Introduction

Approximately 30 million children and teenagers participate in organized sports in the United States (Adirim and Cheng 2003). Despite the fact that sports are the leading cause of injury in adolescent athletes, it is estimated that more than half of those injuries are preventable (Emery 2003). Pain in the elbow is a common occurrence in young baseball players, especially pitchers. Table 2-1 lists possible differential diagnoses in adolescents with elbow pain. One study found that elbow pain in youth baseball pitchers was associated with multiple factors including age, weight, height, number of pitches thrown during the season, satisfaction with performance, fatigue, lifting weights, and playing outside of the league (Lyman et al. 2001). Studies have found that, during a season, 26% to 35% of youth baseball players have either shoulder or elbow pain, with self-reported shoulder pain in more than 30% of pitchers and elbow pain in more than 25% immediately following a game (Lyman et al. 2001, Lyman et al. 2002). The simple act of throwing is violent because of the stresses it places on the elbow. Because ligaments and muscles are attached to the bone at the medial elbow at a time when the secondary ossification centers are not fused, a traction apophysitis can occur when this growth plate is not able to withstand the forces placed on it. Conversely, compression on the lateral side of the elbow commonly is a cause for Panner’s disease or osteonecrosis of the capitellum.

Table 2-1 Adolescent Elbow Pain Differential Diagnosis

Little Leaguer’s elbow

Little Leaguer’s elbow is considered a host of elbow pathology in a young throwing athlete. The various types of injuries that can be considered Little Leaguer’s elbow are listed in Table 2-2.

Table 2-2 Forms of Little Leaguer’s Elbow

Medial tension injuries

Medial tension injuries most commonly include medial epicondylar apophysitis. With repetitive stress to the medial elbow in the throwing adolescent, the flexor pronator mass and the ulnar collateral ligament apply tensile forces that cause medial epicondyle apophysitis (Pappas 1982, Rudzki and Paletta 2004). This apophysitis is thought to occur rather than rupture of the ulnar collateral ligament (Joyce et al. 1995). Chronic attritional tears of the ulnar collateral ligament are fairly rare in adolescent athletes (Ireland and Andrews 1988). Despite this rarity, it appears that ulnar collateral injuries are increasing in high school athletes. Petty et al. (2004) reported that the percentage of high school athletes who required ulnar collateral ligament reconstruction in their center jumped from 8% between 1988 and 1994 to 13% between 1995 and mid-2003. Injuries to the ulnar collateral ligament in adolescent athletes generally occur as acute events, rather than through attrition as in older, more skeletally mature athletes.

Lateral compression injuries

Several conditions caused by compression of the lateral side of the elbow can occur in younger pitchers. Two of the more common are osteochondritis dissecans (OCD) and Panner’s disease. Although traditionally these have been thought to be the same condition by some, they are separate entities. Osteochondritis is a localized condition involving articular cartilage that has separated from the underlying subchondral bone and is caused by repetitive trauma (Yadao et al. 2004). Panner’s disease is a focal osteonecrosis of the entire capitellum seen primarily in boys aged 7 to 12 years old and is not associated with trauma (Yadao et al. 2004).

Posterior compression injuries

Whereas medial and lateral elbow pain occurs as a result of “valgus extension overload” during the late cocking–early acceleration phase of throwing, posterior pain occurs during the terminal phase of throwing as the elbow is locked into full extension. The synovium can be pinched in the olecranon when the elbow is in full extension, resulting in posterior impingement syndrome, or the posterior apophysis can be stressed by triceps traction, causing olecranon apophysitis (Crowther 2009).

Prevention

Parents and coaches need to take more control of players, especially those who are at risk. Unfortunately, these are most commonly the “better players,” which is why they may develop these problems to begin with. Petty et al. suggested that the risk of elbow problems in younger athletes can be reduced by following these guidelines:

Several associations have provided recommendations regarding adolescent athletes and prevention of both elbow and shoulder problems. The American Academy of Pediatrics and USA Baseball each have guidelines regarding pitch counts. The American Academy of Pediatrics recommends limits of 200 pitches per week or 90 per outing, while the USA Baseball Medical and Safety Advisory Committee recommends a more stringent 75 to 125 pitches per week or 50 to 75 pitches per outing depending on age (Committee on Sports Medicine and Fitness, USA Baseball Medical and Safety Advisory Committee 2001).

USA baseball guidelines

USA Baseball has developed guidelines and recommendations in an effort to decrease the risk of elbow or shoulder injury in vulnerable adolescent athletes.

Anatomy and biomechanics

The MCL is composed of two primary bundles. The anterior bundle runs from the sublime tubercle of the ulna and inserts on the inferior surface of the medial epicondyle. The anterior bundle tightens in extension and loosens in flexion. The posterior band runs from the posterior portion of the medial epicondyle and inserts at the ulna proximal and posterior to the sublime tubercle (Fig. 2-1). The posterior bundle tightens in flexion and loosens in extension. The anterior bundle is the prime focus of the MCL reconstruction. The ulnar nerve runs in the space posterior to the medial epicondyle. The space is referred to as the cubital tunnel. The roof of the tunnel is referred to as the cubital tunnel retinaculum. At this location, the nerve is significantly exposed.

