Javelin throwers elbow


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Definition/Description

Javelin throwers elbow is a sprain injury of the ulnar collateral ligament (UCL) of the medial elbow. The pain begins when the elbow is subjected to a valgus force bigger than the tensile properties of the UCL. It’s stretching might be provoked by poor technique of the javelin throw: an explosive elbow propulsion ahead of the shoulder while inertia is working on the rest of the arm weighed down by the javelin. Poor technique consists of throwing with insufficient shoulder abduction (90° - 100°), then the elbow will be too low resulting in a valgus force on that joint. Since the UCL is the principal structure opposing this motion, it will be the primary site of injury. Athletes participating in throwing sports, or overhead sports in general, are at higher risk of being diagnosed with this injury.


elbow joint ligaments

Epidemiology/Etiology

The onset of the injury can be a direct trauma, but is more likely to be insidious due to the accumulation of repetitive sub-threshold valgus forces on the UCL. This will generally result in a sharp pain during the throw and/or an ache at the medial elbow after a heavy and exhausting session. The pain will increase in proportion to the amount and intensity of throwing with the performance of the athlete.[1] 

This injury is commonly caused by a lack of competence of throwing the javelin. In general, there are two ways of throwing the javelin:

1. Round arm, which causes strain on the medial collateral ligament,

2. Over arm, which can lead to roughening and new bone formation at the tip of the olecranon or even might result in avulsion of the tip.[1] 


Management

On examination of the elbow swelling, loss of motion and tenderness along the medial aspect of the elbow might become apparent. When an overhead throwing athlete has medial elbow pain, even if symptoms are minimal, the diagnosis of javelin throwers elbow (or “Little League Elbow” in baseball) is to be expected.[2][3] Recognizing this injury promptly can lead to better treatment outcomes and decrease the risk of permanent damage or persistent functional disability.

Inspection:

Resting position of the elbow and carrying angle of the elbow have to be appraised. The normal carrying angle is 11° of valgus in men and 13° of valgus in women. An increased valgus angle may indicate the body is accommodating for the repetitive stress of valgus instability. Furthermore, it is important to note the presence of an effusion, scars, developmental abnormalities or signs of previous traumas.

Clinical examination:

Range of motion (ROM) is important to assess the injury. Let the patient perform flexion, extension, supination and pronation and detect the endfeel of these movements and any associated pain. A soft endfeel in extension may indicate a soft tissue contracture of the arm flexor apparatus. A bony endfeel in terminal flexion on the other hand may indicate anterior bony osteophytes or loose bodies.[4]. But it is mainly the valgus stress test of the elbow that will reproduce the pain. Other pathologies around the medial elbow, such as golfers elbow or avulsions, have to be excluded.


Treatment

For a good treatment of this injury you must understand the differential diagnosis of medial elbow pain is very important to diagnose medial collateral ligament injury as well as the treatment of other medial elbow injuries.

In the acute phase of the injury, the RICE principle (rest, ice, compression, elevation) as well as paracetamol and NSAIDs will give initial relief for swelling, inflammation and pain. Cessation of throwing or valgus-evoking movements at the elbow is required for at least four to six weeks, during which stretching and strengthening of musculature around the elbow should be encouraged, as well as general conditioning and core strengthening. The patient can indulge in an isotonic program of light weights and high repetitions to specifically target the biceps, triceps, wrist flexors and extensors as well as pronator and supinator musculature, in order to gain maximum stabilisation help from the contractile system. To furthermore support the passive ligamentous system in the beginning of the rehabilitation period, an elbow sleeve could be recommended.

If pain and stability of the elbow allow, a gradual and progressive return to throwing may be initiated. Caution should be taken to assure a safe recovery of the strength of the medial collateral ligament. Since poor throwing technique is the main contributing factor to this injury, implementing technique changes is of upmost importance. The correct method is that the shoulder is abducted higher (120°-130°) so internal rotation of the arm can bring the elbow forward early in order to reach a position directly in front of and above the shoulder. From there, powerful extension of the elbow will transmit the necessary force to the javelin without endangering the UCL. Rehabilitation finishes when the patient can complete a throwing motion with no pain or discomfort.[2][4] 

Patients whose symptoms do not improve conservative treatment or patients with loose cartilaginous bodies, avulsion fractures or osteochondritis dissecans (Osteochondritis Dissecans of the Elbow) should be referred to their orthopaedic specialist. Surgical management Surgery of the medial collateral ligament is necessary when: - a throwing athlete has a complete UCL tear, - diagnosed partial tear that has failed to improve with conservative management, - symptomatic non-throwing athletes after a minimum of three months of non-responding conservative care. When surgery is necessary, two techniques are available: direct repair of the ligament or reconstruction. The latter is the most widespread used surgical modality. [5]


Recent Related Research (from Pubmed)


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References

  1. 1.0 1.1 J.E. Miller. (4 November 1960). Javelin throwers elbow. The journal of bone and joint surgery (level: A1)
  2. 2.0 2.1 James D. O’Holleran, MD& David W. Altchek, MD. (13 February 2006). The Thrower’s Elbow: Arthroscopic Treatment of Valgus Extension Overload Syndrome. HSS Journal pag 83-84 (level: A1)
  3. Michael J. Wells, MS; Gerald W. Bell, EdD, PT, ATC,R. (30 September 1995). Concerns on Little League Elbow. Journal of Athletic Training, volume 30, nummer 3, pag. 249 – 253 (level: A1)
  4. 4.0 4.1 KYLE J. CASSAS, M.D., and AMELIA CASSETTARI-WAYHS, M.D. . (2006). Childhood and Adolescent Sports-Related Overuse Injuries. Journal of the American Academy of Family Physicians (level: A1)
  5. P Langer, P Fadale, M Hulstyn. (17 February 2006). Evolution of the treatment options of ulnar collateral ligament injuries of the elbow. British Journal of Sports Medicine pag 499 – 506 (level: A1)