Between these two bands a few intermediate fibers descend from the medial epicondyle to blend with a transverse band which bridges across the notch between the olecranon and the coronoid process. Imaging is obtained and demonstrates a bony Bankart lesion involving 40% of the glenoid. He denies any trauma or prior shoulder problems, and has good rotator cuff strength. The MRI images are seen in Figures A and B. A positive result is defined as pain between 70 and 120 degrees of flexion.11 A video of the moving valgus stress test is available at http://www.youtube.com/watch?v=plk7G2s8V30. The examiner uses the other hand to passively supinate the arm and extend the elbow and wrist. The multiaxial shoulder joint and the uniaxial elbow joint allow the forearm and hand to be positioned for optimal function. Webin athletes, may develop in response to large valgus forces on elbow. Journal of Shoulder and Elbow Surgery. Which of the nerves in Figure A is most at risk during the planned procedure? Specific exercises can restore flexibility and strength. Proper conditioning, technique, and recovery time can help to prevent throwing injuries in the elbow. Data Sources: A PubMed search was completed in Clinical Queries using the key terms elbow pain, epicondylitis, bursitis, radial tunnel, cubital tunnel, and impingement. (OBQ18.233) Author disclosure: No relevant financial affiliations. His first dislocation occurred after a fall while skiing. Manipulation under anesthesia or arthroscopic capsular release is indicated in patients with progressive loss of motion having failed a prolonged course of physical therapy. 10/21/2019. Which of the following surgical treatments is most appropriate to address his symptoms? 978 plays. In 2014, Wright transformed itself from a patients with pacemakers and/or cochlear implants, due to limited soft-tissue contrast, CT arthrogram not as effective at visualizing internal soft-tissue derangements as MR arthrogram, has been validated as an imaging modality through which to assess bone loss, increases sensitivity and specificity (86-91% and 86-96%) for detecting soft-tissue injuries when compared to conventional MRI (44-100% and 66-95%), acute reduction, immobilization, followed by therapy, management of first-time dislocators remains controversial, current ASES recommendations are for surgical intervention for athletes aged 14 to 30 at the end of their competitive season if they have positive apprehension testing and bone loss, simple traction-countertraction is most commonly used, Kocher: arm at side in external rotation is forward-flexed and then internally rotated, Hippocratic: traction against a heel placed in the patients axilla, Stimson's: weight is hung from the affected arm of a patient in the prone position, studies have not shown any benefit of immobilization > 1 week for decreasing recurrence rates, some studies show immobilization in external rotation, thought to reduce the anterior labrum to the glenoid leading to more anatomic healing, subsequent studies have refuted this finding, strengthening of dynamic stabilizers (rotator cuff and periscapular musculature), goal is return to sport within 7 to 21 days, military and overhead and/or contact athletes experience an unacceptably high rate of recurrent instability, Arthroscopic Bankart repair +/- capsular plication, recurrent dislocation/subluxation (> one dislocation) following nonoperative management, remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track", at least three (preferably four) anchor points shoulder be used, paramount that labrum is fully mobilized prior to repair, results now equally efficacious as open repair with the advantage of less pain and greater motion preservation, increased failure rates seen in patients with global hyperlaxity, glenoid bone loss, or too few fixation points, too many anchors does pose a risk for fracture through the anchor holes (postage stamp fracture), can be considered when there is a concomitant acute glenoid fracture, or if the patient is hyperlax and requires a formal capsular shift during the same procedure, humeral avulsion of the glenohumeral ligament (, can also be performed arthroscopically but is technically challenging, generally accessed through a deltopectoral approach, can fix bony bankart with screws or suture in a linear or bridge technique, results are equivalent to arthroscopic repair, although patients have more pain and less range of motion postoperatively, patients with greater than 13.5% glenoid bone loss have higher rates of recurrent instability, Latarjet (coracoid transfer) or Bristow Procedure, in the setting of glenoid bone loss, excessive stress is transferred to labrum and attenuated anterior soft tissues, increasing the risk of failure of labral repair alone, transfer of coracoid bone with attached conjoined tendon and CA ligament, Latarjet procedure performed more commonly than Bristow, Latarjet triple effect = bony (increases glenoid track), sling (conjoined tendon on top of subscapularis), capsule reconstruction (CA ligament), over recurrent instability rate ranges from 0% to 8%, good to excellent outcomes are seen in over 90% of patients, bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid), distal tibia gaining popularity since graft is a true osteochondral graft, engaging large (>25-40%) Hill-Sachs defect, "off-track" Hill-Sachs lesions with <20-25% glenoid bone loss, posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion, may be performed with concomitant Bankart repair, by decreasing size of Hill-Sachs, converts on off-track lesion into an on-track lesion, when compared to latarjet with 2-year outcomes, remplissage + bankart had lower recurrent instability rates (1.4% vs. 3.2%) despite greater bipolar bone loss, Bone graft reconstruction for Hill Sachs defects, may better replicate line of pull of native subscapularis, Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule, Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater tuberosity), transfer of biceps laterally and posteriorly, high rate of post-operative stiffness and subsequent osteoarthritis, typical presentation of open procedure performed in 1970s-80s, now with presenting complaint of pain and stiffness from glenohumeral OA, especially lack of ER, and signigicant posterior glenoid wear and retroversion, high rate of recurrent instability with Boyd-Sisk, relaxation of patient with sedation or intraarticular lidocaine is essential, drive through sign might be present prior to labral repair and capsulorraphy, studies support