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Chondromalacia of the trochlear notch in athletes who throw
Chondromalacia of the trochlear notch in athletes who throw Julio Robla, MD, Keith S. Hechtman, MD, John W. Uribe, MD, and Marc S. Phillipon, MD, Coral Gables, Fla. Six athletes who throw and one shot-putter who underwent elbow arthroscopy were found to have an area of chondromalacia involving the posterolateral aspect of the olecranon. Preoperative symptoms were pain and tenderness to palpation over the lateral edge of the olecranon. On physical examination, range of motion was full or only slightly decreased (<5 ~) in five patients; coexistent bose bodies were also noted in two patients having a 20 ~ loss of extension. None of the patients exhibited ligamentous laxity to valgus stress testing of the elbow. During arthroscopy, the involved area was distinct from the bare area of the olecranon. This area was found as an isolated lesion in only one of seven patients; localized synovitis was noted in five patients, olecranon osteophytes in three, and loose bodies in two. A reciprocal lesion on the articular surface of the humerus was not identified in any patient. During arthroscopy, the lesion was debrided to a stable margin, and all associated pathologic conditions were addressed. Six of the seven athletes were able to return to their sport at premorbidity levels with this approach. This area of trochlear chondromalacia has not been previously described and, in our study, occurred in individuals whose elbows were subjected to repetitive valgus stress with lateral compression. (J SHOULDERELBOW SURG 1996;5:69-72.)
Elbow arthroscopy is an increasingly used technique to evaluate and treat various disorders of the elbow.r, 4. 8. is The athlete who throws, in particular, places significant stresses on the elbow resulting in a variety of conditions and overuse syndromesT' 3, s, 9, 18 The throwing motion, as described by Slocum, 1~ is divided into four distinct phases: wind-up, cocking, acceleration, and follow-through. During the wind-up and cocking phases, the elbow is in flexion with no significant valgus stress placed on it. 6' 7. lo The acceleration phase, in which the explosive contractions of the shoulder and forearm musculature propel the hand forward, is the phase during which maximum valgus stress and the majority of elbow injuries occur. The effect of this valgus stress translates into medial tensile and lateral compressive forces across the elbowT' 14, r9 In addition, contraction of the triceps From the Universi~ of Miami, Departmenl of Orthopaedics and Rehabihtation, Division of Sports Medicine, Coral Gables. Reprint requests:julio Robla, MD, Health South/Doctors Hospital, 5000 Universily Drive, Coral Gables, FL 33146. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/96/$5.00 + 0 3 2 / 1 / 6 8 ! 53
muscle to extend the elbow during the latter stages of acceleration places tensile forces on the olecranon process. During the follow-through phase, forearm muscles contract to slow the rapidly extending elbow and prevent forceful impingement of the olecranon tip in the supracondylar fossa of the humerus, a' 1r The purpose of this article is to present a previously undescribed chondral lesion of the trochlear notch of the olecranon that we have noted in persons who place significant valgus stress or lateral compressive forces on their elbows. MATERIAL A N D METHODS
Seven male athletes aged 16 to 25 years (average 20 years) with persistent complaints of posterolateral elbow pain underwent elbow arthroscopy after conservative treatment failed. Various competitive levels and activities were represented in this study and included one high school baseball pitcher, one high school shot-putter, three college baseball pitchers, one college third baseman, and one professional baseball pitcher. On initial examination, all seven patients complained of activityrelated pain localized to the posterolateral aspect 69
70
J. Shoulder Elbow Surg. January~February 1996
Robla et al.
CHOh O~'GENER,
BA~E
Figure 2 Arthroscopic view of right elbow from direct lateral portal visualizing medial wall of trochlear notch. chondromdacia is visible inferior)y.
