Pirates Duke on Disabled List with elbow Injury
Pittsburgh Pirates left-handed pitcher, Zach Duke, was placed on the 15-day disabled list on Wednesday. An MRI confirmed no structural abnormalities. So what are some of the throwing injuries that can happen with the elbow?
The elbow is a hinged joint, with many structural supports on the inner and outer parts of the joint. Three bones make up the elbow joint: the humerus (upper arm bone), the ulna (a forearm bone), and the radius (another forearm bone).
On the inner aspect of the elbow, the medial or ulnar collateral ligament (UCL), gives stability to the elbow. On the outer part of the elbow, the lateral or radial collateral ligament (RCL) and annular ligament provide stability for the elbow. A lot of stress and force passes through these structures with certain activities. The UCL must withstand a lot of force with pitching. The motion of pitching produces forces which try to separate the ulna from the humerus. The UCL prevents these bones from moving apart.
In addition to these ligaments, the muscles of the tendons that bend and flex the wrist attach to the humerus on the inner part of the elbow. The muscle attachment to the bone can be stressed with repetitive, high energy motions and forces.
Injury to the elbow is common in pitchers. The repetitive motions, stresses, and forces that go through the structures of the elbow place it at risk for injury. The common injuries to the elbow that happens in the adult pitcher include a strain or tear of the UCL, inflammation and degeneration of the attachment site of the wrist flexors (medial epicondylitis), or an osteochondral defect (OCD) of the elbow joint surface. An OCD is where a chunk of bone and cartilage are divoted out of the joint, similar to a pothole in a road.
Most pitchers with thrower’s elbow will experience pain and swelling on the inner part of the elbow. At times there is also loss of strength and pitching velocity. There will be tenderness and pain over the UCL or the attachment site of the wrist flexors. If the UCL is torn, these players will also feel instability in the elbow with throwing activities. If there is an OCD, players may describe locking or catching of the elbow joint.
Treatments are tailored the structure that is injured. A pitch count is used in baseball to minimize fatigue and stress to these elbow structures.
UCL strain – These players can be treated with rest and anti-inflammatories. Changing the mechanics of throwing can minimize future injury to the UCL. Physical therapy is used to strengthen and stretch the muscles on the inner side of the elbow.
UCL tear – These players will require what has become known as Tommy John Surgery. This surgery is a reconstruction of the UCL. This restores the stability of the elbow.
Medial epicondylitis – This can be treated initially with rest, anti-inflammatories, straps, and physical therapy. At times, a steroid injection can help calm down the pain. If an individual fails these conservative options, then surgery is needed to remove the painful tissues and reattach the tendon to the bone.
OCD – An OCD usually develops on the outer aspect of the elbow. An elbow arthroscopy can be used to remove the loose cartilage and bone. Since the human body is unable to regrow cartilage, the OCD lesion is cleaned and drilled to stimulate scar tissue to fill in the “pothole.”
WHEN TO SEEK MEDICAL CARE
Pitchers who have persistent pain, swelling, or difficultly pitching should seek medical attention.
RETURN TO ACTIVITIES
With rest and anti-inflammatories, most pitchers are able to resume pitching activities with two to four weeks.
Most patients do well with conservative care. Given that Duke’s MRI did not show any structural abnormalities, it is very likely that he has only a strain of the UCL. He should be able to return to play within 2 to 4 weeks.
For a video animation of “Throwing Injuries of the Elbow”, please see the “Education” tab of my website. Click orthopaedics, then elbow, then conditions, then throwing injuries of the elbow.
All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.