Figure 2-1 MCL complex of the elbow, consisting of three bundles: anterior, posterior, and transverse oblique.

Mechanism of injury

Injury to the MCL is a result of the repetitive, extreme valgus loads to the elbow while throwing. The MCL is the primary restraint to valgus stress at the elbow. Dillman et al. (1995) demonstrated that a fastball thrown by an elite baseball pitcher produces a load that approaches the actual tensile strength of the MCL. The MCL attempts to withstand these forces during the late cocking and acceleration phases of throwing. Repetitive overloading can result in inflammation and microtears of the ligament, which can eventually lead to failure. Continuing to throw with instability can lead to degenerative changes in the elbow.

Repetitive valgus stresses can also result in injury to the ulnar nerve, which may be exacerbated by ligamentous insufficiency. These stresses may lead to medial traction on the ulnar nerve, resulting in chronic subluxation or dislocation of the nerve outside the ulnar groove. In addition, throwers often have a hypertrophied flexor–pronator mass, which can result in compression of the nerve during muscle contraction. Injuries to the ulnar nerve may be isolated or associated with an MCL injury.

Evaluation

Diagnosis of MCL insufficiency is based on the history, physical examination, magnetic resonance imaging (MRI), and arthroscopic testing. The history is often chronic medial elbow pain with throwing, especially during the late cocking and early acceleration phases. It often prevents throwing completely. Physical examination includes a valgus stress test that reproduces the symptoms of increased valgus laxity. MRI findings clearly consistent with an MCL injury assist in making the diagnosis. Finally, a positive arthroscopic test, which is defined as more than 1 mm of opening between the coronoid and the medial humerus, is often used.

Surgical treatment

Medial Collateral Ligament Reconstruction

Reconstruction of the medial collateral ligament is performed using the “docking technique” described by Altchek et al. (2000). The anterior bundle is the primary focus of the reconstruction. The ipsilateral palmaris longus is the graft of choice. In the absence of this muscle, the gracilus is used. Our rehabilitation guidelines are not affected by graft choice; however, when using the gracilis, the affected lower extremity must be considered.

This procedure includes a routine arthroscopic evaluation of the elbow through a muscle-splitting approach that preserves the flexor–pronator origin (Fig. 2-2). Bone tunnels are created in the humerus and ulna. The graft is “docked” securely in the tunnels with sutures (Fig. 2-3). This technique also minimizes the number of tunnels and reduces the size of the drill holes. Finally, this technique avoids an obligatory ulnar nerve transposition.

Figure 2-2 Exposure is created by splitting the flexor carpi ulnaris muscle.

(Redrawn from Levinson M: Ulnar Collateral Reconstruction in Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. 1^st edition, St. Louis, Elsevier, 2006.)

Figure 2-3 Docking technique: The graft is “docked” securely into the bone tunnels using sutures.

(Redrawn from Levinson M: Ulnar Collateral Reconstruction in Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. 1^st edition, St. Louis, Elsevier, 2006.)

Definition

The elbow contains three major articulating surfaces. The articulation of the humeral trochlea and the trochlear notch of the ulna is the major facilitator of flexion and extension about the elbow. The radiocapitellar articulation supports motion in both the flexion and extension of the elbow in addition to supination and pronation of the forearm. The proximal radioulnar joint allows supination and pronation movements of the forearm.

The physiologic range of motion has been defined by the American Academy of Orthopaedic Surgeons to be 0 to 146 degrees with respect to extension and flexion, 71 degrees of forearm pronation, and 84 degrees of forearm supination. More important, the functional arc of motion as defined by Morrey et al. (1981) is elbow flexion from 30 to 130 degrees and 100 degrees of forearm rotation, including 50 degrees of supination and 50 degrees of pronation. The functional impairment caused by elbow stiffness is delineated by the individual needs of each patient.

Classification

The etiology of elbow stiffness has been classified by various authors. Kay (1998) based his scheme on the anatomic components involved. Type I involves soft tissue contractures; type II involves soft tissue contractures with ossification; type III involves nondisplaced articular fracture with soft tissue contracture; type IV involves displaced intra-articular fractures with soft tissue contracture; and type V involves post-traumatic bony bars blocking elbow motion.

Morrey (1990) classified elbow stiffness into intrinsic, extrinsic, and mixed causes (Table 2-5). Intrinsic causes are related to intra-articular pathology resulting from deformities or malalignment of the articular surface, intra-articular adhesions, loose bodies, impinging osteophytes, and fibrosis within the olecranon or coronoid fossa. Extrinsic causes are related to all entities aside from the articular surface. Examples include skin contracture from scars or burns, capsular and collateral ligament contracture, and heterotopic ossification. Another important extrinsic cause is injury to brachialis or triceps resulting in a hemarthrosis, which may cause scarring, fibrosis, and limitation of motion. Entrapment of the ulnar nerve can lead to pain resulting in loss of motion and eventual capsular contracture. Mixed etiologies are defined as extrinsic contractures resulting from intrinsic pathology.