Figure ! Trochlear norcn cnonaromaacia ana its relation ro Dare area of o~ecranon. of the olecranon. This pain was accentuated during the cocking and acceleration phases of the throwing motion. 6~ 7. -4. ~9 Two of the seven patients also complained of intermittent locking or catching and had radiographic evidence of posterior compartment loose bodies. All seven patients had tenderness to palpation along the posterolateral aspect of the olecranon. Range of motion was full or only slightly decreased (<5 ~ in five patients. The remaining two patients, in whom loose bodies were present, exhibited a 20 ~ loss of extension. Forearm pronation and suppination were full. Diagnostic evaluation included a detailed clinical examination with plain radiographs of all patients and magnetic resonance imaging of three. Conservative treatment for a minimum of 8 weeks was instituted for all patients and consisted of a 2-week rest from the inciting activity with nonste-
roidal anti-inflammatory medication and formal physical therapy to include stretching, strengthening, massage, and ultrasound to the area of maximal tenderness, Three patients were also unsuccessfully treated with a local corticosteroid injection. Elbow arthroscopy was performed with patients under general anesthesia in the lateral decubitus position with an arm bolster for support. '3 Exami, nation while patients were under anesthesia iden, tiffed no ligamentous instability of any elbow. Standard arthroscopic portals and techniques were used, and any associated pathologic condition was addressed appropriately during the arthroscopic procedure. 1,4, 8, 15Immediate postoperative range-of-motion protocols were instituted.
RESULTS On arthroscopic evaluation, the patients had chondromalacia of the articular surface of trochlear notch of the olecranon process involving an area measuring approximately 0.5 cm 2 with irregular chondral margins (Figures 1 and 2). A comparison of preoperative magnetic resonance imaging with intraoperative findings identified this area to be poorly visualized by current techniques with no scan demonstrating any suspicion of chondromalacia preoperatively. 12 Associated lesions were noted in five of the seven patients and in-
J. Shoulder Elbow Surg. Volume 5, Number 1
Robla etal.
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71
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Figure 3 Illustration demonstrating relation between vdgus elbow stress and trochlear notch chondromalacia.
Table I Lesions associated with trochlear notch chondromalacia Patient
Synovitis
Loose bodies
Olecranon osteophytes
1
Ms Ms Ms No No Ms Ms
No No No No Ms No Ms
No Ms Ms No Ms No No
2 3 4 5 6 7
cluded prominent olecranon osteophytes, loose bodies, and localized synovitis (Table I). These lesions were addressed during arthroscopy by excision of prominent olecranon osteophytes, removal of loose bodies, and localized, partial synovectomy. Five of the 7 patients had grade Ill or grade IV chondromalacia of the trochlear notch requiring chondroplasty and debridement of loose articular cartilage to achieve a stable margin. The remaining two patients had grade II chondromalacia requiring no treatment. Postoperative range of motion was full in all seven patients, including the two patients with a preoperative 20 ~ flexion contracture who also underwent arthroscopic loose body removal.
Return to sport-specific activity at premorbidity levels occurred in 6 of the 7 athletes after arthroscopic treatment. The five high school, college, and professional baseball pitchers were able to return to pitching at their previous levels by the following season and required no further treatment. The college third baseman was also able to return to his sport. The only failure in this series occurred in the high school shot-putter, who was unable to return to shot-putting because of persistent pain over the lateral elbow during the act of putting the shot. DISCUSSION We believe trochlear notch chondromalacia in athletes who throw is a chronic condition resulting
72
J. Shoulder Elbow Surg. January~February 1996
Robla et al.
from repetitive impingement of the midlateral trochlear notch on the trochlear ridge of the humerus. This contact most likely occurs during the late cocking and early acceleration phases of the throwing motion in which valgus stress is maximal (Figure 3). This chondral degeneration appears to be associated with posteromedial decranon osteophytes, which may represent a reciprocal lesion caused by the valgus stress imposed on the elbow by the throwing motion. Although it is uncertain that this chondromalacia is the principal cause of symptomatology in the majority of these patients, it is at the very least a contributing lesion and a potential source of chondral loose bodies. During the arthroscopic evaluation of a patient, particularly an athlete who throws, with complaints of posterior elbow pain during the acceleration phase of throwing, we recommend a full examination of the anterior and posterior compartments. Particular emphasis should be directed to the trochlear notch, preferably through the direct lateral portal, which best visualizes this area of chondromalacia. If significant chondromalacia of the trochlear notch is present, it should be debrided and any associated pathology addressed. This area of chondromalacia is distinct from and should not be confused with the adjacent bare area of the olecranon, which is located in the midportion of the trachlear notch and is normally devoid af articular cartilage.11' l Z Postoperative range-of-motion protocols should be instituted immediately, and the athlete should return to competitive throwing through a supervised progressively advancing protocol. Trochlear notch chondromalacia is currently not detectable by magnetic resonance imaging and should be suspected on clinical grounds in any person, and in particular an athlete who throws, with persistent complaints of posterolateral elbow pain.
