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.
incurred during the intense competition in the coming weeks. Shoulder pain, elbow pain, ankle pain? These joints are common sources of pain for professional athletes and law-abiding citizens alike. Whether you have golfer’s elbow, tennis elbow, speed skater’s knee, shoulder impingement, jumper’s knee, Achilles tendon pain, you are suffering from a “tendinopathy.” Tendons, which connect muscles to bones, are composed of collagen. Tendinitis is the most common term associated with tendinopathy. Tendinitis is the acute injury of a tendon and is typically associated with inflammation (note that “-itis” means inflammation). Tendinosis is a term used less commonly but refers to the process in which tendinitis becomes chronic (lasting greater than 3 weeks). To understand the disease of tendinopathy, it is essential to understand the design of a tendon, common causes, treatments for the different types of tendinopathies and what you can do to prevent these disorders.
of the blood supply that muscles have) which means that it takes tendons notably longer than muscles to heal. Following an acute injury, the tendon strained becomes inflamed (filled with cells trying to repair the tissue). After chronic use of the tendon, type III collagen becomes predominant. This change in collagen will make the tendon larger due to increased collagen rather than from inflammation. Along with the increase in collagen comes an increase in water in the tendon as well. These two changes make the tendon thicker which you notice as increased stiffness. At the same time, the tendon becomes more compliant leading to an increased rate of tendon strain after a chronic tendon injury. Cadaveric studies suggest after a chronic tendon injury, the strain increases causing a decrease in stiffness and strength. Strain is “the amount of displacement with an external load placed on the object” or, in the cadaveric study, “the amount of displacement increased after injury.” Essentially, it means the amount of laxity (“looseness”) in the tendon after injury.
(you know doctors don’t like to put timelines on healing!). The majority of treatment for tendinitis consists of anti-inflammatory medication or a cortisone shot (used only in extreme situations) administered by the physician. The list of anti-inflammatory drugs is extensive, including as Ibuprofen, Motrin, Naproxen, Celebrex, and many more. Physical therapists can help reduce inflammation with a number of treatment modalities (electrical stimulation, low level laser therapy, ultrasound, ice) that can decrease pain and inflammation. The last and the most important treatment for tendinitis is a temporary discontinuation of the activity that caused this inflammation. As stated, true tendinitis is from an acute accident therefore discontinuing that activity while the tendon heals makes sense…let’s agree to agree on this one.
if you are performing a squat, lowering your body down is the eccentric phase of the exercise on your thighs and returning to the start position is the concentric phase for your thighs. Overload eccentric exercise training studies suggest eccentric training increases stiffness of the tendon and help change the tendon back to type I collagen. Increasing the tendon stiffness provides the support your muscles need to contract so that it can maintain the muscle in the position where it produces the most force. Let’s look at another example: Achiles tendinitis is common in runners. Mix in a little hard headedness and a desire to keep running despite injury and you have yourself the perfect storm for the development of a tendinosis. To treat this population of patients, a 12-week exercise program consisting of heel drops has shown excellent results. This program uses high repetitions of the exercise: 3 sets of 15 repetitions two times a day with progressively increasing external weight (you can add weight to backpack that you wear during the exercise)1. One key during this exercise is to only perform the eccentric phase of the heel drop with your injured leg. To do this, slowly lower yourself down on the injured leg (the eccentric phase) and then return to your tippy toes by concentrically using the healthy leg. This type of eccentric exercise can be used in any type of tendinosis.
Begin in a sitting position and put loop theraband (an thick elastic band) in which the loop is on the inside of your foot. Move your foot down and in without resistance and then attach the theraband around the foot with high tension. In a controlled manner, allow the foot return to the up and out position.