Table 2-5 Morrey’s Causes of Elbow Stiffness by Location of Pathology

History

The history of a patient presenting with a stiff elbow should include onset, duration, character, and progression of symptoms. Pain is an infrequent finding in post-traumatic elbow stiffness and implies arthrosis of the joint, entrapment neuropathy, infection, or instability. Important findings with regard to the elbow include history of a traumatic event, previous surgery, and septic arthritis. Comorbid conditions such as hemophilia, which causes hemarthroses, or a spastic neuropathy, which may result in neuropathic joint degeneration, are also important. Finally, the functional demands of the patient with respect to vocation and leisure-time activity have important implications on the treatment regimen.

Physical Examination

The physical examination should consist of a thorough neurovascular examination with particular attention to the ulnar and median nerves, which may be involved in trauma to the elbow or encompassed by HO around the elbow joint. The presence of burns, scars, or areas of fibrosis on the skin surrounding the joint should be noted. The active and passive range of motion in flexion and extension and supination and pronation should be recorded. It is important to understand that deficits in the flexion extension plane are a result of ulnohumeral pathology, whereas deficits in forearm supination and pronation imply a radiocapitellar or proximal radioulnar etiology. Attention to a soft or hard end point at the extremes of each motion is paramount to determining whether a soft tissue or bony constraint is hindering motion. The appreciation of crepitus through range of motion may indicate loose body, fracture, or degenerative changes.

Radiographic Evaluation

Radiographic evaluation should consist of anteroposterior, lateral, and oblique views of the elbow. Fractures, bony blocks to motion, articular loose bodies, degenerative changes, and HO may be noted on the initial radiographs. Computed tomography with three-dimensional reconstructions is helpful in defining the articular anatomy and surgical planning in the presence of HO. Magnetic resonance imaging is not routinely used in the evaluation of elbow stiffness.

Rehabilitation considerations

Anatomy and biomechanics

The elbow joint consists of two types of articulations and thus allows two types of motion. The ulnohumeral articulation resembles a hinge joint, allowing flexion and extension, whereas the radiohumeral and proximal radioulnar joint allows axial rotation (Morrey 1986). Stability of the elbow joint is provided by the osseous articulations, medial and lateral collateral ligaments, and traversing muscles.

Figure 2-5 The lateral ligament complex consists of the radial collateral ligament, the annular ligament, and the lateral ulnar collateral ligament. The lateral ulnar collateral ligament contributes the most to stability on the lateral side of the elbow. Injury to this structure can lead to posterolateral rotatory instability.

Figure 2-6 Simple dislocations are classified as anterior or posterior. Posterior dislocation is by far the most common and is further subdivided by the direction of the dislocated ulna (posterior, posteromedial, posterolateral, direct lateral).

Mechanism of injury

Evaluation and radiographs

Classification

Treatment

The initial treatment of an elbow dislocation is reduction of the dislocation. Reduction requires adequate analgesia and muscle relaxation and usually can be done in the emergency department.

Reduction of a posterior dislocation uses application of longitudinal traction to the forearm beginning with the elbow in extension. One hand is placed on the forearm, pulling longitudinal traction, while the examiner’s other hand is placed around the elbow joint. With traction applied, correcting for varus or valgus alignment, the elbow is gently brought into a flexed position. The fingers of the hand around the elbow joint apply an anterior pressure on the olecranon, while the thumb is placed in the antecubital fossa applying a counter posterior force, gently levering the olecranon anteriorly and distally around the trochlea of the distal humerus. A palpable reduction “clunk” may be felt and is a favorable sign for joint stability.

Once reduction has been achieved, the elbow should be taken through a gentle range of motion, including flexion, extension, and rotation. The examiner should pay particular attention to recurrent posterior instability and the degree of extension at which the olecranon begins to subluxate.

Final radiographs should be obtained to confirm concentric reduction and again look for associated periarticular fractures.

If the reduction is concentric and the elbow joint is stable, a posterior splint is applied with the elbow in 90 degrees of flexion for 5 to 7 days.

Complications

Figure 2-7 Posterolateral rotatory instability (PLRI) of the elbow is assessed with axial compression, valgus stress, and forced supination.

Rehabilitation considerations

Results

Introduction

Injuries to the elbow, specifically humeral epicondylitis, occur frequently in daily activities as a result of the repetitive loads encountered and in athletes from both repetitive and forceful muscular activations inherent in throwing, hitting, serving, and spiking. Management of this important condition involves early diagnosis and treatment coupled with a total arm strengthing or kinetic chain rehabilitation emphasis.

Epidemiology and etiology

One of the most common overuse injuries of the elbow is humeral epicondylitis. The repetitive overuse reported as one of the primary etiologic factors is particularly evident in the history of many athletic patients with elbow dysfunction. Epidemiologic research on adult tennis players reports incidences of humeral epicondylitis ranging from 35% to 50%. This incidence is actually far greater than that reported in elite junior players (11% to 12%).

Reported in the literature as early as 1873 by Runge, humeral epicondylitis or “tennis elbow” as it is more popularly known, has been extensively studied by many authors. Cyriax (1936), listed 26 causes of tennis elbow, whereas an extensive study of this overuse disorder by Goldie (1964) reported hypervascularization of the extensor aponeurosis and an increased quantity of free nerve endings in the subtendinous space. Leadbetter (1992) described humeral epicondylitis as a degenerative condition consisting of a time-dependent process including vascular, chemical, and cellular events that lead to a failure of the cell-matrix healing response in human tendon. This description of tendon injury differs from earlier theories where an inflammatory response was considered as a primary factor; hence, the term “tendinitis” was used as opposed to the term recommended by Leadbetter (1992) and Nirschl (1992).