REFERENCES 1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 2. Barnes DA, Tullos HS. An analysis of 100 symptomatic baseball prayers. Am J Sports Med 1978;6:62. 3. Bennel GE. Shoulder and elbow lesions distinctive of baseball players. Ann Surg 1947; 126:107. 4. Carson WG. Arthroscopy of the elbow. Instr Course Led. 1988;37:195-201. 5. De Haven KE, Evarts CM. Throwing iniuries of the elbow in athletes Orth Clin North Am 1973;t:801. 6. FeltnerME, Dapena J. Dynamics of the shouLderand elbow joints of the throwing arm during a baseball pitch. IntJ Sports Biomech 1986;2:235-59. 7. Gainor BJ, Piotrowski G, Puhl J, Allen WC, Hagan R. The throw: biomechanics and acute injury. Am J Sports Med 1980;8(2):/14. 8. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 1985;8:1290-6. 9. Indelicato PA, Jobe FW, Kerlan RK, Carterm VS, Shields CL, Lombardo S. CorreclabJe elbovv lesions in professional baseball players: a review of 25 cases. Am J Sporls Med 1979;7(1):72 7. 10. King JW, Brelsford HJ, TuJlosHS. Analysis of the pitching arm of the professional baseball pitcher. Chn Orthap 1969;67: 11623. 11. Morrey BF. Anatomy and kinematics of the elbow. Instr Course Lect 1991 ;40:11-6. 12. Murphy BF. Magnetic resonance imaging of the elbow. Radiology 1992;184:525-9: 13. O'Driscol[ SW, Morrey BF. Arthroscapy of the elbow. J Bone Joint Surg 1992;74A(1 ):84 93. 14. Pappas AM, Zanacki RM, Sullivan TJ. Biomechanics of baseball pitching: a preliminary report. Am ] Sports Med 1985; 13:216-22. 15. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: a new technique. Arthroscopy 1989;5:222-4. 16. SIocum DB. Classification of elbow rniuries from baseball pitching Tex Med 1968;64:4853. 17. Till@an BH. Contribution to the function and morphology of articular sur[aces. Stuttgart: George Thieme, 1978. 18. Tullos HS, Erwin WD, Woods GW. UnusuaL lesions of the pitching arm. Clin Orthop 1972;88:169-82. 19. Wilson FD, Andrews jR, Blackburn TA. Valgus extension overload in the pitching elbow. AmJ Sports Med 1983;11: 83-8
Elbow arthroscopy is an increasingly used technique to evaluate and treat various disorders of the elbow.r, 4. 8. is The athlete who throws, in particular, places significant stresses on the elbow resulting in a variety of conditions and overuse syndromesT' 3, s, 9, 18 The throwing motion, as described by Slocum, 1~ is divided into four distinct phases: wind-up, cocking, acceleration, and follow-through. During the wind-up and cocking phases, the elbow is in flexion with no significant valgus stress placed on it. 6' 7. lo The acceleration phase, in which the explosive contractions of the shoulder and forearm musculature propel the hand forward, is the phase during which maximum valgus stress and the majority of elbow injuries occur. The effect of this valgus stress translates into medial tensile and lateral compressive forces across the elbowT' 14, r9 In addition, contraction of the triceps From the Universi~ of Miami, Departmenl of Orthopaedics and Rehabihtation, Division of Sports Medicine, Coral Gables. Reprint requests:julio Robla, MD, Health South/Doctors Hospital, 5000 Universily Drive, Coral Gables, FL 33146. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/96/$5.00 + 0 3 2 / 1 / 6 8 ! 53
muscle to extend the elbow during the latter stages of acceleration places tensile forces on the olecranon process. During the follow-through phase, forearm muscles contract to slow the rapidly extending elbow and prevent forceful impingement of the olecranon tip in the supracondylar fossa of the humerus, a' 1r The purpose of this article is to present a previously undescribed chondral lesion of the trochlear notch of the olecranon that we have noted in persons who place significant valgus stress or lateral compressive forces on their elbows. MATERIAL A N D METHODS
Seven male athletes aged 16 to 25 years (average 20 years) with persistent complaints of posterolateral elbow pain underwent elbow arthroscopy after conservative treatment failed. Various competitive levels and activities were represented in this study and included one high school baseball pitcher, one high school shot-putter, three college baseball pitchers, one college third baseman, and one professional baseball pitcher. On initial examination, all seven patients complained of activityrelated pain localized to the posterolateral aspect 69
70
J. Shoulder Elbow Surg. January~February 1996
Robla et al.
