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CHAPTER 8:
The Elbow

The elbow is an important joint to athletes not only because of its use in so many sports, but also because it is a common source of misery, particularly in racquet and throwing sports. The elbow is actually three separate joints, consisting of the junction of the two bones of the forearm and the junction of each of these bones with the humerus, the bone of the upper arm. These three interfaces allow the elbow to bend and straighten and also to rotate, which allows you to move your hand from palm up to palm down.

      An elbow injury can also be caused by wrist problems. The muscles that control the wrist originate from the elbow's bones. So many of the problems that arise from excessive wrist strain cause pain in the elbow rather than the wrist.

TENNIS ELBOW

Tennis elbow, the most common elbow injury, is really an inflammation of the muscles of the forearm and the tendon that connects the muscles to the bones in the elbow. These muscles are used to bend the wrist backward and to turn the palm face up. When the muscles and tendon become inflamed from overuse, you feel pain on the outside of your elbow (the lateral epicondyle). The pain is worse when you try to lift things with your palm facing down, so you may have trouble picking up a coffee cup or taking a quart of milk out of the refrigerator.

      Tennis elbow also causes pain when you rotate your hand in a clockwise direction, as you would in using a screwdriver or in screwing in a light bulb. You also will feel pain when you clench or squeeze something, such as when you shake hands or hold a racquet or golf club. The pain may become so severe that it makes combing your hair virtually impossible.

      Golfers also suffer from tennis elbow, but on the nondominant side; a right-handed golfer will feel the pain in the left elbow. Pulling the club through the swing with the left wrist causes irritation in the left elbow. So a right-handed golfer who feels pain in the right arm or wrist is doing something terribly wrong during the swing.

      A tennis player most often aggravates the elbow by hitting the ball late on a backhand swing. The backhand, most players' bête noire, is an especially difficult stroke to master. When hitting the ball with your weight on your back foot, you have to compensate by mostly using your arm, and hitting late causes your elbow to be bent. You end up straining the forearm muscles and tendon. You can also get tennis elbow by turning your wrist to put more spin on the serve.

Treatment for Tennis Elbow

Once your elbow becomes inflamed, everyday activities are enough to keep it irritated. Giving up your weekly tennis game to rest your elbow is not enough to solve the problem. Treating tennis elbow requires an exercise program to increase the strength and flexibility of the forearm muscles and tendon. Once they are strong enough to withstand the stress of a bad backhand, the pain will go away and won't return.

Forearm-Strengthening Exercises

You will need a small dumbbell, 5 pounds for men and 2.5 pounds for women. The weight can be gradually increased as your strength improves.

      In addition to the strengthening exercises shown here, do Arm Curls and Reverse Arm Curls (see Chapter 6).

Elbow Flexibility Exercises

When you start the exercise program, you may feel some pain because you are overloading the elbow to make it stronger. The following flexibility exercises such as these elbow stretches will help relieve this pain.

      In a week to 10 days you should begin to feel better. You may need to use anti-inflammatory agents during those first 10 days of therapy.

"Just Say No" to Cortisone

In the past, and even now, the standard treatment for tennis elbow has been cortisone injections. This is not the best long-term treatment. Injecting an anti-inflammatory agent such as cortisone around an inflamed tendon will reduce the inflammation and ease the pain. But this doesn't address the cause of the problem, which is overstressing the forearm tendon.

      When the cortisone begins to wear off in four to six weeks, the forces that caused the tendinitis in the first place will remain, causing the pain and stress to recur, and you will need a second injection of cortisone. To remain pain-free, you will have to repeat the whole process again and again. This may be good for your doctor's bank account, but it isn't good for your elbow. Eventually, these cortisone injections can irreparably damage the tendon.

Alternative Treatments

Occasionally, I have patients who are resistant to treatment with the exercise program alone. I then use a cortisone injection to reduce the inflammation so that they can actively work on strengthening the elbow without too much pain. I use cortisone only as a last resort, not as a primary treatment for tennis elbow. I also put some patients into physical therapy, where they can exercise under supervision.