use of > 3 anchors (< 4 anchors is a risk factor for failure), recurrence, most often due to unrecognized glenoid bone loss or lack of concomitantly addressing "off-track" HS lesion, stiffness, especially in external rotation, further loss of ER may occur with the addition of remplissage, over-tightening increases the risk of post-capsulorrhaphy arthropathy, especially in older patients, axillary nerve is on average 12mm from infra-glenoid tubercle, chondrolysis (from use of thermal capsulorraphy which is no longer used), shoulder anterior (deltopectoral) approach, subscapularis transverse split or tenotomy, most often due to unrecognized glenoid bone loss, post-operative physical exam will show a positive lift off and excessive ER, treat with Z lengthening of subscapularis, iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure), seen with Putti-Platt and Magnuson-Stack procedures, coracoid transfer to anterior inferior glenoid bone defect, traditional or congruent arc technique for coracoid graft placement, after harvest, coracoid is passed through a split in the distal 1/3 or middle 1/2 subscapularis, traditional versus congruent arc technique, in the congruent arc technique, the undersurface of the coracoid ends up articulating with the humeral head, graft can be placed intraarticularly (capsular repaired to CA ligament stump) or extraarticularly (capsule repaired to native glenoid rim), concerns exist for increased rates of subsequent osteoarthritis with intraarticular placement, although this isn't fully supported by high-quality literature, generally higher than arthroscopic or open Bankart, some studies report up to 25% incidence, up to 90% of patients undergo some degree of resorption within the first six months, stiffness, particularly in external rotation, will rapidly occur with lateral overhang of graft into the joint space, majority are traction or contusion neuropraxias and resolve spontaneously, treat with observation for 3-6 weeks; delayed EMG if deficits persist, occurs during instrumentation around the conjoint tendon, pieces conjoint tendon, on average, 5.6 cm distally to the tip of the coracoid, located, on average, 12mm from infra-glenoid tubercle, Boyd-Sisktransfer of biceps laterally and posteriorly, Putti-Platt and Magnuson-Stackboth lead to decreased external rotation and increased loading on the posterior glenoid, which can lead to post-capsulorraphy arthropathy, often due to unrecognized glenoid bone loss treated with a soft tissue only procedure (especially with glenoid bone loss >20-25%), can be due to poor surgical technique (ie, < 4 suture anchors), increased risk with preoperative risk factors including age < 20, male sex, contact/collision sport, ligamentous laxity, and unrecognized glenoid and/or humeral head bone loss (critical bone loss or "off-track" lesion), medical management should be exhausted prior to surgery in patients with seizures, as there is a high recurrence risk even when bony augmentation techniques are used, high incidence of posterior and/or combined front-to-back tears in the military population, overtightening during labral repair can lead to post-capsulorrhaphy arthropathy, especially in external rotation (particularly with Latarjet and additional remplissage), present in up to 90% of patients at six-months, historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular pain pumps (now contraindicated), Arthroscopy, shoulder, surgical; capsulorrhaphy, - Traumatic Anterior Shoulder Instability (TUBS), Capsulorrhaphy, anterior, any type; with coracoid process transfer. Resisted supination typically recreates pain deep in the antecubital fossa. For this procedure, a small amount of blood is drawn from the patient. The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? He was subsequently treated in the emergency department and discharged home. 1/31/2020. In biceps tendon ruptures, no cord-like structure under which the examiner may hook a finger. WebA UCL tear can be diagnosed through a history and physical examination. At the upper end of the ulna is the olecranon, the bony point of the elbow that can easily be felt beneath the skin. Biceps tendinopathy is a relatively common source of pain in the anterior elbow; history often includes repeated elbow flexion with forearm supination and pronation. It runs from the inner side of the humerus to the inner side of the ulna and must withstand extreme stresses as it stabilizes the elbow during overhand throwing. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, University of Pittsburgh Physicians, Department of Orthopaedic Surgery, Bankart Repair with capsular plication- Arthroscopic, Latarjet Procedure for Glenoid Deficit - Open, Bankart Repair with Remplissage Procedure - Arthroscopic, Bankart Repair - Arthroscopic - Dr. Stephen Snyder, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Pro: Facts: The Performance On The Field After Nonop Versus Surgery For Anterior Shoulder Instability & No Bone Loss - Kevin E. Wilk, PT, DPT, FAPTA, Pro: Nonoperative Treatment Will Do Just Fine - Ellen Shanley, PhD, PT, OCS, Pro: Fix it Now: My Indications For Surgery In This Patient - Raffy Mirzayan, MD, Shoulder & Elbow Traumatic Anterior Shoulder Instability (ft. Dr. Anthony Romeo), Shoulder & ElbowTraumatic Anterior Shoulder Instability (TUBS), Question SessionTraumatic Anterior Shoulder Instability (TUBS), Bony Bankart fracture in nondominant shoulder, Recurrent Shoulder Instability s/p Bankart Repair in 21M. Wartenberg sign (the inability to adduct the little finger), a clawhand deformity, and flexion of the proximal interphalangeal joint and the distal interphalangeal joint of the ring and small fingers may also be present (Table 23,7,8,11,1317 ). Active Radiocapitellar Compression Test. WebLittle league elbow refers to a continuous spectrum of injuries to the medial side of the elbow seen in adolescent pitchers, which includes: medial epicondyle stress fractures, ulnar collateral ligament (UCL) injuries and flexor-pronator mass strains. This is an AAOS Self Assessment Exam (SAE) question. On examination 3 days later, he has weakness in the deltoid. Eventually, the fatigued muscle transfers the overload of stress to the bone, causing a tiny crack called a stress fracture. The abnormal bone growth of VEO is apparent in these illustrations of the back of the elbow and inner side of the elbow. