Baseball is a sport that requires exerting large forces on the elbow to throw the ball. Throwing athletes are susceptible to specific ligament injuries of the elbow. Not all elbow pain is related to ligament injury, though. Other ligament injuries can occur in baseball due to other traumas. Tendinitis and bursitis are common soft tissue causes of elbow pain seen in baseball players. In the pediatric population, a variety of bony defects can occur at the elbow joint related to throwing, but are not related to the ligaments.
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The elbow is made up of the articulation of three bones: the radius, ulna and humerus. There are ligament structures on the medial/inside and lateral/outside portions of the elbow. Many of the muscles that allow for movement of the elbow joint have attachments around the elbow joint.
Ulnar Collateral Ligament
The ulnar collateral ligament is part of the medial ligament complex. It can be stretched or torn as a result of the throwing motion. Athletes can often feel a "pop" when there is the initial injury. Usually regular life activities are not affected, just throwing activities. Chronic changes can occur to the elbow after injury to the ligament if throwing is resumed prior to healing or surgical repair. Often patients will not be able to fully extend the elbow because of inflammation. Patients might also develop numbness and tingling in the fourth and fifth digits because of injury to the ulnar nerve (neuropathy).
Treatment with non-operative methods can be attempted but is usually not successful. Rest, bracing, and anti-inflammatory medications can be helpful. Avoiding throwing activities is important. According to Dr. Denise Eygendaal of Amphia Hospital in the Netherlands, higher demand throwing athletes do worse with physical therapy and other non-operative measures and typically require surgery. If physical therapy and non-operative management fails, a surgery can be performed to reconstruct the ligament using a graft ligament. This is referred to colloquially as "Tommy John Surgery".
Posterior Impingement/ Valgus Extension Overload
Throwing with poor mechanics can lead to excessive stress on the posteromedial part of the elbow (inside and back portion). Athletes will complain of pain in the back of the elbow as it extends during throwing. There can be impingement symptoms, catching, locking and pain. There can be development of microtears in the medial ligaments because of valgus extension overload (extra force on the medial ligaments as the elbow straightens). Extra bone growth can develop in the back of the elbow that leads to impingement as the elbow loses range of motion. Treatment involves stopping all throwing, resting the elbow, using ice, physical therapy and using anti-inflammatory medications. Surgery is indicated for patients with valgus laxity (medial ligaments are stretched) or for removal of the osteophytes that are causing impingement. Posteromedial shear is a similar injury to posterior impingement, but the pain occurs during the acceleration phase of throwing. It is treated similarly with physical therapy, and surgery if necessary.
Posterolateral Rotary Instability
Posterolateral rotary instability (PLRI) typically occurs after elbow trauma or after surgery on the lateral collateral ligament of the elbow. It is not linked to throwing trauma itself, but can result after surgery for other conditions or elbow trauma from other activities of baseball. PLRI can affect both athletic performance and daily activities. The elbow is painful, can have clicks with movement, and there can be other mechanical symptoms. Treatment with non-operative methods usually fails. Surgery is aimed at reconstructing the lateral ligaments of the elbow or "tightening up" the lateral collateral ligament with the overall goal to improve stability of the joint.
The major non-ligamentous injuries that occur around the elbow include lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow). These conditions are both related to tendons rather than ligaments. Lateral epicondylitis is a condition of overuse that causes pain over the lateral epicondyle where the extensor carpi radialis brevis (ECRB) has its origin. The ECRB muscle allows for extension of the wrist. Treatment consists of physical therapy and symptom relief with anti-inflammatory medications and bracing. Sometimes surgery is required. Medial epicondylitis is a condition that is less common than lateral epicondylitis. There is elbow discomfort over the inside/medial part of the elbow. There is tenderness typically over the pronator teres and flexor carpi ulnaris muscles. These muscles are involved in pronating (turning) the forearm and flexing the wrist. Treatment is physical therapy and symptom relief with anti-inflammatory medications. Sometimes surgery is required for patients that do not respond to physical therapy.