Posts in elbow pain
Imaging's Role in Youth Baseball

In our previous blog posts we have written on the limitations of MRI for many injuries and conditions.  In general, these expensive tests have high rates of false positives where patients without pain often have positive results including ligament/labrum tears or tendon changes.  The incidence of false of positives increases in athletes with the majority of major league baseball players, regardless of symptoms, demonstrating rotator cuff tears or labrum injury.   It appears these changes are no different in our little leaguers.  

An article in the Journal of Bone and Joint Surgery examined 10-13 year old little league baseball players.  Each player underwent an MRI on both elbows at the start of the season.   The authors found many of the players with or without pain had imaging findings in their elbow.  Adding to our existing data that many athletes have positive MRI findings without pain or injury.  Two factors were associated with a positive MRI and elbow pain including year round baseball play and working with a private pitching coach.  

Athletes are encouraged to work with a local Physical Therapist to treat their elbow pain and reduce their risk of throwing injuries. 

The Impact of Core and Leg Muscle Fatigue on Baseball Throwing Mechanics

As we move into Spring we begin to see our youth athletes return to the baseball diamond often with a sudden increase in practice volume.  The sudden increase in throwing volume, either in the field or on the mound, places the athlete's shoulder and elbow at greater risk of baseball injuries. The greatest risk factors for injury include throwing more than 80 pitches/game, playing baseball greater than 8 months/year, and pitching with arm fatigue. As discussed in our prior posts, an athlete's throwing velocity is driven by their legs strength and power. Athletes with leg weakness are more likely to suffer from progressive changes in performance and increased injury risks.

A recent study in the Orthopedic Journal of Sports Medicine authors analyzed the impact of fatigue on throwing velocity, accuracy, and throwing mechanics (Chalmers et al. 2016). Authors studied 28 elite adolescent (13-16 year old) pitchers as they pitched a simulated game (90 pitches). Each pitch was analyzed for velocity and accuracy while every 15th pitch was analyzed for pitching mechanics. As expected the velocity, accuracy, and mechanics suffered with increased pitch counts. Importantly, the authors showed the loss of velocity, accuracy, and biomechanics were preceded first by core and leg muscle fatigue.

This study adds to the importance of controlling pitch counts and treating the lower extremities in order to improve throwing performance and reduce injury risk.  

Improving Throwing Velocity Through Leg Strengthening
leg-strengthening-baseball-arm-injury

In our practice, we commonly see adolescent baseball athletes suffering from shoulder and elbow injuries.  On average 1 in 2 youth throwers will develop arm injuries and on average major league throwers lose 22 days per season due to arm injury (Conte et al. 2001).  These injuries are mainly overuse in nature secondary to muscle imbalances, skeletal immaturity in youth, and poor pitching mechanics.  In particular, the majority of these athletes are throwing primarily with their arms and not taking advantage of the power generated by the lower body during the pitching sequence.  Injured throwers may also present with lower extremity weaknesses leading to increased arm stresses during pitching.

Baseball pitching is a whole body movement pattern requiring coordinated movement and strength from multiple joint regions in legs and arm described as the kinetic chain.  In pitching, the kinetic chain allows the transfer of power through a series of body regions from the feet through the throwing hand (Pappas, 1995).   Kibler et al. stated proximal stability (foundation) allows for effective distal mobility and acceleration of the arm (2006).  Effective utilization of the kinetic chain is responsible for fastballs exceeding 100 mph.  Major league throwers with the highest velocity, accuracy, stamina, often have the greater leg strength and power compared with lessor pitchers. 

boulder physical therapy, leg strength and pitching

Prior research has demonstrated up to 50% of a thrower’s velocity is produced by the lower body (Calbrese et al. 2013).  We also know the utilization of this strength in a pitching movement, either a lateral or forward hop, is directly related to pitching velocity (Lehman et al. 2013, Nakata et al. 2013).  Clearly the strength and movement produced by the legs improves the ability of the arm to produce forces and movements needed in baseball.

A recent article in the Journal of Strength and Conditioning Research examined if stride forces between the foot and the ground could predict pitching velocity  (McNally et al. 2015).  The authors found contact forces during the cocking and acceleration phase of the throw was associated with increased ball velocity by the pitchers.  The throwers with the highest ground reaction forces were able to produce the fastest throws. 

boulder physical therapy, baseball injury

In short, a thrower with inadequate leg strength and mechanics is at higher risk for arm injury and limited effectiveness on the mound. 

Lateral Elbow Pain and Physical Therapy Solutions
lateral elbow pain, tennis elbow, boulder physical therapy

Elbow pain on the outside of the elbow is most common in individuals’ aged 30-50 y.o. and effects 1-3% of the general population (Shiri et al. 2006).  Risk factors for this condition include blue collar workers utilizing repetitive gripping and manipulation in the work place, smokers, and tennis athletes.  This condition has previously been described as tennis elbow or tendonitis.  The first term is a non specific umbrella term and the second has been proven to be incorrect based on our current understanding of the pathophysiology behind this condition.  Tissue sampling of the wrist and finger tendons running along the outside of the tendon has failed to show any inflammatory cells making the term lateral epicondylosis, epicondylalgia, or lateral elbow tendinopathy more appropriate. 