Nirschl and Ashman (2003) defined humeral epicondylitis as an extra-articular tendinous injury characterized by excessive vascular granulation and an impaired healing response in the tendon, termed “angiofibroblastic hyperplasia.” In a thorough histopathologic analysis, Kraushaar and Nirschl (1999) studied specimens of injured tendon obtained from areas of chronic overuse and reported that they did not contain large numbers of lymphocytes, macrophages, and neutrophils. Instead, tendinosis appears to be a degenerative process characterized by large populations of fibroblasts, disorganized collagen, and vascular hyperplasia. It is not clear why tendinosis is painful, given the lack of inflammatory cells, and it is also unknown why the collagen does not mature.

Nirschl (1992) described the primary structure involved in lateral humeral epicondylitis as the tendon of the extensor carpi radialis brevis. Approximately one third of cases involve the tendon of the extensor communis. Additionally, the extensor carpi radialis longus and extensor carpi ulnaris can be involved. The primary site of medial humeral epicondylitis is the flexor carpi radialis, pronator teres, and flexor carpi ulnaris tendons. Finally, Nirschl (1992) reported that the incidence of lateral humeral epicondylitis is far greater than that of medial humeral epicondylitis in recreational tennis players and in the leading arm (left arm in a right-handed golfer), whereas medial humeral epicondylitis is far more common in elite tennis players and throwing athletes because of the powerful loading of the flexor and pronator muscle tendon units during the valgus extension overload inherent in the acceleration phase of those overhead movement patterns. Additionally, the trailing arm of the golfer (right arm in a right-handed golfer) is reportedly more likely to have medial symptoms than lateral.

Clinical examination of the elbow

Structural inspection of the patient’s elbow must include a complete and thorough inspection of the entire upper extremity and trunk. The heavy reliance on the kinetic chain for power generation in sports and daily activities and the important role of the elbow as a link in the kinetic chain necessitate examination of the entire upper extremity and trunk in the clinical evaluation. However, because many overuse injuries occur in athletic individuals, structural inspection of the patient or athlete with an injured elbow can be complicated by a lack of bilateral symmetry in the upper extremities. Adaptive changes are commonly encountered during clinical examination of the athletic elbow, particularly in the unilaterally dominant upper extremity athlete. In these athletes, use of the contralateral extremity as a baseline is particularly important to determine the degree of actual adaptation that may be a contributing factor in the patient’s injury presentation. A brief overview of the common adaptations that have been reported in the literature can provide valuable information to assist the clinician during the structural inspection of the injured athlete with elbow pain.

Anatomical adaptations in the athletic elbow

Several classic studies have reported on elbow range of motion adaptations.

Although it is beyond the scope of this chapter, it is imperative that glenohumeral joint rotational range of motion be measured because of the important role of glenohumeral internal rotation deficiency in valgus loading of the throwing elbow. Identification of a loss of glenohumeral joint internal rotation and, more importantly, loss of total rotation range of motion with internal rotation range of motion loss should lead the clinician to interventions to correct the proximal rotational deficiency in addition to providing proximal stabilization of the scapulothoracic and glenohumeral joints.

Several studies have also been cited regarding osseous adaptations in the athletic elbow.

These data help to portray the chronic muscular adaptations that can be present in the overhead athlete and active individual who presents with an elbow injury and help to determine realistic and accurate discharge strength levels following rehabilitation. Failure to return the stabilizing musculature to its often dominant status (10% to as much as 35%) on the dominant extremity in these athletes may represent an incomplete rehabilitation and prohibit the return to full activity.

Elbow examination special tests

In addition to accurate measurement of both distal and proximal upper extremity joint range of motion, radiographic screening, and muscular strength assessment, several other tests should be included in the comprehensive examination of the elbow. Although it is beyond the scope of this section to completely review all necessary tests, several are highlighted based on their overall importance. The reader is referred to Morrey (1993), Ellenbecker and Mattalino (1997), and Magee (1997) for more complete information on examination of the elbow.

Clinical testing of the joints proximal and distal to the elbow allows the examiner to rule out referred symptoms and ensure that elbow pain is from a local musculoskeletal origin. Overpressure of the cervical spine in the motions of flexion–extension and lateral flexion–rotation, and the quadrant or Spurling test combining extension with ipsilateral lateral flexion and rotation, are commonly used to clear the cervical spine and rule out radicular symptoms. Tong et al. (2002) tested the Spurling maneuver to determine the diagnostic accuracy of this examination maneuver and found a sensitivity of 30% and specificity of 93%. Caution therefore must be used when basing the clinical diagnosis on this examination maneuver alone. The test is not sensitive but is specific for cervical radiculopathy and can be used to help confirm this diagnosis.

In addition to clearing the cervical spine centrally, clearing the glenohumeral joint is important. Determining the presence of concomitant impingement or instability is also recommended. Use of the sulcus sign to determine the presence of multidirectional instability of the glenohumeral joint, along with the subluxation–relocation sign and load and shift test, can provide valuable insight into the status of the glenohumeral joint. The impingement signs of Neer (1983) and Hawkins and Kennedy (1980) are also helpful to rule out proximal tendon pathology.