      I may also introduce deep friction massage. This is a quite painful technique in which a physical therapist applies deep thumb pressure back and forth across the tendon. The irritation causes increased blood flow to the tendon and promotes healing. Another way of increasing blood flow is electrotherapy, which passes an electric current through the tendon.

      Other modalities include iontophoresis, in which a cortisone solution is painted on the skin and then driven through to the tendon with an electric current. This concentrates cortisone around the tendon without subjecting the tendon to the damage of an injection. When all else has failed, I have had success in some patients with a cold quartz laser.

      Every one to two years I get a patient who needs surgery to repair tennis elbow. Such a patient has detached some tendon fibers from the bone and has a "dead spot" in the center of the tendon. The only therapy is surgery to clean out the dead area of tendon, followed by reattachment of the tendon.

How to Prevent Tennis Elbow

To prevent tennis elbow, do the same strengthening and flexibility exercises that were outlined for treatment. Also, make sure that you warm up and stretch your arm before playing a vigorous set. You should also seek the advice of a tennis instructor to correct your backhand stroke so that you hit the ball properly. Choosing the proper tennis racquet and string pressure can also prevent tennis elbow; see Chapter 29.

      If you have a history of tennis elbow or feel twinges of pain after playing, wait at least half an hour after your match and then ice the elbow down. Icing is more effective once the elbow has returned to normal body temperature.

TENNIS ELBOW II

Another type of tennis elbow is characterized by pain on the inner side of elbow (the medial epicondyle). This pain involves inflammation of the muscles and tendon that allow you to pronate the wrist, that is, turn it over so that the palm faces down. I see this elbow pain in tennis players who hit topspin forehands, which require them to turn the racquet head over the top of the ball. Many top-ranked tennis players feel pain on the inner side of the elbow because they hit a lot of topspin shots. For the weekend player, the culprit may be a late forehand that requires snapping the wrist and pronating the forearm.

      Other sports that require a snap of the wrist, such as the throwing sports, can also lead to this type of elbow pain. Prevention and treatment measures are the same. The exercises outlined earlier also strengthen and stretch the inner side of the elbow. I also recommend that you work on your biomechanics with a coach, particularly if you feel pain during the throwing motion. Pitchers with good biomechanics can throw for years without elbow problems.

PITCHER'S ELBOW

Baseball pitchers suffer a type of elbow pain that occurs on the inner side of the elbow or on both the inner and outer sides. In the pitching motion, there is a tremendous external rotational force on the elbow that spreads the inner side and compresses the outer side. The ligaments that hold the inner bones together are stretched and become painful. At the same time, compression of the outer side causes the head of the outer forearm bone (radius) to jam against the upper bone (humerus).

      The repeated trauma of this compression can cause an area of bone in the humerus to die. This is similar to the injury Bo Jackson suffered in his hip, but it is due to repeated trauma rather than the one blow he took playing football. It is called osteochondritis dissecans. The dead piece of bone can actually fall into the joint, leaving a crater. This causes continued pain and clicking in the elbow. If a fragment gets caught in the joint, it can cause the elbow to lock.

      To diagnose this injury, your doctor will have you extend your arm from the side. While you hold the upper part of your arm close to your body, the doctor will push the lower part of the arm away from your body. This reproduces the rotational forces that cause pitcher's elbow.

      The treatment for this condition is rest, which will allow the elbow ligament and bone to heal. It may take a full year for the bone to heal. If you have loose pieces of bone inside the elbow, you will need arthroscopic surgery to remove them.

      The cause of this injury is throwing too many pitches too often. After the elbow heals, you should watch how many pitches you throw and change your throwing routine so that you are not overusing your arm.

LITTLE LEAGUE ELBOW

A young baseball player who throws too often or too hard can irritate the growing part of the elbow bone in the medial epicondyle. This area, called the growth center, widens and enlarges the medial epicondyle. The flexor muscles of the wrist contract to propel the ball. These muscles connect to the medial epicondyle, and the constant yanking pulls the soft growth center apart, causing pain. Also, the irritation of the growth center stimulates it and causes the medial epicondyle to overgrow.

