Medial elbow anatomy: A paradigm shift for UCL injury prevention and management

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Abstract

To improve the management outcomes and diagnostic accuracy of the ulnar collateral ligament (UCL) injury, the anatomy of the medial side of the elbow joint is necessary to be understood in terms of the periarticular surroundings rather than the specific ligaments. The aim of this study was to anatomically clarify the medial side of the elbow joint in terms of the tendinous structures and joint capsule. We conducted a descriptive anatomical study of 23 embalmed cadaveric elbows. We macroscopically analyzed the relationship between the flexor pronator muscles (FPMs) and the joint capsule in 10 elbows, histologically analyzed in 6 elbows, and observed the bone morphology through micro computed tomography in 7 elbows. The two tendinous septa (TS) were found: between the pronator teres (PT) and flexor digitorum superficial (FDS) muscles, and between the FDS and flexor carpi ulnaris (FCU) muscles. These two TS are connected to the medial part of the brachialis tendon, deep aponeurosis of the FDS, and FCU to form the tendinous complex, which linked the humeroulnar joint and could not be histologically separated from each other. Moreover, the capsule of the humeroulnar joint under the tendinous complex had attachment on the ST of 7 mm width. The two TS, the brachialis tendon, the deep FDS and FCU aponeuroses, and the joint capsule linked the humeroulnar joint. These anatomical findings could lead to a paradigm shift in the prevention, diagnosis, and treatment of UCL injuries in baseball players. Clin. Anat. 32:379–389, 2019. © 2018 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.

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Most cited references 43

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An electromyographic analysis of the upper extremity in pitching.

F Jobe, M Pink, N Digiovine … (1991)

The upper extremity is vulnerable to injury during the baseball pitch because of the repetitious nature of the action, the extremes in range of motion, and the high angular velocities and torques generated at the shoulder and elbow. Hence this study was designed to describe the muscle-firing patterns through fine-wire electromyography in 29 muscle bellies in the upper extremities of skilled pitchers during the fastball pitch. The results demonstrated that the muscles functioned with precise timing for joint stabilization to prevent injury, joint activation to transfer forces to the ball, and joint deceleration to dissipate forces after ball release. The synchrony of reciprocal and sequential muscle contraction necessary to accomplish these functions was clearly evident. This study provides a better understanding of the coordinated sequence of muscle activity during the throwing motion; this understanding is crucial to the development of exercise protocols and surgical procedures used for treatment and prevention of shoulder and elbow injuries in the throwing athlete. Copyright © 1992 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

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Prevention of Elbow Injuries in Youth Baseball Pitchers

Glenn S. Fleisig, James R Andrews (2012)

Context: Although baseball is a relatively safe sport, numerous reports suggest a rapid rise in elbow injury rate among youth baseball pitchers. Evidence Acquisition: PubMed was searched for epidemiologic, biomechanical, and clinical studies of elbow injuries in baseball (keywords: “youth OR adolescent” AND baseball AND pitching AND “ulnar collateral ligament OR elbow”; published January 2000 – April 2012). Studies with relevance to youth baseball pitchers were reviewed. Relevant references from these articles were also retrieved and reviewed. Original data, insight, and recommendations were added. Results: The majority of baseball elbow injuries are noncontact injuries to the dominant arm resulting from repetitive pitching. Five percent of youth pitchers suffer a serious elbow or shoulder injury (requiring surgery or retirement from baseball) within 10 years. The risk factor with the strongest correlation to injury is amount of pitching. Specifically, increased pitches per game, innings pitched per season, and months pitched per year are all associated with increased risk of elbow injury. Pitching while fatigued and pitching for concurrent teams are also associated with increased risk. Pitchers who also play catcher have an increased injury risk, perhaps due to the quantity of throws playing catcher adds to the athlete’s arm. Another risk factor is poor pitching biomechanics. Improper biomechanics may increase the torque and force produced about the elbow during each pitch. Although throwing breaking pitches at a young age has been suggested as a risk factor, existing clinical, epidemiologic, and biomechanical data do not support this claim. Conclusions: Some elbow injuries to youth baseball pitchers can be prevented with safety rules, recommendations, education, and common sense. Scientific and medical organizations have published safety rules and recommendations, with emphasis on prevention of overuse and pitching while fatigued. Strength-of-Recommendation Taxonomy (SORT): A

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Current concepts in the rehabilitation of the overhead throwing athlete.