Full inspection of the scapulothoracic joint also is recommended. Our clinical experience suggests a high association of scapular and rotator cuff weakness with elbow overuse. The presence of overuse injuries in the elbow occurring with proximal injury to the shoulder complex or with scapulothoracic dysfunction is widely reported; thus a thorough inspection of the proximal joint is extremely important in the comprehensive management of elbow pathology.

Therefore, removal of the patient’s shirt or examination of the patient in a gown with full exposure of the upper back is highly recommended. Kibler et al. (2002) devised a classification system for scapular pathology. Careful observation of the patient at rest and with the hands placed on the hips, and during active overhead movements, is recommended to identify prominence of particular borders of the scapula and a lack of close association with the thoracic wall during movement. Bilateral comparison forms the primary basis for identifying scapular pathology; however, in many athletes, bilateral scapular pathology can be observed.

Several tests specific for the elbow should be performed to assist in the diagnosis of humeral epicondylitis and, more importantly, rule out other types of elbow dysfunction. These include Tinel test, varus and valgus stress tests, milking test, valgus extension overpressure test, bounce home test, provocation tests, and the moving valgus test.

Some of the most useful tests for identifying humeral epicondylitis include the use of provocation tests to screen the muscle tendon units of the elbow. Provocation tests consist of manual muscle tests to determine pain reproduction. The specific tests used to screen the elbow joint of a patient with suspected elbow pathology include wrist and finger flexion and extension (Fig. 2-8) and forearm pronation and supination. These tests can be used to provoke the muscle tendon unit at the lateral or medial epicondyle. Testing of the elbow at or near full extension can often recreate localized lateral or medial elbow pain secondary to tendon degeneration. Reproduction of lateral or medial elbow pain with resistive muscle testing (provocation testing) may indicate concomitant tendon injury at the elbow and would direct the clinician to perform a more complete elbow examination. In addition to the provocation tests themselves, careful palpation of the extensor origin at the lateral epicondyle and medial epicondyle is also indicated. Careful inspection of the orientation of the tendons on the lateral epicondyle shows that the primary insertion of the extensor carpi radialis longus is actually on the lateral supracondylar ridge proximal to the lateral humeral epicondyle. Additionally, the extensor carpi radialis brevis (ECRB) can be palpated on the medial aspect of the lateral epicondyle just proximal to the extensor digitorum communis (EDC), with the extensor carpi ulnaris being just distal to the EDC.

Figure 2-8 Extension provocation test performed with the elbow near extension to provoke the muscle tendon unit.

One of the more recent elbow special tests described in the literature is the moving valgus test. This test is performed with the patient’s upper extremity in approximately 90 degrees of abduction (Fig. 2-9). The elbow is maximally flexed and a moderate valgus stress is imparted to the elbow to simulate the late cocking phase of the throwing motion. Maintaining the modest valgus stress on the elbow, the elbow is extended from the fully flexed position. A positive test for ulnar collateral ligament injury is confirmed when reproduction of the patient’s pain occurs and is maximal over the medial ulnar collateral ligament between 120 and 70 degrees in what we have termed the “shear angle” or pain zone. O’Driscoll et al. (2005) examined 21 athletes with a primary complaint of medial elbow pain from medial collateral ligament insufficiency or other valgus overload abnormality using the moving valgus test. The moving valgus test was found to be highly sensitive (100%) and specific (75%) when compared with arthroscopic exploration of the medial ulnar collateral ligament. The mean angle of maximal pain reproduction in their study was 90 degrees of elbow flexion. This test can provide valuable clinical input during the evaluation of the patient with medial elbow pain.

Figure 2-9 Moving valgus test for medial ulnar collateral ligament.

These special examination techniques are unique to the elbow and, when combined with a thorough examination of the upper extremity kinetic chain and cervical spine, can result in an objectively based assessment of the patients’ pathology and enable the clinician to design a treatment plan based on the examination findings.

Treatment

Patients initially are treated to reduce pain and increase range of motion, muscular strength, and overall function of the injured upper extremity. As mentioned earlier, the entire upper extremity kinetic chain is evaluated and is integrated into the treatment process. For the purposes of this section, several key concepts in the treatment of humeral epicondylitis are discussed. These include understanding the treatment basis for tendinitis versus tendinosis, a very important distinction for the treatment of humeral epicondylitis. Additionally, the important concept of rotator cuff and scapular stabilization, often viewed as only applicable for the treatment of shoulder dysfunction, is outlined because it forms an extremely important base for the treatment of the distal upper extremity. Finally, exercise progressions for the distal upper extremity and return to activity guidelines are described.