These terms suggest a more degenerative condition consistent with increased cellular and collagen formation (Cook et al. 2009).  Our previous blog post detailed the ineffectiveness of anti-inflammatory treatments, including NSAIDs and corticosteroid injections, for the long term management of lateral elbow pain.  In fact, corticosteroid and platelet rich plasma (PRP) injections have been shown to have poor long-term outcomes and the highest rates of recurrence among conservative treatments (Coombes et al. 2013).  Recent evidence advocates for early diagnosis and management based on an individual’s unique presentation (Coombes et al. 2015).  Differences in the clinical presentation of this condition are normal and our examination and treatment must be based on the patient’s presentation.

Clinical examination involving pain at a patient’s lateral elbow, and pain with gripping or finger and wrist extension is consistent with lateral elbow pain.  Caution is advised to rule out competing diagnoses including referral from the neck, nerve entrapment, ligament tears, and elbow instability.  Clinicians should examine surrounding areas of the body to determine their impact on pain processing and/or   

Patients with higher levels of baseline pain and disability require early interventions due to the poor long-term prognosis associated with this presentation (Smidt et al. 2006).   This patient population may also present with greater symptoms at rest including night pain interfering with sleep patterns.  Another factor often associated in patients with lateral elbow pain includes concomitant musculoskeletal complaints in the neck and shoulder.   A treatment plan aimed at treating impairments in the upper quarter, in addition to the elbow, may accelerate recovery and reduce future recurrence (Cleland et al. 2005).

manual therapy, lateral elbow pain, physical therapy

Conservative treatment remains a hallmark of lateral elbow tendinopathy.  The vast majorities of patients treated conservatively with either a wait and see approach or with Physical Therapy demonstrate improvements in pain and function at one year (Bisset et al. 2006).  The difference among treatment groups is secondary to the speed of recovery and economic impact seen in groups assigned to Physical Therapy.  Physical Therapy groups undergo a rapid improvement in the short term while the wait and see group takes up to 26 weeks to reach the same level of improvement.  This rapid improvement in symptoms leads to decreased costs due to decreased utilization of health care resources in the coming year.   The key question in the literature is what treatment should patients be provided with once they enter Physical Therapy. 

Manual therapy including spinal and extremity joint mobilization and manipulation has been shown to reduce pain processing and improve pain and function.  Pain free grip strength has immediately increased in response to these elbow interventions.  These techniques are designed to reduce pain and allow a faster transition to an exercise program. 

Exercise is one of the most important components of a treatment programs.  Upper quarter exercises have been shown to reduce time off work and future medical costs, as well as, improve work and ADL tolerance (Pienimaki et al. 1998).  Programs should gradually load the wrist extensors to restore coordination and strength to the tendon.  A more irritable patient will benefit from isometric exercise whereas a more chronic, less irritable condition will benefit from eccentric exercises.  Progression of the exercises should involve multi joint and functional movements to restore function in the upper quarter.

A recent review article suggests sub grouping patients based on their presenting signs and symptoms to best determine how to allocate these PT interventions (Coombes et al. 2015).  These authors suggest advice, NSAIDs, and a wait and see approach for patients without risk factors for long term disabiilty, low pain severity and disability.   Conversely, moderate and high risk patients with risk factors for long term disability, high pain and disability scores are most appropriate for pain medication and physical therapy interventions. 

Physical Therapy sub groups, lateral elbow pain

In conclusion, lateral elbow pain is not a homogenous condition and should be examined and treated based on an individual’s presentation for optimal outcomes. 

Shoulder Range of Motion and Risk of Injury in Professional Baseball Players

Shoulder and elbow injuries are on the rise among youth and professional baseball players.  Our previous post on baseball injuries detailed the risk of future injury if an athlete has lost range of motion in his shoulder prior to the season.  In particular, emphasis has been placed on the amount of internal rotation (hand behind lower back) in an athlete's throwing shoulder.  A common adaptation in a thrower's shoulder is to develop additional external rotation (cocking phase of throwing) and lose internal rotation (Figure A).  An important point is the athlete should maintain the same total range of motion from side to side given this adaptation (Figure B).  An at risk shoulder would have an total range of motion less than the uninvolved side.  

A recent prospective study in the American Journal of Sports Medicine examined the impact of a Professional thrower's range of motion on their injury incidence during the season.  Wilk et al. examined 296 professional pitchers for range of motion and followed these players through the upcoming season.  As expected, the authors noted significant side to side differences in their shoulder range of motion.  51 pitchers reported 75 shoulder injuries for a total of 5570 days on the disabled list and 20 surgeries were performed.  The authors found <5 degrees greater external range of motion in the throwing shoulder of pitchers made them 2 and 4 times as likely to become placed on the disabled list or undergo surgery during the season.  