CHOh O~'GENER,
BA~E
Figure 2 Arthroscopic view of right elbow from direct lateral portal visualizing medial wall of trochlear notch. chondromdacia is visible inferior)y.
Figure ! Trochlear norcn cnonaromaacia ana its relation ro Dare area of o~ecranon. of the olecranon. This pain was accentuated during the cocking and acceleration phases of the throwing motion. 6~ 7. -4. ~9 Two of the seven patients also complained of intermittent locking or catching and had radiographic evidence of posterior compartment loose bodies. All seven patients had tenderness to palpation along the posterolateral aspect of the olecranon. Range of motion was full or only slightly decreased (<5 ~ in five patients. The remaining two patients, in whom loose bodies were present, exhibited a 20 ~ loss of extension. Forearm pronation and suppination were full. Diagnostic evaluation included a detailed clinical examination with plain radiographs of all patients and magnetic resonance imaging of three. Conservative treatment for a minimum of 8 weeks was instituted for all patients and consisted of a 2-week rest from the inciting activity with nonste-
roidal anti-inflammatory medication and formal physical therapy to include stretching, strengthening, massage, and ultrasound to the area of maximal tenderness, Three patients were also unsuccessfully treated with a local corticosteroid injection. Elbow arthroscopy was performed with patients under general anesthesia in the lateral decubitus position with an arm bolster for support. '3 Exami, nation while patients were under anesthesia iden, tiffed no ligamentous instability of any elbow. Standard arthroscopic portals and techniques were used, and any associated pathologic condition was addressed appropriately during the arthroscopic procedure. 1,4, 8, 15Immediate postoperative range-of-motion protocols were instituted.
RESULTS On arthroscopic evaluation, the patients had chondromalacia of the articular surface of trochlear notch of the olecranon process involving an area measuring approximately 0.5 cm 2 with irregular chondral margins (Figures 1 and 2). A comparison of preoperative magnetic resonance imaging with intraoperative findings identified this area to be poorly visualized by current techniques with no scan demonstrating any suspicion of chondromalacia preoperatively. 12 Associated lesions were noted in five of the seven patients and in-
J. Shoulder Elbow Surg. Volume 5, Number 1
Robla etal.
\
71
r# ~r
,:~i~ 84184
9 9
/
~',,%
9
~i~
84
k M~ ~84184184184184184 84
Figure 3 Illustration demonstrating relation between vdgus elbow stress and trochlear notch chondromalacia.
Table I Lesions associated with trochlear notch chondromalacia Patient
Synovitis
Loose bodies
Olecranon osteophytes
1
Ms Ms Ms No No Ms Ms
No No No No Ms No Ms
No Ms Ms No Ms No No
2 3 4 5 6 7
cluded prominent olecranon osteophytes, loose bodies, and localized synovitis (Table I). These lesions were addressed during arthroscopy by excision of prominent olecranon osteophytes, removal of loose bodies, and localized, partial synovectomy. Five of the 7 patients had grade Ill or grade IV chondromalacia of the trochlear notch requiring chondroplasty and debridement of loose articular cartilage to achieve a stable margin. The remaining two patients had grade II chondromalacia requiring no treatment. Postoperative range of motion was full in all seven patients, including the two patients with a preoperative 20 ~ flexion contracture who also underwent arthroscopic loose body removal.