Definitions: tendinitis and tendinosis

Several studies have described the histopathologic findings with tennis elbow as chronic degeneration, regeneration, and microtears of the tendinous tissue called tendinosis. Neurochemicals including glutamate, substance P, and calcitonin gene-related peptides have been identified in patients with chronic tennis elbow and in animal models of tendinopathy. More recent research shows that tendons exhibit areas of degeneration and a distinct lack of inflammatory cells (Ashe et al. 2004). Consequently, tendinosis is degeneration of the collagen tissue as a result of aging, microtrauma, or vascular compromise. Riley (2005) described the tendon matrix as being maintained by the resident tenocytes, and there is evidence of a continuous process of matrix remodeling, although the rate of turnover varies at different sites. A change in remodeling activity is associated with the onset of tendinopathy and some changes are consistent with repair, but they may also be an adaptive response to changes in mechanical loading. Additionally, repeated minor strain is thought to be the major precipitating factor in tendinopathy. Metalloproteinase enzymes have an important role in the tendon matrix; the role of these enzymes in tendon pathology is unknown, and further work is required to identify novel and specific molecular targets for therapy. Riley (2008) also reported that the neuropeptides and other factors released by stimulated cells or nerve endings in or around the tendon might influence matrix turnover and could provide novel targets for therapeutic intervention.

Although much of the research in this area does not include tendons of the elbow, but rather the patellar and Achilles tendons, it does provide insight into the degenerative responses encountered when treating a patient with tennis elbow.

Alfredson and Ohberg (2005) using color Doppler examination showed structural tendon changes with hypoechoic areas and a local neovascularization, corresponding to the painful area. They demonstrated that treatment with sclerosing injections, targeting the area with neovessels, has the potential to eliminate pain in the tendons and allow patients to go back to full patellar tendon loading activity. Ohberg and Alfredson (2004) examined the occurrence of neovascularization in the Achilles tendon before and after eccentric training. After 12 weeks of painful eccentric calf muscle training, there was a more normal tendon structure, and in the majority of the tendons there was no remaining neovascularization.

Additionally, Ohberg et al. (2004) reported that after a 12-week eccentric calf muscle training program most patients with mid-portion painful chronic Achilles tendinosis showed a localized decrease in tendon thickness and a normalized tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon. Fredberg and Stengaard-Pedersen (2008) stated that, although the prevailing opinion is that no histologic evidence of acute inflammation has been documented, newer studies using immunohistochemistry and flow cytometry inflammatory cells have been detected. Consequently, the “tendinitis myth” needs to continue to be investigated. Existing data indicate that the initiators of the tendinopathic pathway include many proinflammatory agents. Because of the complex interaction between the classic proinflammatory agents and neuropeptides, it seems impossible and somewhat irrelevant to distinguish between chemical and neurogenic inflammation. Furthermore, glucocorticoids are, at the moment, an effective treatment in tendinopathy with regard to reduction of pain, tendon thickness, and neovascularization. An inflammatory process may be related not only to the development of tendinopathy, but also to chronic tendinopathy.

Wilson and Best (2005) described many of the clinical findings of tendinopathy. The natural history is gradually increasing load-related localized pain coinciding with increased activity. The examination should check for the signs of inflammation (swelling, pain, erythema, and heat), which would be indicative of a tendinitis response, asymmetry, ROM testing, palpation for tenderness, and examination maneuvers that simulate tendon loading and reproduce pain. Despite the absence of inflammation, patients with tennis elbow present with pain. Zeisig et al. (2006) suggested that the pain involves a neurogenic inflammation mediated via the neuropeptide substance P. Furthermore, the area with vascularity found in the extensor origin seems to be related to pain. Most likely, the findings correspond with the vasculo-neural in-growth that has been demonstrated in other painful tendinosis conditions.

There is no consensus regarding the optimal treatment for tendinitis or tendinosis. Paoloni et al. (2003) indicated that no treatment has been universally successful. Nirschl (1992) and Nirschl and Ashman (2004) described the primary goal of nonsurgical treatment as revitalization of the unhealthy tissue that produces pain. Revascularization and collagen repair of the pathologic tissue are keys to a successful rehabilitation program. Successful nonsurgical treatment involves rehabilitative resistance exercises and progression of the exercise program. A variety of treatment interventions have been reported in the literature, including hypospray, topical nitric oxide, oxygen free radicals, ice, phonophoresis and ultrasound, low-level laser, extracorporeal shock wave therapy, deep transverse friction massage (DTFM), manipulation and mobilization, acupuncture, bracing, orthotics, combined low-level laser and plyometrics, eccentric training programs, eccentric isokinetic program, and a combined exercise program.

Manias and Stasinopoulos (2006) compared an exercise program alone to the same program supplemented by icing. There were no significant differences in the magnitudes of reduction between the groups at the end of treatment and at the 3-month followup. However, because of the confounding variables with multiple treatment interventions, it is difficult to determine the efficacy of icing. Klaiman et al. (2007) demonstrated that ultrasound resulted in decreased pain and increased pressure tolerance in selected soft-tissue injuries. The addition of phonophoresis with fluocinonide did not increase the benefits of ultrasound alone.

Bjordal et al. (2008) performed a systematic review and meta-analysis of studies reporting low-level laser therapy (LLLT) for the treatment of humeral epicondylitis. Twelve randomized controlled trials satisfied the methodological inclusion criteria. LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions seemed to offer short-term pain relief and less disability in humeral epicondylitis, both alone and in conjunction with an exercise regimen. Stasinopoulos and Johnson (2005) in a qualitative analysis of nine studies found poor results with LLLT for humeral epicondylitis because it is a dose-response modality and the optimal treatment dosage has not been identified.

