X-ray of the elbow.
X-ray of the elbow.
A 17-year-old male presents with right elbow pain for several months. He plays baseball 7 months of the year and either pitches or plays third base. His pain is made worse when throwing, and he has lost velocity on his fastball. Ice and nonsteroidal anti-inflammatory drugs (NSAIDs) provide little relief. He tried taking a few months off from pitching, but the pain returned as he started throwing again. On examination, you note tenderness over the radiocapitellar joint and pain during the lateral compression test. He has no medial-sided laxity or pain with valgus stress. Anteroposterior and lateral X-rays of the right elbow are shown in Figures 1 and 2.
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The overhead throwing motion places significant stress on the elbow, which can often lead to overuse injury. Determining pathology in the overhead throwing athlete starts with the basic understanding that a valgus force is placed on the elbow during the throwing motion. This causes tensile forces to the medial elbow and compression forces to the lateral elbow. Common sources of medial elbow pain in the throwing athlete are often attributed to a stretch of the medial structures, including ulnar collateral ligament tearing, ulnar neuritis, flexor pronator strain, and medial apophysitis. Repetitive compressive forces at the lateral elbow may cause a condition called osteochondritis dissecans (OCD) of the capitellum.1
OCD of the capitellum occurs when repetitive trauma starts to damage the articular cartilage and subchondral bone of the capitellum. The condition generally occurs between the ages of 11 and 21 and is more common in males. Pain is often described as worse with activities and better with rest, with the occasional catching or locking occurring during throwing motion. On examination, tenderness along the radiocapitellar articulation and pain with the lateral compression test are often noted. Radiographs are generally negative early in the disease but may show irregularity to the articular surface as the disease advances. MRI is the most sensitive study for picking up OCD early. Early stable OCD can be treated successfully with 3 to 6 weeks of rest followed by a gradual return to throwing. Large or unstable OCD lesions often require operative debridement and lesion excision, debridement and bone marrow stimulation, or fragment fixation. (Note: Panner disease occurs almost exclusively in males younger than 10 years of age and is not associated with trauma.1,2)
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Patel RM, Lynch TS, Amin NH, Gryzlo S, Schickendantz M. Elbow injuries in the throwing athlete. JBJS Review. 2014;2. doi: 10.2106/JBJS.RVW.N.00011
- Ruchelsman DE, Hall MP, Youm T. Osteochondritis dissecans of the capitellum: current concepts. J Am Acad Orthop Surg. 2010;18:557-567.