      The treatment for this condition, known as Little League elbow, is simply to rest until the condition subsides. This usually takes anywhere from six weeks to six months depending on the severity of the injury.

      The best way to deal with Little League elbow is to prevent it. First, young pitchers need to be taught the proper mechanics of throwing. Then they have to be limited in the number of pitches they can throw each week. Little League and high school pitchers are often overused by coaches not familiar with the cause of this strictly biomechanical injury.

      Sanctioned Little Leagues now restrict the number of innings a pitcher can pitch per week. But if a young pitcher is wild, he may throw a lot of pitches per inning, many more than a pitcher who has good control. Coaches should limit the number of pitches thrown to 80 twice a week and not simply count the number of innings pitched.

      In severe cases, a Little Leaguer may tear the medial epicondyle right off the bone through the soft growth center. You can recognize this injury by swelling, severe pain, and limited arm motion. This is an emergency situation, and the epicondyle will need to be surgically reimplanted.

      Rehabilitation, which includes immobilization followed by gradual range-of-motion exercises with an experienced physical therapist, may take six months or longer after surgery. In most cases, the pitcher will be back in action the following year, although he may never be an effective pitcher again.

POPEYE ELBOW

Besides his huge forearms and jutting jaw, the cartoon character Popeye the Sailor also has tiny knobs sticking out from behind his elbows. That's the site of a bursal sac called the olecranon bursa. Like any bursal sac, it can become inflamed, causing bursitis. This generally happens as a result of being hit on the end of the elbow. It can also become a chronic condition for people who lean on their elbows when they talk on the phone. This bursal sac becomes inflamed and quite painful, and a noticeable lump develops on the back of the elbow. This condition is known as Popeye elbow.

      When the bursitis is due to an acute condition, the excess fluid in the sac will need to be drained with a needle. Then cortisone is injected into the sac, which is the standard treatment for any bursitis.

      If the condition is chronic, you may feel little lumps behind the point of the elbow as you move it. These lumps are often misdiagnosed as bone chips, which have to be removed surgically. They really represent a less-threatening thickening in the wall of the bursal sac due to constant inflammation.

      To prevent the chronic condition, don't spend so much time leaning on your elbows. If necessary, get a headset for your telephone. This problem has a tendency to recur, so if you have had it in the past, use an elbow pad during sports for protection.

THE "FUNNY BONE" SYNDROME

Everyone knows the numbing, tingling pain of hitting the "funny bone" at the end of the elbow. The ulnar nerve traverses the back of the elbow in a groove behind the medial epicondyle. Hitting your elbow in a certain way stimulates the ulnar nerve and causes the numbness, tingling, and pain of the "funny bone" syndrome.

      Some athletes may feel as if they have hit their "funny bone" as a result of repeated trauma to the elbow. Scar tissue may form over the nerve and compress it into the canal, allowing it no room to move. This causes fairly severe pain in the elbow. The numbness and tingling radiate down into the fourth and fifth fingers, and you may lose strength in these fingers. This syndrome, called the cubital tunnel syndrome, is similar to carpal tunnel syndrome in the wrist (see Chapter 9). When center Mike Gminski joined the New Jersey Nets, he hit his elbow on the rim of the basket and developed cubital tunnel syndrome: as a result, he missed much of his rookie season.

      The treatment is surgery to remove the scar tissue from the nerve. The nerve may have to be transplanted outside of the canal to prevent scar tissue from building up again. The surgery is usually successful, as it was for Gminski, who returned the next year to begin a long, successful career.

HYPEREXTENDED ELBOW

When force applied to the elbow forces it to extend farther than normal, the result is hyperextension. This tears the fibers that hold the front of the elbow joint together and overextends the biceps muscle, which attaches just below the elbow.

      A hyperextended elbow will cause pain and swelling. Treat this by resting and icing it intermittently at first. It may require a splint to keep the elbow bent until the pain subsides. Then you must gently stretch until your range of motion returns and you can fully extend the elbow without pain. Then strengthen the elbow with arm curls using weights. Total recovery time is usually three to six weeks, depending on the severity of the injury.