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. Copyright 2022 Lineage Medical, Inc. All rights reserved. The bones, major nerves, and ligaments are highlighted. (OBQ07.80) What is the most likely finding seen at the time of arthroscopy? Golfers Elbow Test. He admits to multiple previous shoulder dislocations in the past which were treated conservatively with physical therapy. (OBQ10.68) Reproduced and adapted with permission from J Bernstein, ed: Musculoskeletal Medicine. Examination reveals a positive apprehension test. The purpose of todays post is to review some of the special tests for the elbow exam that all members of the sports medicine team should be familiar with. He sustained the injury shown in Figure A three weeks ago after trying to catch himself as he fell off a dock. Occasionally, separation of the osteochondral fragment may occur, resulting in a loose body. Superior border is defined by the biceps long head tendon, Inferior border is defined by anterior band of inferior glenohumeral ligament, Contains the axillary pouch which is a common site for intra-articular loose bodies, Superior border is defined by anterior edge of supraspinatus tendon, Inferior border is defined by middle glenohumeral ligament. insertion. This graft acts as a scaffolding for a new ligament to grow on. Reproduced with permission from Miller CD, Savoie FH III: Valgus extension injuries of the elbow in the throwing athlete. WebValgus Extension Overload (Pitcher's Elbow) anterior shoulder pain with resisted forearm supination with the arm at the side and the elbow flexed to 90 degrees. ; Foot and ankle our experts will investigate your foot problem and restore stability, whether it's through rehab or foot or ankle surgery. Pain is also frequently brought on by bending the foot and toes up towards the shin. Sports Medicine Review is a website dedicated to all things primary care sports medicine. Absence of this motion indicates a complete tear. What is the most likely cause of the recurrent instability? WebValgus Extension Overload (Pitcher's Elbow) Multidirectional shoulder instability (MDI) is a condition characterized by generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy. It consists of two portions, an anterior and posterior united by a thinner intermediate portion. Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. Rotator cuff; http://www.youtube.com/watch?v=plk7G2s8V30. A 21-year-old rugby player has recurrent pain and instability of the right shoulder recalcitrant to conservative management. Elbow joint. A positive test is reproduction of the pain. It may be superior to MRI in detecting soft tissue calcification, such as myositis ossificans or intra-articular bodies. When athletes throw repeatedly at high speed, the repetitive stresses can lead to a wide range of overuse injuries. His medical history is significant for Crohn's disease which is controlled medically with prednisone therapy during flares. An acceptable recurrence risk of 10% with arthroscopic stabilization. Clinical examination is remarkable for a postive apprehension sign and a positive sulcus sign. Which of the following provocative maneuvers indicates the most common associated pathology in this age cohort? Shoulder & Elbow - Adhesive Capsulitis (Frozen Shoulder) Listen Now 15:40 min. Started in 1995, this collection now contains 7146 interlinked topic pages divided into a tree of 31 specialty books and 738 chapters. X-rays. A similar condition exists in older persons with osteoarthritis. Problems most often occur at the inside of the elbow because considerable force is concentrated over the inner elbow during throwing. They may also evaluate the athlete's shoulder. If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered. Pain and decreased strength with resisted gripping and with wrist supination and extension are often present.22, There is some controversy about whether radial tunnel syndrome and posterior interosseous nerve syndrome are two separate entities or a continuum of the same condition. Accessed December 2012. She has not previously sought treatment. These scans are not typically used to help diagnose problems in throwers' elbows. This information is provided as an educational service and is not intended to serve as medical advice. When the elbow is bent, the ulnar nerve stretches around the bony bump at the inner end of the humerus. Joint fracture, with marked cubitus varus or cubitus valgus . He now complains of symptoms of repetitive instability and a "catching" feeling whenever he abducts and externally rotates his arm. A 24-year-old football player presents with recurrent shoulder instability. Labral tear involving the biceps attachment, An inverted pear-shaped glenoid on arthroscopy. 5.0 (3) See More See Less. Pain during resisted pronation is the most sensitive physical examination finding. is present in 80%-100% of traumatic dislocations and 25% of traumatic subluxations, is not clinically significant unless it engages the glenoid, is associated with anterior dislocation in patients > 50 years of age, is associated with posterior dislocations, is most often a transient neurapraxia of the axillary nerve, global hyperlaxity (i.e. ankylosis. instability with valgus stress notes more severe involvement. This hyperpronation imparts a medial rotatory force to the ulnohumeral joint. Ulnar neuritis can also occur in non-throwers, who frequently notice these same symptoms when first waking up in the morning, or when holding the elbow in a bent position for prolonged periods. The posterior portion, also of triangular form, is attached, above, by its apex, to the lower and back part of the medial epicondyle; below, to the medial margin of the olecranon. Physical examination reveals maximal tenderness approximately 1 cm distal to the epicondyle at the origin of the extensor carpi radialis brevis. In many cases, overuse injuries develop when an athletic movement is repeated often during single periods of play; when these periods of play (including games and practices) are so frequent, the body does not have enough time to rest and heal. (OBQ07.259) The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments. 4.7 (6) See More See Less. 10/15/2019. (SBQ11UE.106) The patient cant be seated or standing. Pivot-shift is not straightforward to perform. Note that this ligament is also referred to as the medial collateral ligament[1] and should not be confused with the lateral ulnar collateral ligament (LUCL).