Department of Orthopaedics, Brown University, School of Medicine, Rhode Island
Hospital, Providence, USA.
One of the greatest challenges when examining an injured athlete is ensuring
that the examination encompasses the whole patient and not just the obvious
deformity. Bony injuries of the wrist, forearm, and elbow are uncommon in
athletes and when present should always lead to suspicion of possible
concomitant soft tissue injury. Mechanisms causing osseous disruption are of
fairly high energy and can be quite disabling to the long-term career of the
athlete. Appropriate expectations with regard to both treatment and the
possible return to sports are critical in providing successful treatment for
these often complex injuries. There is no substitute for a careful clinical
history and physical examination in not only establishing the diagnosis but
ensuring that a complete diagnosis with its subsequent prognostic outcome can
be rendered.
Methodist Sports Medicine Center, Department of Research and Education,
Indianapolis, Indiana, USA.
Competitive and recreational athletes sustain a wide variety of soft tissue,
bone, ligament, tendon and nerve damage to their upper extremities. Most such
injuries are related to direct trauma or repetitive stress, and account for a
significant amount of 'down time' for athletes participating in a wide range
of sports, particularly those in which the arm is utilised for throwing,
catching or swinging. Overuse injuries to the elbow include musculotendinous
injuries, ulnar nerve injuries and ligamentous injuries. Osteochondrol lesions
of the capitellum and posterior impingement injuries in the joint are
frequently seen in athletes as well. Acute traumatic injuries to the elbow
include tendon ruptures, elbow dislocations and intra-articular fractures.
Forearm overuse injuries in athletes include fracture of the carpal scaphold,
fracture of the hook of the hamate, Kienbock's syndrome and pisoquetral
syndromes. ligamentous injuries include scapholunate, lunotriquetral and
midcarpal instability injuries. Injuries to the distal radio-ulnar joint and
triangular fibrocartilage are also quite common in athletes, and require
careful evaluation and treatment.
Albert Einstein College of Medicine, Bronx, New York, USA.
Overuse syndromes of the upper extremity in the athletic population are a
common and often difficult problem for physician and patient alike. Optimal
function of the upper extremity is tied intimately to success in many sporting
activities. Correct diagnosis and proper care require a thorough knowledge of
the pertinent anatomy, pathophysiology, and pathomechanics involved in each
disorder. Conservative care with rest, activity modification, and medication
is adequate for most athletic injuries. Surgical intervention may be indicated
for continuing pain, decreased performance, or to prevent chronic changes.
Surgery must be followed by thoughtfully prepared training and rehabilitation
programs to optimize the chances of a successful outcome.
Department of Orthopaedic Surgery, University of Mississippi School of
Medicine, Jackson, USA.
Athletes of all ages and skill levels are increasingly participating in sports
involving overhead arm motions, making elbow injuries more common. Among these
injuries is lateral epicondylitis, which occurs in over 50% of athletes using
overhead arm motions. Lateral epicondylitis is characterised by pain in the
area where the common extensor muscles meet the lateral humeral epicondyle.
The onset of this pathological condition begins with the excessive use of the
wrist extensor musculature. Repetitive microtraumatic injury can lead to
mucinoid degeneration of the extensor origin and subsequent failure of the
tendon. Lateral epicondylitis can almost always be treated nonoperatively with
activity modification and specific exercises. If the athlete fails to respond
to nonoperative treatment after 6 months to 1 year, they are candidates for
surgical intervention. Medial epicondylitis is characterised by pain and
tenderness at the flexor-pronator tendinous origin with pathology commonly
being located at the interface between the pronator teres and flexor carpi
radialis origin. Golfers and tennis players often develop this condition
because of the repetitive valgus stress placed on the medial elbow soft
tissues. Careful evaluation is important to differentiate medial epicondylitis
from other causes of medial elbow pain. As with lateral epicondylitis,
patients with medial epicondylitis not responding to an extensive nonoperative
programme are candidates for surgical intervention. A less common cause of
medial elbow pain is medial ulnar collateral ligament injury. Repetitive
valgus stress placed on the joint can lead to microtraumatic injury and valgus
instability. When the medial ulnar collateral ligament is disrupted, abnormal
stress is placed on the articular surfaces that can lead to degenerative
changes with osteophyte formation. As with other elbow injuries, a strict
rehabilitation regimen is first employed; ligament reconstruction is only
recommended if the injury fails to improve and only in athletes requiring a
high level of performance. Excessive valgus stress can also lead to
posteromedial olecranon impingement on the olecranon fossa producing pain,
osteophyte and loose body formation. Arthroscopic elbow debridement can often
be helpful in improving motion and in reducing pain in such patients.