Return to sport-specific activity at premorbidity levels occurred in 6 of the 7 athletes after arthroscopic treatment. The five high school, college, and professional baseball pitchers were able to return to pitching at their previous levels by the following season and required no further treatment. The college third baseman was also able to return to his sport. The only failure in this series occurred in the high school shot-putter, who was unable to return to shot-putting because of persistent pain over the lateral elbow during the act of putting the shot. DISCUSSION We believe trochlear notch chondromalacia in athletes who throw is a chronic condition resulting
72
J. Shoulder Elbow Surg. January~February 1996
Robla et al.
from repetitive impingement of the midlateral trochlear notch on the trochlear ridge of the humerus. This contact most likely occurs during the late cocking and early acceleration phases of the throwing motion in which valgus stress is maximal (Figure 3). This chondral degeneration appears to be associated with posteromedial decranon osteophytes, which may represent a reciprocal lesion caused by the valgus stress imposed on the elbow by the throwing motion. Although it is uncertain that this chondromalacia is the principal cause of symptomatology in the majority of these patients, it is at the very least a contributing lesion and a potential source of chondral loose bodies. During the arthroscopic evaluation of a patient, particularly an athlete who throws, with complaints of posterior elbow pain during the acceleration phase of throwing, we recommend a full examination of the anterior and posterior compartments. Particular emphasis should be directed to the trochlear notch, preferably through the direct lateral portal, which best visualizes this area of chondromalacia. If significant chondromalacia of the trochlear notch is present, it should be debrided and any associated pathology addressed. This area of chondromalacia is distinct from and should not be confused with the adjacent bare area of the olecranon, which is located in the midportion of the trachlear notch and is normally devoid af articular cartilage.11' l Z Postoperative range-of-motion protocols should be instituted immediately, and the athlete should return to competitive throwing through a supervised progressively advancing protocol. Trochlear notch chondromalacia is currently not detectable by magnetic resonance imaging and should be suspected on clinical grounds in any person, and in particular an athlete who throws, with persistent complaints of posterolateral elbow pain.
REFERENCES 1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 2. Barnes DA, Tullos HS. An analysis of 100 symptomatic baseball prayers. Am J Sports Med 1978;6:62. 3. Bennel GE. Shoulder and elbow lesions distinctive of baseball players. Ann Surg 1947; 126:107. 4. Carson WG. Arthroscopy of the elbow. Instr Course Led. 1988;37:195-201. 5. De Haven KE, Evarts CM. Throwing iniuries of the elbow in athletes Orth Clin North Am 1973;t:801. 6. FeltnerME, Dapena J. Dynamics of the shouLderand elbow joints of the throwing arm during a baseball pitch. IntJ Sports Biomech 1986;2:235-59. 7. Gainor BJ, Piotrowski G, Puhl J, Allen WC, Hagan R. The throw: biomechanics and acute injury. Am J Sports Med 1980;8(2):/14. 8. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 1985;8:1290-6. 9. Indelicato PA, Jobe FW, Kerlan RK, Carterm VS, Shields CL, Lombardo S. CorreclabJe elbovv lesions in professional baseball players: a review of 25 cases. Am J Sporls Med 1979;7(1):72 7. 10. King JW, Brelsford HJ, TuJlosHS. Analysis of the pitching arm of the professional baseball pitcher. Chn Orthap 1969;67: 11623. 11. Morrey BF. Anatomy and kinematics of the elbow. Instr Course Lect 1991 ;40:11-6. 12. Murphy BF. Magnetic resonance imaging of the elbow. Radiology 1992;184:525-9: 13. O'Driscol[ SW, Morrey BF. Arthroscapy of the elbow. J Bone Joint Surg 1992;74A(1 ):84 93. 14. Pappas AM, Zanacki RM, Sullivan TJ. Biomechanics of baseball pitching: a preliminary report. Am ] Sports Med 1985; 13:216-22. 15. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: a new technique. Arthroscopy 1989;5:222-4. 16. SIocum DB. Classification of elbow rniuries from baseball pitching Tex Med 1968;64:4853. 17. Till@an BH. Contribution to the function and morphology of articular sur[aces. Stuttgart: George Thieme, 1978. 18. Tullos HS, Erwin WD, Woods GW. UnusuaL lesions of the pitching arm. Clin Orthop 1972;88:169-82. 19. Wilson FD, Andrews jR, Blackburn TA. Valgus extension overload in the pitching elbow. AmJ Sports Med 1983;11: 83-8