[2]. Tenderness over the UCL has a sensitivity of 81% to 94%, but a specificity of only 22% for UCL tears.11, The most important examination for a possible UCL injury is assessment of the medial joint space laxity or instability against valgus forces. Patients with septic olecranon bursitis present with pain, swelling, warmth, and erythema over the olecranon; roughly one-half will have a fever. The results of these tests help the doctor decide if additional testing or imaging of the elbow is necessary. Which of the following patients is most likely to have a fibroblastic proliferative process as a cause for their shoulder complaints? History of contralateral shoulder dislocation, Young age (<20-years-old) at time of dislocation. 55% (695/1258) 2. anteroinferior aspect of medial epicondyle. All material on this website is protected by copyright. The doctor will ask the athlete to identify the area of greatest pain, and will frequently use direct pressure over several distinct areas to try to pinpoint the exact location of the pain. In general, a thorough physical examination will include inspection, palpation, active and passive range of motion, strength, neurovascular and special tests. What factor has highest risk for recurrent instability following a traumatic anterior shoulder dislocation? A positive test is pain or discomfort along the medial epicondyle or common flexor tendon. This stress causes impingement of the olecranon tip in the olecranon fossa, which may cause osteophyte formation and a fixed flexion deformity over time. She elects arthroscopic treatment. (OBQ09.143) About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an Orthopaedist. WebValgus Extension Overload . What nerve is the most frequently injured in the condition shown in the radiograph? He has continued to have recurrent instability. In most cases, treatment for throwing injuries in the elbow begins with a short period of rest. It is a combination hinge and pivot joint. A 61-year-old male presents to your office for evaluation of his right shoulder. SHAWN F. KANE, MD, JAMES H. LYNCH, MD, MS, AND JONATHAN C. TAYLOR, MD. origin. Humeral avulsion of the glenohumeral ligament (HAGL lesion) stabilization and EMG/NCV studies, Immobilization in sling with external rotation and EMG/NCV studies, Anterior labral periosteal sleeve avulsion (ALPSA) stabilization, Transfer of the infraspinatus tendon and greater tuberosity to the humeral head. 994 plays. Elbow injuries in throwers are usually the result of overuse and repetitive high stresses. While maintaining constant valgus torque on the elbow, the elbow is quickly flexed and extended. There are both non-surgical and surgical treatment options.[4]. What is the best treatment option? If surgery is required, however, recovery may take much longer, depending upon the procedure performed. Which of the following interventions would best mitigate the chances of her developing the most common complication of surgical treatment? Web(OBQ12.204) A 44-year-old left-hand dominant carpenter experienced immediate left elbow pain after trying to stop a heavy object from falling two days ago. is present in 80-90% of patients with TUBS, humeral avulsion of the glenohumeral ligament (HAGL), occurs in patients slightly older than those with Bankart lesions, associated with a higher recurrence rate if not recognized and repaired, an indication for possible open surgical repair, is a sheared off portion of articular cartilage along with the labrum, anterior labral periosteal sleeve avulsion (ALPSA), can cause torn labrum to heal medially along the medial glenoid neck, associated with higher failure rates following arthroscopic repair, common finding in patients with recurrent instability managed nonoperatively, 97% of patients with recurrent instability have either a Bankart or ALPSA lesion, is a fracture of the anterior inferior glenoid, present in up to 49% of patients with recurrent dislocations, higher risk of failure of arthroscopic treatment if not addressed, defect >20-25% is considered "critical bone loss" and is biomechanically highly unstable, stability cannot be restored with soft tissue stabilization alone (unacceptable >2/3 failure rate), requires bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft), suggest critical bone loss may be as low as 13.5%, each dislocation event causes, on average, 6.8% bone loss, glenoid takes on an inverted-pear appearance as bone loss increases, 89% failure rate following arthroscopic repair in patients with this glenoid morphology. In some cases, if the ligament is in good condition but is torn at the bony attachment, it can be reattached to the arm, eliminating the need for a graft. For cubital tunnel, tapping or pressing against the cubital tunnel can recreate the symptoms if an ulnar neuropathy is present. In cases of ulnar neuritis, the nerve can be moved to the front of the elbow to prevent stretching or snapping. (OBQ05.42) 50-year-old woman with hypothyroidism and loss of both active and passive shoulder motion. It controls the muscles of the hand and provides sensation to the small and ring fingers. deformity or with ununited fracture of head of radius 20 20. Isolated posterior capsular tightness; Hemoglobin A1C 11.7%, Isolated posterior capsular tightness; TSH 15 mU/L, Fibroblastic proliferation of joint capsule; Hemoglobin A1C 11.7%, Decreased blood supply to humeral head leading to bony matrix cell death; TSH 15 mU/L, Chronic degenerative tear of shoulder-stabilizing tendons; Hemoglobin A1C 11.7%. Arthroscopy. The examiner places one hand on the common extensor tendon and one hand on the middle finger in a neutral position. Elbow pain with supination which improves with pronation is also considered a positive finding. This stretching or snapping leads to irritation of the nerve, a condition called ulnar neuritis. WebThis finding is consistent with the anterior glenohumeral instability found in many throwing athletes and emphasizes the importance of proper mechanics throughout the entire kinematic chain . The moving valgus stress test (Figure 4) has a 100% sensitivity and a 75% specificity for diagnosing UCL injuries (Table 23,7,8,11,1317 ). He has had 2 anterior dislocations of his throwing shoulder, both of which were able to be reduced on the pool deck. This pain is worst during throwing or other strenuous activity, and occasionally occurs during rest. They will often limit the ability to throw or decrease throwing velocity. The elbow is held in 20 flexion, one hand supporting the elbow with the humerus somewhat externally rotated. Magnetic resonance imaging (MRI) or musculoskeletal ultrasonography can be used to demonstrate continuity and changes in caliber of the tendon.4. WebWhile maintaining internal rotation, a valgus force is applied