Elbow Strains: What’s the deal with LeBron?
by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com
Elbow injuries are common in every overhead sport. Most recently, you’ve probably heard talk about elbow strains with regards to the Cleveland Cavaliers’ LeBron James. Unfortunately, professional sports teams do not disclose the exact diagnoses. In fact, they usually conceal any elbow injury by labeling it a strain or sprain. What we all want to know is, “What does that really mean?” Strains are injuries that affect muscles or tendons. A sprain is an injury which affects a ligament (you may have heard outbursts such as “My freakin’ ligament of struthers is acting up again!”). King James of the Cavilers suffered an elbow strain which indicates that he damaged his muscle or tendon. If we had to place a wager, we would put my money on LeBron’s injury being a flexor strain due to the cocking back motion of the wrist flexors (which are anchored at the elbow) during a shot causing an eccentric strain of the muscles and tendons. Sprains are prevalent in almost every sport but elbow strains in particular are commonly seen in baseball. 
The typical elbow sprain is of the ulnar collateral, or “Tommy John,” ligament. This ligament is excessively stretched during the cocking motion of a pitch, most notably the breaking ball pitch. To make matters worse, elbows are notorious for their slow healing and painful nature. Before we discuss proper management and prevention of common elbow injuries, particularly a proper rehabilitation and prevention program of both strains and sprains, we need to gain a better understanding of the anatomy of the elbow.
Stat Fact: In 2002-2003 seasons, 1 in 9 pitchers were “Tommy John” surgery recipients (1).
Elbow Anatomy
The elbow is classified as a hinge joint, similar to the knee. A hinge joint, like those found on household doors, swings in a single plane (from flexion to extension in the knee and elbow). This limited range of motion makes the elbow less likely to dislocated or sublux but, due to its high stability, performing repeated exercises to the end range of this motion put high degrees of stress on the joint (imagine repeatedly slamming a door open to the limits of the hinge). The elbow is composed of two bones, the radius and ulna, ajoining with one bone, the humerus. The radius is the narrower of the two forearm bones at the point where it forms the elbow. Elbow strains occur at 4 sites (all locations where muscles are inserting on bones):
1. The group of wrist extensors located behind the radius
2. The group of wrist flexors on the front of the ulna
3. The middle of the elbow from the biceps distal attachment
4. The posterior elbow where the triceps attach to the elbow.
Strain often result from overuse and can become progressively more painful as you continue to use the injured area…sounds fun, we know. Elbow strains occur at the medial (inside) and lateral (outside) aspect of the elbow, the exact location of the main ligaments, the ulnar and radial collateral ligaments. These ligaments prevent the elbow from overstretching and subsequent injury. Injury to both of these ligaments can occur progressively or acutely. Progressive injuries are typically caused by overuse and are treated conservatively. Acute injuries usually involve a tear of the ligament which will most likely buy you a trip to the OR with the orthopaedic surgeon of your choosing.
Stat Fact: Roughly 145 degrees of elbow flexion is needed to wash one’s hair…depending, of course, on the length of the hair but you get the point.
Rehabilitation
Depending on the exact injury, a strain, sprain or tear of one of the elbow structures requires varying recovery durations and treatment approaches. The most severe of the injuries is a tear of one of the collateral ligaments. 
A tear of the ulnar collateral ligament (“Tommy John”) takes nearly 12 months to repair properly and requires the use of a autograft (tissue from the athlete’s own body) or allograft (tissue from an outside source, typically a cadaver). This ligament is stronger than the current ligament and pitchers are able to return to the prior level of function and sometimes superior level of function prior to the injury. Speculation about the increased strength of the repaired ligament has led to discussions about preventative “Tommy John” injuries in young pitchers, allowing the young athlete to optimize their new stronger ligament (this discussion remains heated to say the least). This idea of putting in a stronger ligament before damage, inflammation, etc. occurs seems one step closer to building a bionic player to some…we’ll let you be the judge. Muscle strains and sprains require a more hands-on treatment approach. Maintaining and regaining optimal range of motion is the number one priority since the elbow is tough to return to full range of motion and a large range of motion is necessary to be functional in everyday life. For optimal range of motion, soft tissue mobilization can be used to breakdown tight muscles or knots. Additionally, joint mobilization can be used to mimic motions of the bones sliding on one another. 
Exercises will push the patient to their end range of motion with minimal discomfort. If the strain is to the tendon, eccentric overload training can be utilized. This form of training uses higher force but requires less effort from the patient. To eccentrically train the wrist flexors, the patients hand would face up and they would slowly lower a weight towards the floor (see picture). This lowering movement stretches the wrist flexors. Overload training is gaining street cred in all forms of tendon injuries due to its successful track record.
Stat Fact: Major League pitches have noted a 4-5 MPH improvement in the speed of their pitches following surgery, convincing them that the surgery improved their pitch velocity (thus recommending it to other pitchers). It is most likely, however, that the improvement in velocity stems from the increased stability of the elbow joint following rehabilitation rather than the surgery itself (2).
Prevention
Proper biomechanics is a mandatory aspect of prevention. Combating improper biomechanics while increasing strength of the whole arm is the most efficient way to preventing injury. Strengthening needs to begin with the axial component of the body. The arm is stabilized at the shoulder blade (i.e. the shoulder and shoulder blade are the stabilizing muscles of the arms). Think of them as the strong anchoring roots of your human tree. The roots need to be strong to move the branches or arms. Once you have established this stability, begin strengthening further down the “tree.” Focus on the forearm next via eccentric and concentric training, beginning with static movements and progressing to dynamic, plyometric programs. This progression enhances muscle timing, an essential aspect of proper biomehcanics and injury prevention.
Questions? E-mail the author: mullen@myhousecallmd.com
References:
1. Carroll WG, T. Baseball Prospectus | Inside Tommy John Surgery: Baseball Prospectus; 2009.
2. Matson J. News Blog: Does Tommy John surgery give pitchers an arm up in competition?: Scientific America; 2009.
3. Metzl J. Peidatric Video Series Volume 1: Little League Elbow Case Stusy from Sports Medicine in the Pediatric Office. American Academy of Pediatrics.
With the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return. The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle. The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday. As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination. Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.
The most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot. You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them. This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined). There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments. In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.
Wrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done. Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).
Ankle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity. This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly. If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).
your ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging. A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles. Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.
Strengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual. Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball. One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock. I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock,
and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left. Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle). Movements in all these planes of direction will greatly strengthen your ankle and improve your balance. These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult. A little TV time makes them infinitely more enjoyable.