A thrower requires a greater degree of shoulder external rotation than another athlete, if this adaptation is not present it may be a sign of further problems.  In particular, the total range of motion should be measured and be equal between the throwing and non throwing shoulders.  For more injury prevention information or to address risk factors for your sport contact the experts and Mend Physical Therapy. 

Lateral Elbow Pain (tennis elbow) and Physical Therapy Treatments
Lateral elbow pain and boulder physical therapy treatments

Lateral Elbow Pain and Lateral Epicondylalgia

Lateral epicondylalgia, also known as tennis elbow, is an overuse injury involving the common origin tendon of the wrist and finger extensors. Patients with this condition often report pain in the lateral elbow exacerbated by gripping, lifting, or manipu- lating objects with their hands.

Previously thought to be a condition of inflammation (lateral epicondylitis), new research shows a lack of inflammatory cells in this condition. Instead, lateral epicondylalgia is considered a degenerative condition and one of dysfunctional, immature healing of the tendon(5,6). Tendons have been shown to remodel and heal along the lines of stress from exercise and appropriate loading(7).

4-7 cases per 1000 patients experience the condition and lateral epicondylalgia has a 1-3% incidence within the general population(1,2).

The condition primarily effects the dominant arm of individuals between 35-54 years old1. Amateur tennis players, patients with poor posture, frequent computer use, and manual tasks involv- ing force and repetition are at greater risk for the condition(2).

The majority of patients reports resolution of their symptoms by 1 year but may range up to 24 months(1).

Physical Therapy interventions have been shown to accelerate this recovery process and have been shown to be more cost effective than a wait and see approach or a corticosteroid injection(9). 

Elbow Pain and Physical Therapy Treatments

elbow pain, manual physical therapy, treatments

Review articles do not support the use of Physical Therapy modalities including ultrasound and iontophoresis in the treatment of lateral epicondylalgia(4).

Corticosteroid injections have been advocated for short term relief by many studies. While experiencing early relief, patients undergoing corticosteroid injections have a higher recurrence rate (72%) compared to a wait and see (10%) or Physical Therapy treatments (4%). (3)

Recent systematic report strong evidence against the utilization of platelet rich plasma (PRP) injections in patients with lateral elbow tendinopathy(12).

Evidence reviews on the topic of lateral elbow pain advocate for a multimodal Physical Therapy treatment model including spinal and extremity joint manipulation/ mobilization, soft tissue treatments, and strengthening exercises(4,13). 

boulder manual physical therapy, elbow pain, mobilization with movement

Physical Therapy Evidence

A manual physical therapy approach combined with exercise has been shown to accelerate a patient’s recovery by reducing pain and disability in the short term. Medical evidence has also shown patients receiving this treatment approach have the lowest recur- rence rate of pain and medication use(10,11).

Conversely, poorer long term outcomes and higher recurrence rates have been documented in patients receiving corticosteroid injections(10).

Bisset et al. reported the utilization of manual therapy and exercise is superior to wait and see and corticosteroid injection at short-term follow up11. It appears PT helps accelerate recovery and is superior to a wait and see approach.

Evidence suggests treatment of the upper quarter including the cervical, thoracic, elbow, and wrist regions may provide positive effects on patient’s pain and function(14). 

physical therapy, wait and see, injection for elbow pain

When to Seek Physical Therapy Care

Patient’s with lateral elbow pain exacerbated by gripping or manipulation of the hand and wrist should be treated with a multimodal Physical Therapy treatment plan to reduce pain and disability. 

References

1. Smidt N, Lewis M, Van Der Windt DA, et al. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol 2006;33:2053–9.

2. Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006;164:1065–74.

3. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939.

4. Coombes, B. et al. A new integrative model of lateral epicondylalgia. Br J Sports Med 2009;43:252–258

5. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports 2008;18:3–15.

6. Alfredson H, Ljung BO, Thorsen K, et al. In vivo investiga- tion of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand 2000;71:475–9.

7. Riley G. Chronic tendon pathology: molecular basis and therapeutic implications. Expert Rev Mol Med 2005;7:1- 25.

8. Smidt N, Assendelft WJ, van der Windt DA, et al. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23–40.

9. Coombes, B. et al. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sp Med. 2015.

10. Coombes, B. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia A Randomized Controlled Trial. JAMA. 2013. 309(5):461-469.

11. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corti- costeroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.

12. De Vos, R. et al. Strong evidence against PRP injections for chronic lateral elbow tendinopathy. A systematic review. Br J Sp Med. 2014.

13. Fernandez-Carnero, J. et al. EXAMINATION OF MOTOR AND HYPOALGESIC EFFECTS OF CERVICAL VS THORACIC SPINE MANIPULATION IN PATIENTS WITH LATERAL EPICONDYLALGIA: A CLINICAL TRIAL. J Manipulative Ther Phys. 2011. 34(7):432-440.

14. Vicenzino, B. et al. Joint manipulation in the management of lateral epicondylalgia. A clinical commentary. JMMT. 2007. 15(1):50-56.