to the knee while it is slowly flexed. the MCL provides resistance to valgus and distractive stresses. Patients with biceps tendinopathy may present with vague anterior elbow pain. The patient's occupation and recreational activities can be important clues to diagnosis. acts as a lever arm when positioning the hand, 40% of weight is through ulnohumeral joint, 60% of weight is through radiohumeral joint, the shaft for humerus has a spiral groove posteriorly (contains radial nerve), this lies approximately 13 cm proximal to the articular surface of trochlea, the distal flare of humerus includes the medial and lateral epicondyles, the flare accounts for half of the elbow joint, the sublime tubercle on the ulna is where the anterior bundle of the medial ulnar collateral ligament attaches distally, distal humerus contains medial and lateral column, the joint surface is anteriorly tilted approximately, it passes through anteroinferior medial epicondyle, radial head is covered by cartilage for approximately 240 degrees, the lateral 120 degrees contains no cartilage, this is crucial for internal fixation of radial head fractures, coronoid fossa on distal humerus receives the coronoid tip in deeper flexion, the coronoid tip has a buttress effect in the prevention of posterior dislocations, distal attachment of anterior capsule is found 6 mm distal to tip of coronoid, the distal biceps attachment is at the level of the radial tuberosity, the attachment of the brachialis 11 mm distal to the tip of the coronoid, loss of 50% or more of coronoid height results in elbow instability, the MCL is composed of the anterior, posterior and transverse bundles, the MCL provides resistance to valgus and distractive stresses, anteroinferior aspect of medial epicondyle, sublime tubercle of medial coronoid process, most important restraint against valgus stresses, the posterior bundle forms the floor of the cubital tunnel, primary restraint to valgus stress in maximal elbow flexion, if this is contracted, flexion may be limited, lateral collateral ligament complex (LCL), primary restraint to varus and external stress during full arc of elbow motion, some believe that the the accessory collateral ligament and the radial collateral ligament contribute substantially to lateral elbow stability, provides stability to the proximal radioulnar joint, the LCL arises from isometric point on lateral aspect of capitellum, optimal stability is conferred with an appropriately tensioned LCL repair, this functions as an important constraint to valgus stress, the radial head provides approximately 30% of valgus stability, this is most important at 0-30 deg of flexion/pronation, greatest contribution the capsule on stability occurs with the elbow extended, origins of the flexor and extensor tendons, it exits laterally, distal to the biceps tendon, it will terminate as the LABC (forearm), which is found deep to the cephalic vein, it leaves the triangular interval (teres major, long head of triceps and humeral shaft), found in spiral groove 13 cm above the trochlea, pierces lateral intermuscular septum 7.5 cm above the trochlea, this is usually at the junction of the middle and distal third of the humerus, lies between the brachialis and the brachioradialis, distally it is located superficial to the joint capsule, at the level of the radiocapitellar joint, medial/lateral cords of the brachial plexus, it courses with brachial artery, running from lateral to medial, lies superficial to brachialis muscle at level of elbow joint, runs medial to brachial artery, pierces medial intermuscular septum (at the level of the arcade of Struthers) and enters posterior compartment, it traverses posterior to the medial epicondyle through the cubital tunnel, first motor branch to FCU is found distal to the elbow joint, contents-- biceps tendon (lateral), brachial artery, median nerve (medial), at the level of elbow it splits into the radial and ulnar arteries, the axis of rotation is found at the center of trochlea, pronation (pronator teres and quadratus) & supination (biceps and supinator), the axis of motion is found at the capitellum through to the radial/ulnar heads, there are large joint reaction forces due to short and inefficient lever arms around elbow (biceps inserts not far from center of rotation), this contributes to degenerative changes of the elbow, is a line through isometric points on the capitellum about trochlea, the axis of pronation / supination is a line drawn from capitellum, through radial head, to distal ulna, Free body diagram demonstrate inefficiencies of elbow, Dynamic loads are greater than body weight, one elbow in 110 of flexion for feeding, one elbow in 65 of flexion for perineal hygiene, Intra-articular injection best given in soft spot formed by, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. The ulnar nerve crosses the elbow joint right behind the bony prominence on the inner aspect of the elbow. A 19-year-old right hand dominant male high school wide receiver complains of recurrent right shoulder subluxation. Magnetic resonance imaging is shown in Figures A and B. Anti-inflammatory medications. Anterior view. To recreate the stresses placed on the elbow during throwing, the doctor will perform the valgus stress test. Oct 2022 . She has significantly limited right shoulder active and passive range of motion (ROM) in all planes but full left shoulder active and passive ROM. up to 80-90% in teenagers (90% chance for recurrence in age <20), anteriorly directed force on the arm when the, shoulder is abducted and externally rotated, "on-track" versus "off-track" concept of Hill-Sachs lesion (instability as a bipolar concept), Hill-Sachs defect is "off-track" and will "engage" on the glenoid if the size of the Hill-Sachs defect > glenoid articular track (HSI > GT), conversely, the Hill-Sachs defect is "on track" and will NOT "engage" if the size of the Hill-Sachs defect < glenoid articular track (HSI < GT), Glenoid Track (GT) = 0.83D-d (D = diameter of inferior glenoid, d = width of anterior glenoid bone loss), Hill-Sachs Interval (HSI) = HS+BB (HS = width of the Hill-Sachs, BB = width of bony bridge), may have implications regarding surgical management, goal is to convert on off-track lesion into an on-track lesion. Elbow Varus Stress Test. The elbows are placed at 90 flexion, forearms supinated, arms abducted greater than shoulder width. If an ulnar collateral ligament injury is suspected, the medial joint space of the symptomatic elbow should be compared with the asymptomatic side for the