflammation of the tendon around the lateral epicondyle, or bony elbow bump, thought to be the result of tissue degeneration within the tendon.

Initially moderate pain is felt at the outer portion of the elbow. Over time pain increases and may spread down the forearm and to the back of the middle and ring fingers – eventually causing debilitating pain and weakness in arm function. Reaching and grasping activities may become painful, and a nagging discomfort may be present while resting after activities.

Those at Risk
While it got its name because five in 10 recreational and professional tennis players suffers from the condition, the average man and woman between the ages of 40 and 60 is far more likely to suffer from the condition doing everyday activities – painting with a brush or roller, using a chain saw or hand tools, pruning shrubs, lifting children up and down. The overuse of the muscles and tendons of the forearm and elbow is likely to prompt the condition.

Diagnosis
In diagnosing tennis elbow, patient history and a pain analysis are generally followed by a physical exam that places the arm and wrist in various positions that require the forearm muscles and tendons to stretch. An X-ray may be indicated in order to eliminate other causes of elbow pain. A magnetic resonance image (MRI) or ultrasound test may also be used in establishing and confirming diagnosis.

Treatment
Beginning always with conservative nonsurgical treatment for such conditions, a plan to prevent further degeneration and promote an environment conducive to tendon healing is established. This may entail a course of anti-inflammatory medications if acute inflammation is determined. A physical or occupational therapy program helps instruct patients on ways to perform activities without placing strain on the elbow. And recently available to patients suffering from chronic tennis elbow nonresponsive to traditional conservative treatment options is a new noninvasive high-energy shockwave therapy. This nonsurgical procedure is called the OssaTron Treatment and is performed as an outpatient procedure that takes less than 20 minutes.

When the condition is nonresponsive to conservative treatment and not conducive to shockwave therapy, surgery may be indicated, in order to relieve the tension from the extensor tendon. This procedure is called lateral epicondyle release and can also be done as outpatient.

Ulnar Collateral Ligament (UCL) Tears, often referred to as a Tommy John injury, were once devastating injuries to an athlete involved in overhead and throwing sports such as swimmers, volleyball players, pitchers and ice hockey players. But today early diagnosis and treatment keeps players in the game without skipping a beat.

The UCL of the elbow is critical for valgus stability and serves as the primary elbow stabilizer. It consists of three bands – the anterior, posterior and transverse. The anterior band contributes the greatest in valgus stability.

The acceleration phase of an overhead throw causes the greatest amount of valgus stress on the elbow – while the forearm lags behind the upper arm and creates valgus stress. This leaves the elbow primarily dependent on the anterior band of the UCL for stability. The extreme acceleration can cause the valgus force to overcome the tensile strength of the UCL and result in either chronic microscopic tears or an acute rupture.

Tearing of the ligament generally occurs after a period of localized internal soreness around the elbow. When the tear occurs, patients report feeling a “pop” followed by weakness and inability to function properly.

Those at Risk
Athletes regularly subjecting their elbow to high acceleration activities in flexion and extension are likely to incur this type of injury.

Diagnosis
Patient history and physical examination are followed by a radiologic exam. Those patients experiencing extended periods of pain may have an X-ray performed, while those experiencing deep sharp pains – particularly during a sport activity – may require magnetic resonance imaging (MRI).

Treatment
A change in activity is recommended initially in order to remove the stress from the elbow. This may mean a temporary change in position for an athlete, while the damage is assessed. A course of conservative treatment followed by rehabilitation is generally the first phase of addressing an injury or condition.

When a tear or rupture requires surgery, an exploratory arthroscopy is generally performed to confirm no other damage. And a surgery popularized by a former major league pitcher, Tommy John, called the Tommy John surgery may be necessary. The procedure – known to doctors as ulnar collateral ligament reconstruction – takes only an hour and returns full strength to the elbow and forearm by replacing the damaged ligament with a tendon from another area of the body (generally taken from the forearm, hamstring or foot).