Department of Research and Education, Methodist Sports Medicine Center,
Indianapolis, Indiana, USA.
Upper extremity injuries in athletes cause pain, impairment of function, and
time loss from sport participation. This article briefly discusses the
epidemiology of elbow, forearm, and wrist injuries in various athletic
endeavors. Included is an overview of the epidemiology of nerve dysfunction,
tendon ruptures, fractures about the wrist and forearm, ligamentous injuries
of the wrist, distal radioulnar joint injuries, and overuse injuries.
Thomas A. Brady Clinic, Methodist Sports Medicine Center, 201 Pennsylvania
Parkway, Suite 200, Indianapolis, IN 46280, USA. JGladfelter@methodistsports.com
Traumatic injuries to the elbow are not uncommon in the athlete. A fall onto
the out-stretched arm may result in fracture of the radial head, dislocation
of the elbow, or other injuries about the joint. Strength training and contact
sports may cause rupture of the biceps or triceps tendon at the elbow. It is
important for the sports medicine physician to become familiar with injury
patterns about the elbow in athletes and treatment options. This article will
be devoted to a summary of classification, diagnosis, and treatment
considerations for selected traumatic athletic injuries of the elbow.
Methodist Sports Medicine Center, Indianapolis, Indiana 46280-1381, USA.
Hand and wrist injuries in sports are some of the most common injuries
reported. This review discusses briefly the causes of hand and wrist injuries
in sports and discusses pertinent biomechanical findings regarding the range
of motion required in different sports activities. The bulk of the review
discusses specific traumatic and overuse injuries to the hand and wrist
commonly seen in the athlete. Emphasis is placed on problematic traumatic
injuries such as carpal scaphoid fractures and hook of the hamate fractures,
as well as ligament injuries to the wrist with regard to diagnosis, treatment,
and return to athletic competition.
University of Pittsburgh, Center for Sports Medicine and Rehabilitation, PA,
USA.
Elbow injuries are becoming more common as increasing numbers of people
participate in throwing and racquet sports. The understanding and treatment of
elbow injuries is becoming more sophisticated in conjunction with better
noninvasive and invasive diagnostic techniques. The majority of injuries to
the elbow in the athlete are chronic, overuse injuries. These injuries are the
result of repetitive intrinsic or extrinsic overload, or both, resulting in
microrupture of soft tissue such as ligament or tendon. In children, apophyses,
being the weakest link in the immature musculoskeletal system, are susceptible
to stress injuries. Elbow injuries are most commonly caused by valgus stress,
from throwing or axial compression, resulting in increased force absorbed by
the medial elbow. With repetitive valgus stress, patients may develop
chondromalacia, loose bodies in the posterior or lateral compartments, injury
to the ulnar collateral ligament, myotendinous injury to the flexor-pronator
muscle group, osteochondritis dissecans, or ulnar neuritis. The purpose of
this paper is to (1) define the significance of elbow injuries in athletics,
(2) review the anatomy and biomechanics of the elbow, and (3) discuss the
prevention and treatment of elbow injuries.
The wrist is a complex joint that biomechanically transmits forces generated
at the hand through to the forearm. The radial side of the wrist carries 80%
of the axial load and the ulnar side the remaining 20% of the load. The
incidence of wrist (and hand) injuries in the sporting population is
approximately 25%. This tends to be higher in those sports using the hand and
wrist, and when the potential for trauma is present. The injuries are divided
into 4 categories: overuse, nerve (and vascular), traumatic, and
weight-bearing injuries. Overuse injuries are common in sports involving the
hand and wrist, such as racquet sports, netball, basketball and volleyball.