amount of opening, the subjective quality of the end point while a valgus force is applied across the joint, and pain. A 47-year-old woman presents with concerns of chronic right shoulder pain and stiffness without antecedent trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003. [3] Acute or chronic disruption and/or attenuation of the ulnar collateral ligament often result in medial elbow pain, valgus instability, neurologic deficiency, and impaired throwing performance. The elbow is a complex joint designed to withstand a wide range of dynamic exertional forces. Throwing Injuries in the Elbow in Children. Based on his MRI shown in Figure B, what structure is torn, what is the eponym for this lesion, and at what position does it most contribute to stability? A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. A neurapraxic musculocutaneous nerve injury, An axonotmetic musculocutaneous nerve injury. This ligament is in relation with the triceps brachii and flexor carpi ulnaris and the ulnar nerve, and gives origin to part of the flexor digitorum superficialis. The milking maneuver (Figure 5) can provide additional information on the possible presence of a UCL injury. The patient patient actively extends their forearm against resistance. Physical examination typically reveals a positive Tinel sign at the radial tunnel. The point of maximal tenderness is usually at the insertion of the flexor-pronator mass, 5 to 10 mm distal and anterior to the medial epicondyle. The physical examination of the elbow should include a standardized exam approach as well as a series of special tests to help diagnose the cause of the patients elbow pain. Elbow Valgus Stress Test. Ulnar collateral ligament injuries occur in athletes participating in sports that involve overhead throwing. Which of the following is a known risk factor for the development of adhesive capsulitis of the shoulder? Webstand behind patient, flex elbow to 90, hold shoulder at 20 elevation and 20 extension. To avoid introducing infection, aspiration of olecranon bursitis should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases. 65-year-old woman with ulnar drift of the fingers and shoulder pain and stiffness. J Am Acad Orthop Surg 1994; 2:261-269. He denies any trauma or prior shoulder problems, and has good rotator cuff strength. Knees, as seen from front, showing normal valgus alignment of tibiofemoral articulation. 2022. Olecranon bursitis is a common cause of posterior elbow pain and swelling. He works as a lawyer and has been treating the pain with non-steroidal anti-inflammatory drugs with little improvement. Shoulder & ElbowMultidirectional Shoulder Instability (MDI) Elbow In many cases, pain will resolve when the athlete stops throwing. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. Overhand throwing places extremely high stresses on the elbow. Computed tomography (CT) scans. Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions, rather than the larger incision needed for standard, open surgery. During activities such as overhand baseball pitching, this ligament is subjected to extreme tension, which places the overhand-throwing athlete at risk for injury. (OBQ07.252) Decreased range of motion compared to contralateral shoulder, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Cleveland Combined Hand Fellowship Lecture Series 2018-2019, Shoulder Stiffness - Inyang Udo-Inyang, MD, 2017 Orthopaedic Summit Evolving Techniques, Case Presentations with Questions and Answers - Moderator: Brian J. Cole, MD, MBA & Claude T. Moorman, III, MD, My Shoulder is Stiff: I Would Rather Be Weak Than Stiff Doc, I Am Not Happy - Felix H. Buddy Savoie, III, MD, Shoulder & Elbow | Adhesive Capsulitis (Frozen Shoulder). During this test, the doctor holds the arm still and applies pressure against the side of the elbow. Other specialized physical examination maneuvers may be necessary, as well. (OBQ13.165) Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Repeat the test with forearms in pronation. Injuries of the UCL can range from minor damage and inflammation to a complete tear of the ligament. Patients have pain and tenderness over the affected tendinous insertion that are accentuated with specific movements. A positive test is elbow pain during forearm rotation. Medial epicondylitis is much less common than lateral epicondylitis and typically occurs in athletes or workers who participate in activities that involve repetitive valgus stress and flexion at the elbow, as well as repetitive wrist flexion and pronation. Then, the patient is asked to return the hand to the supinated position against resistance. MRI is also useful in identifying a stress fracture that is not visible in an X-ray image. (OBQ10.63) Taller and heavier pitchers, pitchers who throw with higher velocity, and those who participate in showcases are also at higher risk of injury. (OBQ05.5) The patient is asked to perform a pushup from the floor. The hinge part of the joint lets the arm bend and straighten; the pivot part lets the lower arm twist and rotate. Throwing mechanics can be evaluated in order to correct body positioning that puts excessive stress on the elbow. Which of the following ligaments is injured? is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid. Which nerve is most likely to be injured? Pronate and supinate the forearm while maintaining axial force. A 24-year-old male gymnast is scheduled for arthroscopic repair of the right shoulder. This is sometimes called the middle finger extension test. (OBQ06.256) She has tried non-steroidal anti-inflammatory drugs, but they have not alleviated her pain. (OBQ18.210) Webloss of 50% or more of coronoid height results in elbow instability. Which of the following is the MOST appropriate next step in management. Web(OBQ11.78) A 66-year-old male presents with a three-month history of increasing right shoulder pain. WebTraumatic Anterior Shoulder Instability, also referred to as TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery), are traumatic shoulder injuries that generally occur as a result of an anterior force to the shoulder while its abducted and externally rotated and may lead to recurrent anterior shoulder instability. is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim. - Jeffrey R. Dugas, MD, 7th Annual Frontiers in Upper Extremity Surgery, DES/IJS Managing the Unstable Terrible Triad - Jorge Orbay, MD, Shoulder & Elbow | Elbow Anatomy & Biomechanics. The elbow is held in sight flexion at 20 with one of the examiners arms on medial side of the