Rompe and Maffulli (2007) performed a qualitative study-by-study assessment that was thought to be of greater relevance than a pooled meta-analysis of statistically and clinically heterogeneous data of randomized controlled studies, which are difficult to interpret. In a qualitative systematic per-study analysis identifying common and diverging details of 10 randomized controlled trials that included 948 participants, evidence was found for effectiveness of shockwave treatment for tennis elbow under well-defined, restrictive conditions only.

Brosseau et al. (2002) in a Cochrane review determined that deep tendon friction massage (DTFM) combined with other physiotherapy modalities did not show consistent benefit in the control of pain or improvement of grip strength and functional status for patients with extensor carpi radialis tendinitis. LLLT and plyometrics were more effective using a variety of outcome measures than plyometrics by themselves for treatment of lateral humeral epicondylitis.

Eccentric training programs

One variable studied with specific regard to the treatment of tendon pathology is the use of eccentric exercise. There is limited research regarding the efficacy of eccentric overload training for humeral epicondylitis and treatment of other tendon overuse injuries. Kingma et al. (2007) performed a systematic review of eccentric overload training in patients with chronic Achilles tendinopathy. The nine included trials showed an improvement in pain after eccentric overload training; however, because of the methodological shortcomings of the trials, no definite conclusion could be drawn concerning the effects of eccentric overload training. Although the effects of eccentric exercise training in tendinopathy on pain are promising, the magnitude of the effects cannot be determined. Knobloch et al. (2007) using a laser Doppler system for capillary blood flow, tissue oxygen saturation, and postcapillary venous filling pressure evaluated the tendon’s microcirculation in response to a 12-week daily painful home-based eccentric training regimen (3 × 15 repetitions per tendon each day). They found daily eccentric training for Achilles tendinopathy to be a safe and easy measure, with beneficial effects on the microcirculatory tendon levels without any adverse effects in both mid-portion and insertional Achilles tendinopathy. Malliaras et al. (2008), in a review of eccentric training programs for humeral epicondylitis, determined that eccentric training has demonstrated encouraging results, although the literature is limited and eccentric programs are varied.

Combined exercise programs

Stasinopoulos et al. (2005) described strengthening and stretching exercise programs for the treatment of humeral epicondylitis. They recommended slow progressive eccentric exercises done with the elbow in extension, forearm in pronation, and wrist in an extended position. However, the speed of loading and the details (repetitions, sets, volume) of the eccentric exercise programs were not defined. They also recommended static stretching exercises to the lateral muscle-tendon unit before and after the eccentric exercises for 30 to 45 seconds with a 30-second rest interval between exercises. The details of the optimal parameters for treating humeral epicondylitis have yet to be elucidated in a well-designed trial.

Rotator cuff and scapular stabilization

In addition to the use of therapeutic modalities and eccentric exercise to directly treat the injured tendon at the elbow, proximal stabilization and exercise techniques also are warranted during the treatment of an athlete with an overuse elbow injury. Several key scapular strengthening exercises are recommended that target strengthening of the lower trapezius and serratus anterior force couple. Scapular stabilization exercises are emphasized and include external rotation with retraction, an exercise shown to recruit the lower trapezius at a rate 3.3 times more than the upper trapezius and utilize the important position of scapular retraction. Multiple seated rowing variations are recommended. These include the lawn mower exercise and low row variations, which have been studied with electromyographic quantification by Kibler et al. (2008).

Progression to closed-chain exercise using the “plus” position, which is characterized by maximal scapular protraction, has been recommended by Moesley et al. (1992) and Decker et al. (1999) for its inherent maximal serratus anterior recruitment. Closed-chain step-ups, quadruped position rhythmic stabilization, and variations of the pointer position (unilateral arm and ipsilateral leg extension weightbearing) are all used in endurance-oriented formats (timed sets of 30 seconds or more) to enhance scapular stabilization. Uhl et al. (2003) demonstrated the effects of increasing weightbearing and successive decreases in the number of weightbearing limbs on muscle activation of the rotator cuff and scapular musculature and provide guidance to closed-chain exercise progression in the upper extremity.

Strengthening the posterior rotator cuff to provide strength, fatigue resistance, and optimal muscle balance is of paramount importance when working with athletic individuals. Figure 2-10 shows our recommended exercises for rotator cuff strengthening. These exercises are based on EMG research showing high levels of posterior rotator cuff activation. Use of the prone horizontal abduction exercise is emphasized because research has shown this position creates high levels of supraspinatus muscular activation, making it an alternative to the widely used empty can exercise, which often can cause impingement because of the combined inherent movements of internal rotation and elevation. Three sets of 15 to 20 repetitions are recommended to create a fatigue response and improve local muscular endurance. For patients with elbow dysfunction, these exercises can be performed using a cuff weight attached proximal to the elbow if the distal weight attachment provokes pain or stresses the healing elbow structures. These isotonic exercises are coupled with an external rotation exercise with elastic resistance to provide resistance to the posterior rotator cuff in both neutral and 90-degree abducted positions in the scapular plane.

Figure 2-10 Rotator cuff exercise movement patterns based on electromyographic (EMG) research emphasizing posterior rotator cuff activation and positions with less than 90 degrees of glenohumeral joint elevation.