Nerve injuries are more commonly compressive neuropathies, and are seen with
cyclists who may compress the ulnar nerve in Guyon's canal. Vascular injuries
are uncommon and usually result from a high velocity impact from balls.
Traumatic injuries are the most common and are due to either a fall on to the
wrist, a direct blow, or combination of a rotatory and torsional force. The
weight-bearing injuries are more specific to gymnastics, and result from
repetitive excessive compressive and rotational forces across the wrist. The
pommel horse event is associated with a high incidence of wrist pain in male
competitors. Arthroscopy of the wrist provides direct inspection of
intra-articular structures and diagnosis of conditions that may be unclear
with other investigations. As techniques advance, more conditions may be
treated arthroscopically and potentially facilitate an earlier return to sport.
Division of Sports Medicine, Department of Orthopaedic Surgery, Baylor College
of Medicine, 6550 Fannin Street, Suite #400, Houston, TX 77030, USA.
The unique anatomy of the elbow combined with the angular velocity and
stresses placed across this hinge joint while throwing can cause a large
number of pathologic changes associated with nerves. Although the ulnar nerve
is the most commonly injured, neuropathies are also seen with the branches of
the median and radial nerves. These neuropathies are typically responsive to
rest, activity modification, ice, splinting, and anti-inflammatories. A
graduated return to throwing is then needed before returning to play. When
conservative measures fail, surgical decompression is warranted, but results
have been less than perfect.
The athlete represents a special population in which injuries can occur either
from a single acute traumatic event or as part of a continuum of overuse that
leads to osseous or soft tissue failure. The spectrum of overuse with
superimposed acute trauma makes the evaluation of the upper extremity in the
competitive athlete more challenging. The expectation of this population for
quick, full, painless recovery, coupled with the desire to return to the sport
that caused the injury, makes the treatment difficult as well. This article
will discuss athletic injuries of the forearm and wrist with an emphasis on
evaluation, treatment, and criteria for return to play.
American Sports Medicine Institute, Birmingham, AL.
Because of the popularity of sports participation, sports physical therapists
must recognize in the athlete the many clinical conditions that occur about
the elbow. The purpose of this paper is to present the most common elbow
problems that an athlete may encounter and to provide information to
facilitate recognition of elbow pathology. This information is essential
before initiating treatment. An attempt is made to include sprains, strains,
neuropathies, dislocations, fractures, contusions, vascular insults, and skin
problems in the distal humerus, elbow, and proximal forearm of both the
immature and mature athlete. Comprehension of the mechanism of injury aids
clinical evaluation and rehabilitation and enhances early return to activity.
Department of Orthopaedic Surgery, University of California Irvine, Orange,
USA.
The wide spectrum of athletic activities places demands of different
magnitudes, orientations, and degrees of repetition on the wrists of athletes.
These demands can result in injuries to the soft tissues of the wrist, which
may make optimal athletic performance difficult if not impossible. With the
advent of increased awareness of injuries particular to a sport and advances
in diagnostic acumen, both technologic and clinical, these once enigmatic
pathologic entities can be approached with a treatment plan that often can
return the athlete to competition quickly. A number of these injuries and
their pathomechanics, diagnosis, and treatment options have been described in
this article. Although adequate treatment of the subject of athletic
soft-tissue injuries to the wrist requires a more lengthy discussion than is
appropriate here, the material presented on dorsal pain disorders, carpal
instability, and the triangular fibrocartilage complex should serve as a
starting point for increasing cognizance and understanding of the injured
wrist in the athlete.
Miami Hand Center, Miami, Florida 33176, USA. info@drbadia.com
Sports-related injuries about the elbow occur commonly and are often managed
by a wide variety of health care providers. It is particularly important that
a surgeon well versed in arthroscopy, reconstructive trauma, and peripheral
nerve techniques evaluates potentially complex injuries. It is equally
imperative that the preoperative care regimen and postoperative management be
conducted by an experienced therapist who understands elbow biomechanics and
function. Acute pathology, such as fracture or severe ligamentous and
tendinous injury, usually warrants operative treatment. A thorough
understanding of the anatomy and biomechanics of the elbow is crucial since
the expected recovery in the nonathlete will not suffice for the competitive
athlete. Demanding activities, such as the overhead-throwing motion cycle,
require a much more complete recovery than simple return to activities of
daily living. Chronic elbow problems in the athlete can often be managed with
appropriate therapy and modification to the training protocol. Poor response
to conservative means should lead to a more thorough evaluation by an
experienced elbow surgeon as these injuries can often be career ending. The
spectrum of commonly seen lesions in the athlete's elbow is described here, as
are conservative care measures, operative treatments, and postoperative
management.
Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh,
Pennsylvania 15203, USA.
The elbow is a commonly injured joint, yet physicians may be less comfortable
treating injuries to the elbow compared with knee and shoulder injuries.
Common injuries involving the elbow are tendinosis, instability, tendon
ruptures, osteochondritis dissecans, and fractures. Tendinosis is a common
overuse injury and may occur on the lateral, medial, or infrequently, the
posterior side of the elbow. Injury to the medial or lateral ulnar collateral
ligaments may result in instability. Repetitive trauma from overuse is the
most common etiologic factor in athletes. Distal biceps and triceps tendon
injuries may result in elbow disability in active individuals. Partial tears
are more difficult to diagnose than complete ruptures. Osteochondritis
dissecans of capitellum affects adolescents involved in overhead throwing
athletics. Fractures about the elbow most commonly involve the radial head in
adults, and the distal humerus in children. Athletes are prone to elbow
injuries resulting from both overuse and acute trauma. Our purpose is to
describe the diagnosis and treatment of these common elbow injuries in
athletes of all ages.
Indiana University School of Medicine, Indianapolis.
Neurovascular syndromes in the wrist and hand are uncommon occurrences in the
athlete. They are usually related to repetitive use of the wrist such as in
racquet sports or sports with repetitive impact to the hands such as handball
and catching. Common syndromes are discussed with regard to anatomy,
pathophysiology, diagnosis, treatment, and return to sport.
Providence Athletic Medicine, Providence Medical Center-Providence Park, 47601
Grand River Avenue, Suite A101, Novi, MI 48374, USA.
Primary care physicians not only have an important role in the diagnosis and
initial treatment of wrist injuries, but also play a key role in the education
of families about prevention. Children and adolescents are often competitive
in sports throughout the year. Periods of rest can be important in prevention
of overuse injuries in the very active, developing athlete.Protective gear
such as wrist guards, used during activities such as inline skating and
snowboarding, has been shown to prevent acute injuries that often require
surgery or lead to prolonged disability [84,85].A primary care physician will
often be the first health care provider to assess most wrist complaints. The
intent of this article is to familiarize the primary care physician with the
most common wrist injuries in active people, and to demonstrate that many
injuries can have poor outcomes if unrecognized. It is important to have good
clinical knowledge of the functional anatomy of the wrist in order to maximize
the information gathered on examination and to narrow one's differential
diagnosis. The athlete's sport and desires regarding return to play, and the
impact of the timing of injury management on his or her further participation
in sport are important to consider. A highly active person may be referred to
a musculoskeletal specialist for advanced testing or surgical repair earlier
in the evaluation of certain injuries than a less active one. Armed with good
clinical knowledge of anatomy and an understanding of common wrist injuries,primary
care physicians can successfully manage many wrist complaints.
Department of Orthopaedic Surgery, University of Cincinnati College of
Medicine, Ohio, USA.
Overuse injuries are the result of repetitive microtrauma to the
musculotendinous unit. Treatment protocols are based on the stage of the
inflammatory process that is active at the time of diagnosis. Control of the
inflammatory response with rest, elevation, and ice is the treatment objective
during the inflammatory stage. Prevention of further injury is the primary
treatment goal throughout the proliferative phase. Once the inflammatory
process has reached the maturation stage, rehabilitation can begin with
flexibility exercises, isometric contractions, and a slow return to strength
training. Surgical decompression is frequently necessary if chronic
inflammation causes fibrosis of the fibro-osseous tendon sheaths. Anomalous
muscle bellies and tendinous interconnections can be contributing factors to
overuse syndromes. Properly structured training programs and rehabilitation
regimens can prevent tendinitis and overuse syndromes.