elbow. Ehlers-Danlos Syndrome, collagen disorders), often associated with atraumatic instability, global hyperlaxity confers an odds ratio (OR) of 2.68 for the development of anterior shoulder instability, individuals with global hyperlaxity have a 3x higher rate of recurrent instability, patients with global hyperlaxity are less likely to develop capsulolabral lesions, labrum contributes 50% of additional glenoid depth, Anterior static shoulder stability is provided by, Anteroposterior Translation Grading Scheme, Humeral head translation up to glenoid rim, Humeral head translation over glenoid rim with spontaneous reduction once force withdrawn, Humeral head translation over glenoid rim without spontaneous reduction. Resisted Active Forearm Extension Test. Web(OBQ18.137) A 20-year-old male college-level thrower complains of chronic right shoulder pain and has been prescribed formal physical therapy with stretches consisting of laying in the lateral position on the affected side with your arm forward flexed 90, elbow flexed 90, and pushing the ipsilateral forearm towards the table. A preoperative MRI of the right elbow is found in Figure A. Superior labrum anterior posterior (SLAP) tear, Supraspinatus partial articular sided tendon avulsion (PASTA). ASES Podcast. A 23-year-old offensive lineman had an arthroscopic anteroinferior labral repair 1 year ago for shoulder instability. Which of the following is the most common outcome following non-operative management of adhesive capsulitis with a stretching program? Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. The physician pulls on the patients thumb. Compared with MRI, computed tomography has a limited role in the evaluation of chronic elbow pain. can show increased T2 signal, and displacement out of the bicipital groove. In addition to the pathology seen in Figure A, what other associated intra-articular condition is most likely present? Magnetic resonance imaging (MRI) scans. Table 1 provides the differential diagnosis of elbow pain by anatomic location. All rights reserved. A MRI will most likely show which of the following? Apply an axial force down the arm. However, he feels the shoulder is still unstable and cannot return to play at his desired level. Several muscles, nerves, and tendons (connective tissues between muscles and bones) cross at the elbow. post-traumatic (following proximal humerus fracture or immobilization for other upper extremity injury), post-surgical (following rotator cuff repair or axillary dissection for malignancy), inflammatory process causing fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus, fibroblasts/myofibroblasts with abundant Type III collagen present, stiffness may be first manifestation of diabetes and warrants further workup, increased risk with older age, increased duration of DM, autonomic neuropathy, history of MI, contribute to stability of the glenohumeral joint, act as check reins at extremes of motion in their non-pathologic state, inferior glenohumeral ligament (IGHL) complex with the following components, a triangular region between the anterior border of supraspinatus and the superior border of subscapularis, Gradual onset of diffuse pain (6 wks to 9 months), Decreased ROM affecting activities of daily living (4 to 9 months or more), Gradual return of motion (5 to 26 months), Capsular contraction and fibrinous adhesions, Increasing contraction, synovitis resolving, variable character and severity of pain, loss of motion dependent on the stage of disease at presentation, freezing- insidious onset of pain at rest and with movement, difficulty sleeping, frozen- pain lessens but significant motion limitations affecting ADLs, thawing- pain is gone and motion improves but less than normal, note any muscle atrophy or scars denoting prior surgery, document all motion planes and compare to contralateral side, pain throughout motion arc or at terminal motion depending on stage of disease, impingement, biceps, and SLAP maneuvers often positive, rotator cuff testing may be limited given loss of motion, Metabolic panel and endocrine labs (TSH, A1c), must be obtained to evaluate for osteoarthritis, posterior dislocation, or surgical hardware, not necessary for diagnosis but can evaluate for other pathology, physical therapy program of gentle, pain-free, should be supervised and last for 3-6 months, failure to improve with non-operative modalities, controversial if done during freezing/inflammatory phase, after extensive therapy has failed (3 months), arthroscopy will spare subscapularis tendon with the advantage of releasing intra-articular and subacromial adhesions, daily progressive stretching exercises to point of pain, in-dwelling catheter for regional anesthesia often used to aid in therapy, steady force applied after full muscle paralysis achieved, fracture, dislocation, rotator cuff and labral tears, standard skin incisions with portal placement slightly higher than normal given contracted and thickened capsule, intra-articular structures may be obscured by adhesions and contractures, coracohumeral ligament can then be visualized and released, subacromial bursectomy and adhesions released as needed, no acromioplasty done, MUA may be done before or after release to increase to range of motion, perform inferior release near to glenoid rim, Proximal humerus fracture, dislocation, rotator cuff tears or brachial plexopathy, following overzealous manipulation with osteoporotic bone, After surgical treatment, gains in range of motion and improved function are maintained at long-term follow, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. Instability causes repeated and unnatural wear and tear leading to early onset of osteoarthritis. You may feel locking or catching from loose bodies. A 20-year-old female presents with recurrent anterior shoulder instability. The normal anatomy of the elbow joint shown from the side closest to the body. Although a change of position or even a change in sport can eliminate repetitive stresses on the elbow and provide lasting relief, this is often undesirable, especially in high level athletes. can give dynamic test of bicep instability. Plain radiography also has a role in the evaluation of chronic conditions such as enthesopathy, bone spurs, and osteochondral diseases.18 At a minimum, anteroposterior and lateral plain radiography should be performed at the initial visit.37. The ligament on the inner part the elbow (closer to the body) is the ulnar collateral ligament. What is the most likely diagnosis? The flexor/pronator