Carter et al. (2007) studied the effects of an 8-week program of plyometric upper extremity exercise and external rotation strengthening with elastic resistance. They found increased eccentric external rotation strength, concentric internal rotation strength, and improved throwing velocity in collegiate baseball players. Figure 2-11 shows a prone 90/90 plyometric exercise with the athlete maintaining a retracted scapular position with the shoulder in 90 degrees of abduction and 90 degrees of external rotation. The plyo ball is rapidly dropped and caught over a 2- to 3-inch (3 to 6 cm) movement distance for sets of 30 to as much as 40 seconds to increase local muscular endurance. This exercise also provides a fatigue response to the wrist flexors and extensors as a result of the rapid grasping and releasing of the ball during the exercise. Another exercise used in elbow rehabilitation is the reverse-catch plyometric exercise that is performed with the glenohumeral joint in the 90/90 position. The ball is tossed from behind the patient to eccentrically load the posterior rotator cuff (external rotators) with a rapid concentric external rotation movement performed as the patient throws the ball back, keeping the abducted position of the shoulder with 90 degrees of elbow flexion. These one-arm plyometric exercises can be preceded by two-arm catches over the shoulder to determine readiness for the one-arm loading. Small (0.5 kg, 1-pound) medicine balls or soft weights (Theraband, Hygenic Corporation, Akron, OH) are used initially with progression to 1 to 1.5 kg as the patient progresses in both skill and strength development.

Figure 2-11 Prone 90/90 external rotation plyometric.

Advanced distal upper extremity exercises for rehabilitation of humeral epicondylitis

Exercises to improve strength and promote muscular endurance of the forearm and wrist include both traditional curls for the flexors and extensors with either light isotonic dumbbells or elastic tubing or bands and forearm pronation–supination and radioulnar deviation with a counterbalanced weight. These exercises help provide additional muscular support to the distal extremity and help counter the large forces generated in this region with both throwing and overhead serving motions.

Progression to isokinetic exercise for wrist flexion–extension and forearm pronation supination is also recommended once a tolerance to the more basic isotonic exercises is demonstrated. Intermediate and fast contractile velocities (180 to 300 degrees per second) are used to simulate speeds used in functional activities and to provide an endurance-oriented stimulus for the stabilizing muscles of the elbow and forearm. Three to five sets of 15 to 20 repetitions are recommended.

More advanced, ballistic-type exercises can be integrated for end-stage strengthening in patients returning to aggressive work activity or in athletes who need high levels of muscular strength and endurance. Rapid ball dribbling in sets of 30 seconds with a basketball or small physio ball both off the ground and in an elevated position off the wall (Fig. 2-12) is recommended. Additionally, specific plyometric drills for the forearm musculature include wrist flexion flips and wrist flexion snaps.

Figure 2-12 Ball dribbling for distal upper extremity strengthening.

Return to sport/interval return programs

Of the phases used in the rehabilitation process for elbow injury, the return to activity phase is most frequently ignored or cut short, resulting in serious risks of reinjury. Objective criteria for entry into this stage are tolerance of the resistive exercise series, objectively documented strength equal to the contralateral extremity with either manual assessment or preferably isokinetic testing and isometric strength, distal grip strength measured with a dynamometer, and a functional range of motion. It is important to note that often in elite athletes with chronic musculoskeletal adaptations full elbow range of motion is not always attainable because of osseous and capsular adaptations.

Characteristics of interval sport return programs include alternate-day performance and gradual progressions of intensity and repetitions of sport activities. For the interval tennis program, for example, low compression tennis balls such as the Pro-Penn Star Ball (Penn Racquet Sports, Phoenix, AZ) or foam balls are used during the teaching process of tennis to children. These balls are highly recommended for use during the initial phase of the return-to-tennis program and result in a decrease in impact stress and increased patient tolerance to the activity. Additionally, performing the interval program under supervision, either during therapy or with a knowledgeable teaching professional or coach, allows biomechanical evaluation of technique and guards against overzealous intensity levels, which can be a common mistake in well-intentioned, motivated patients. Using the return program on alternate days, with rest between sessions, allows for recovery and decreases reinjury.

An interval tennis program has been published and the reader is referred to these publications for additional discussion of this important process (Ellenbecker et al. 2006). Additionally, similar concepts are used in the interval throwing program, which has been published previously (Reinhold et al. 2002). Similar to the interval tennis program, having the patient’s throwing mechanics evaluated using video and by a qualified coach or biomechanist is a very important part of the return-to-activity phase of the rehabilitation process.

Two other important aspects of the return to sport are the continued application of resistive exercise and the modification or evaluation of the patient’s equipment. Continuation of the total arm strength rehabilitation exercises using elastic resistance, medicine balls, and isotonic or isokinetic resistance is important to continue to enhance not only strength, but also muscular endurance. Inspection and modification of the patient’s tennis racquet or golf clubs also are important. For example, lowering the string tension several pounds and ensuring that the player uses a more resilient or softer string, such as a coreless multifilament synthetic string or gut, are widely recommended for tennis players with upper extremity injury histories. Grip size also is important, with research showing changes in muscular activity with alteration of handle or grip size. Measurement of proper grip size has been described by Nirschl (1981) as corresponding to the distance between the distal tip of the ring finger along the radial border of the finger to the proximal palmar crease. A counterforce brace also can be used to decrease stress on the insertion of the flexor and extensor tendons during work or sport activity.