BONE CHIPS

Bone chips are something you read about frequently in the sports pages, but they are quite rare. They are the result of many years of overuse of the elbow and usually afflict an older, wellknown pitcher or tennis player, so they get a lot of publicity. The condition is caused by little pieces of bone breaking off the elbow due to long and repeated stress. Many young pitchers with sore elbows come into my office worried that they have bone chips. Their pain is almost always due to something else, because they rarely have had enough trauma to form chips, unless they have osteochondritis dissecans, described earlier.

      Even in old-timers, bone chips are rare. Former major league pitcher Jim Bouton is one of my long-time patients. Nearly age 50, he still pitches regularly in a high-quality semiprofessional league. He always complains about various aches and pains, but even after all these years he has no elbow problems, and he says that his arm feels as good as ever.

TRICEPS TENDINITIS

Throwing sports can cause pain in the back of the elbow right above the point of the joint. This is the area where the triceps tendon hooks to the back of the elbow. The triceps muscle and tendon combine to straighten out the elbow. In the throwing motion, the elbow begins at a bent position as the arm is cocked and straightens out as the throw is delivered. This causes stress where the triceps tendon attaches to the elbow. The pain of triceps tendinitis can be severe, primarily for baseball pitchers.

      Rest alone is not the answer. As with most forms of tendinitis, triceps tendinitis responds to a structured exercise program. I have athletes do Triceps Curls with fairly light weights for many repetitions. This helps build up the triceps muscles and the tendon so that they can tolerate the overuse from throwing. This exercise program also can help you return to action more quickly if you already have triceps tendinitis.

      Some pitchers are resistant to this treatment and may need a cortisone injection in the area of the triceps tendon. Once the inflammation disappears, they can use this exercise program to help prevent the injury from recurring.

BICEPS TENDINITIS

Pain in the lower portion of the biceps muscle where it attaches to the elbow is a common phenomenon in beginning weight lifters who overstress themselves, and among veteran lifters who make too big a step up in weights. You will usually experience the pain on the day after lifting, and it can be very severe. You will also have a limitation in your range of motion: You will probably not be able to fully straighten or bend your elbow. This is due to swelling and spasm in the muscle fibers that have been overstressed. If both elbows are affected, you can be virtually disabled. Even eating is nearly impossible because you cannot bend your elbow enough to get a fork to your mouth.

      The proper treatment is to ice the elbow for 20 minutes at a time three or four times during the day. By the second day you can start a gentle stretching program.

      Do two or three repetitions of the Biceps Stretch every hour, and the muscle fibers will gradually relax and lengthen. It is important that the stretch be even and gradual. Any sudden movement or force may tear some of the muscle fibers and actually make matters worse.

      The next step is to bend and straighten the elbow frequently to restore your range of motion. Do this for three or four days, and the biceps muscle should return to normal. Once it has recovered, you can return to lifting, doing Arm Curls with a slow progression of weight to allow the biceps to adapt to increasing weight (see the strength program in Chapter 1).

TORN BICEPS

A sudden, severe movement of the arm can tear the biceps muscle. One head of the biceps can be literally torn in half. This is usually seen in an older athlete, such as a golfer who hits the ground hard with a club or a tennis player who hits a hard forehand smash, or in a young weight lifter attempting the sudden, violent motion of a clean-and-jerk. The torn muscle causes pain, bleeding, loss of function, and muscle deformity.

      You need to take care while recovering from a biceps tear. If the biceps contracts as the swelling subsides, the upper part of the muscle can ball up, causing a defect the size of a small orange on top of the muscle.

      Cosmetic surgery can correct the muscle defect, but it cannot bring the muscle back to its original strength. The buildup of scar tissue weakens the muscle. In fact, a torn biceps muscle that has been repaired will likely tear again.

      Treatment involves allowing the torn muscle to rest for two or three weeks while it heals. This is followed by a training program to strengthen the other head of the biceps so that it can take over full function of the muscle. Arm Curls are the best exercise to strengthen the biceps muscle (see the strength program in Chapter 1).

      I have never seen the second head of a biceps tear in somebody who has torn the first head. If the muscle tears again, it's usually the same head. So muscle strengthening usually works to restore function to the biceps.




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