muscles of the forearm and wrist begin at the elbow and are also important stabilizers of the elbow during throwing. A Laterjet procedure is planned for the patient. (OBQ09.136) A positive test is reproduction of the pain at the lateral epicondyle or common extensor tendon. A slight modification of the test involves performing the exam with the patients hand flat on the table (pictured). A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Plain radiography is the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and joint effusions. Adhesive capsulitis (also known as frozen shoulder) is a, condition of the shoulder characterized by. A positive test is apprehension when the elbow is terminally extended from a flexed position with voluntary and involuntary guarding or complete dislocation. After a full evaluation, you determine she has adhesive capsulitis, and is in the early stiffening stage. Reproduced with permission from Ahmad CS, ElAttrache NS: Elbow valgus instability in throwing athletes. Which patient would be ideal for an open shoulder reduction and glenoid bone augmentation? WebWright leads the way with an impressive history of ground-breaking products for the foot and ankle industry. WebPlantar fasciitis or plantar heel pain (PHP) is a disorder of the plantar fascia, which is the connective tissue which supports the arch of the foot. He reports a history of multiple subluxations in the past, but this is the first time he had to "pop" his shoulder back into place. Pitchers who throw with arm pain or while fatigued have the highest rate of injury. This content is owned by the AAFP. Understanding the anatomy and the physical forces of movement will aid in diagnosis.2, The biceps tendon is a relatively common source of pain in the anterior elbow. In some cases, an injection of platelet-rich plasma (PRP) can be beneficial in patients with partial tearing of the UCL. Copyright 2014 by the American Academy of Family Physicians. This website also contains material copyrighted by third parties. Weakness in extensor muscles dorsally can also be seen. On physical examination, the patient will have posterior elbow pain when forced into full elbow extension.27, Table 3 summarizes key aspects of the diagnosis and treatment of selected causes of elbow pain.4,14,15,17,2436, Plain radiography is the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and joint effusions. Below is the preoperative MRI from 1 year ago. Superior labrum tear from anterior and posterior (SLAP), Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA), Partial articular-sided supraspinatus tendon avulsion (PASTA). It is a tendinopathy of the common flexor tendon, usually the flexor carpi radialis and the pronator teres.1,5, Patients typically report the insidious onset of pain at the medial elbow with or without accompanying grip-strength weakness. We will review some of the more commonly used exam techniques but it is worth mentioning there are dozens of others that are not covered here. He is noted to have anterior glenoid bone loss and a coracoid transfer (Latarjet) procedure is recommended. If the condition exists for an extended period of time, weakness of the intrinsic muscles of the hand may develop.19 Patients may also have nighttime pain from sleeping with the elbow fully flexed. His current radiograph is shown in Figure A. Increasing the glenoid bony support and excursion distance prior to dislocation. A patient sustains the injury seen on the radiograph in Figure A. Internally rotate shoulder to near maximum holding the wrist by passively lifting the dorsum of the hand away from the lumbar spine then supporting the elbow, tell patient to maintain position and release the wrist while looking for a lag. As with other musculoskeletal problems, the keys to diagnosing elbow pain are a history to include mechanism of injury or exacerbating movements, and a focused physical examination. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. from the American Academy of Orthopaedic Surgeons. Shoulder & ElbowSubacromial Impingement Shoulder & Elbow - Subacromial Impingement; Listen Now 12:40 min. What is the diagnosis? Copyright 2022 Lineage Medical, Inc. All rights reserved. A 60 year-old diabetic man presents with increasing right shoulder pain and stiffness for 10 weeks. Diagnosis is confirmed by bursal fluid analysis.25 By contrast, patients with aseptic olecranon bursitis may present with a history of minor trauma to the elbow and a boggy, nontender mass over the olecranon without redness, warmth, limited range of motion, or other signs of infection.26 Because aspiration of bursae can be associated with complications such as introducing infection, this should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases.24, Tendinopathy at the triceps insertion occasionally occurs in weight lifters or industrial workers in whom repetitive elbow extension against resistance is required. 40-year-old woman with antinuclear antibodies with knee and shoulder pain. This special maneuver is used to diagnose a series of neuropathies, most commonly carpal tunnel syndrome. The other hand is on the forearm applying valgus stress. A 17-year-old basketball player presents to your office with persistent shoulder soreness following a fall during a game 2 months ago. He undergoes arthroscopic Bankart repair and re-dislocates his shoulder within 1 month after surgery. The patients elbow is fully extended. (SBQ11UE.31) Our goal is to help generate a community that fosters original ideas and content for medical students, residents, fellows and attendings interested in or involved in sports medicine. What is the most common finding during surgery for traumatic anterior shoulder instability? Orthopaedic Knowledge Online Journal 2004. UCL injuries commonly occur in athletes participating in sports that involve overhead throwing, such as baseball, javelin, and volleyball.7-9 Injury to the UCL results in significant valgus elbow instability and may predispose an athlete to secondary injuries.8,10, The history should include questions about the onset of pain, what the patient was doing when the pain started, sports played, and the frequency of participation. X-rays provide clear pictures of dense structures, like bone. A score of > 6 points has an unacceptable recurrence risk of 70% and should be advised to undergo open surgery (i.e. A valgus stress test, during which a physician tests your elbow for instability, is the best way to assess the condition of the UCL. 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