Kevin E Wilk, Keith Meister, James R Andrews (2002)

The overhead throwing motion is an extremely skillful and intricate movement that is very stressful on the shoulder joint complex. The overhead throwing athlete places extraordinary demands on this complex. Excessively high stresses are applied to the shoulder joint because of the tremendous forces generated by the thrower. The thrower's shoulder must be lax enough to allow excessive external rotation, but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. We refer to this as the "thrower's paradox." This balance is frequently compromised, which leads to injury. Numerous types of injuries may occur to the surrounding tissues during overhead throwing. Frequently, injuries can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough clinical examination and accurate diagnosis. Athletes often exhibit numerous adaptive changes that develop from the repetitive microtraumatic stresses observed during overhead throwing. Treatment should focus on the restoration of these adaptations during the rehabilitation program. In this article, the typical musculoskeletal profile of the overhead thrower and various rehabilitation programs for specific injuries are discussed. Rehabilitation follows a structured, multiphase approach with emphasis on controlling inflammation, restoring muscle balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing.

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Author and article information

Contributors

Akimoto Nimura:

ORCID: https://orcid.org/0000-0002-3054-0273

nimura.orj@tmd.ac.jp

Journal

Journal ID (nlm-ta): Clin Anat

Journal ID (iso-abbrev): Clin Anat

Journal ID (doi): 10.1002/(ISSN)1098-2353

Journal ID (publisher-id): CA

Title: Clinical Anatomy (New York, N.y.)

Publisher: John Wiley & Sons, Inc. (Hoboken, USA )

ISSN (Print): 0897-3806

ISSN (Electronic): 1098-2353

Publication date (Electronic): 09 January 2019

Publication date (Print): April 2019

Volume: 32

Issue: 3 ( doiID: 10.1002/ca.v32.3 )

Pages: 379-389

Affiliations

[ ¹ ] Department of Clinical Anatomy, Graduate School of Medical and Dental Science Tokyo Medical and Dental University Tokyo Japan

[ ² ] Shoulder & Elbow Service Funabashi Orthopaedic Sports Medicine & Joint Center Funabashi Chiba Japan

[ ³ ] Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan

Author notes

[*] [* ] Correspondence to: Akimoto Nimura, MD, PhD, Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1‐5‐45 Yushima, Bunkyo‐ku, Tokyo 113‐8519 Japan.

E‐mail: nimura.orj@ 123456tmd.ac.jp

Author information

Akimoto Nimura https://orcid.org/0000-0002-3054-0273

Keiichi Akita https://orcid.org/0000-0002-2927-2937

Article

Publisher ID: CA23322

DOI: 10.1002/ca.23322

PMC ID: 6850211

PubMed ID: 30521139

SO-VID: ed08b09e-498e-445b-a6ed-afb343bb0e3d

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

History

Date received : 07 October 2018

Date revision received : 29 November 2018

Date accepted : 02 December 2018

Page count

Figures: 7, Tables: 1, Pages: 11, Words: 7612

Funding

Funded by: JA Kyosai Research Institute (Agricultural Cooperative Insurance Research Institute)

Custom metadata

source-schema-version-number 2.0

cover-date April 2019

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.1 mode:remove_FC converted:12.11.2019

ScienceOpen disciplines: Anatomy & Physiology

Keywords: elbow,collateral ligament,ulnar,anatomy and histology,baseball,rehabilitation

Data availability:

ScienceOpen disciplines: Anatomy & Physiology

Keywords: elbow, collateral ligament, ulnar, anatomy and histology, baseball, rehabilitation

Medial elbow anatomy: A paradigm shift for UCL injury prevention and management

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