Welcome to New Orleans, remember you probably know this already, it's a marathon not a sprint. So we're glad you're even here for an elbow talk. So this is actually, my apologies, these are my conflicts, but we're talking about a throwing elbow in football players is actually not a common injury at all. So most of the data we'll show you is from baseball. We have had an epidemic increase in elbow injury rates in the last 15 years. It's gotten all the way down to, we'll show you all the way almost to t-ball where they've had more injuries and everybody talks about Tommy John and the medial collateral, but as you just heard, most injuries in football are going to be totally different from that. But these are the kind of things you're going to see where you see a tiny, a tiny fleck if you look at the screen on the left at the bottom of the medial, medial epiphysis, and then here you have an avulsion, here's an OCD from repetitive use, and then electro non-stress fractures. And you'll see some of this usually related to trauma in terms of football players. So baseball risk factors, Glenn Fleissig and Jimmy Andrews did a ton of work on this and it's almost all overuse in baseball players, different from football. So football, common injuries in professional football, quarterbacks basically almost never involve the elbow. The San Francisco quarterback this year notwithstanding, that's not a throwing injury, that was a traumatic injury, right? So we hardly ever see throwing injuries in our football players, unless you're dealing with multi-sport athletes at younger ages, and so we'll kind of talk about this a little bit. We actually started looking into this, interestingly, about a year and a half ago, the throwing motion for quarterbacks is very different from baseball players, and this is something we presented last year, Andre Labbe is one of our therapists, and we have an outerwear system and we're trying to look at the throwing motion, mostly because a very famous high school quarterback here last year who's no longer in our state and is now in Texas, started having some elbow problems and we wanted to correct it without a surgical intervention, we were able to do that. So I can't say names because it's a HIPAA violation, and it actually worked out pretty well. He actually started throwing better and so that inspired us to start looking at this and we've changed some things and we can put you in the system and actually change your mechanics if you're a high school quarterback. Professional quarterbacks have already set up their stuff, you're not going to change anything about what they're doing, but this is actually some pretty good work, I think. Small numbers, again, because we're analyzing mostly normal quarterbacks. So let's talk about youth to NFL, what kind of things do we see? Well, it changes by age, and we'll go through these a little bit, but these are the things you see at different ages related to throwing injuries. So age less than seven, they're playing minor league sports, they're not going to get hurt, they're going to fall down, they'll get a little nursemaid's elbow, they might get a fracture, you already heard some good talks about that, but throwing-wise, it just doesn't happen that you'll have anything you deal with. When they get up in the eight or nine range, they actually are susceptible, so they have growth plate issues, the medial apophysis is not really ossifying that well. The thing you have to watch for very carefully is if they start to separate the bottom. We've all seen things like this, again, if you look to your left where you have a little osculate at the bottom, I'll show you that a little bit later, but that can be a bad actor. That's where the medial onoculatoral ligament attaches, and if you're seeing this at a young age, you really want to take care of it, that's where we see those folks down the road with some bony overgrowth. It doesn't mean surgery, it just means you need to look for it. Nine to 13, you're going to see that avulsion fracture, it can be traumatic where they hit and pull off as part of a beginning of an elbow dislocation, and it can be overuse where they make the one throw and it pops, or a combination as we saw in the NFL this year. Oftentimes it's acute on chronic, where you see it in quarterbacks is when they're playing in the fall, they're also doing fall baseball on Sundays, because they're obviously going to play both sports when they get to the major league level, and so you see this where they're hitting both of them, and then one of them will cause a separation. Early treatment is important, if you can get them before there's about two to three millimeters of separation and there's no rotation on your x-rays or MRI scan, then you can treat them non-operatively with an elbow brace and a wrist brace to protect the flexor pronator, and kind of just work on it. You check these by palpating along the back of the apophysis, not the front, because you're looking for rotation, and if you feel a step off, or if that hurts when you push, you really need to treat this a bit more aggressively, but it usually will heal with non-operative treatment. If it's more than about three millimeters, or if there's rotation which will result in medial laxity, then you want to put a couple of screws in, and so for these young athletes, three millimeters is career ending. I just saw a kid yesterday in the office that we're going to fix, he's playing professional baseball, who I treated 12 years ago for one of these injuries, and his parents were like, they came in and said, we're so thankful that you saw that he was going to be such a good player down the road, and play in Major League Baseball, and I went, no way. I mean, he's a little bitty kid, he's grown up, he's so big, I had no idea. I mean, hell, I didn't know, I just fixed the fracture. So anyway, so watch out for separate pieces when you see these things, but it's probably worth fixing them, and be careful of the ulnar nerve, and then we go really aggressively with these. If you have a young athlete, we put it down, you put two good screws in, they don't have to be really long screws, you go up the medial column, we put them in a couple of braces for about three weeks while it locks down, and really start. Your biggest risk is stiffness, not recurrence of the avulsion. Usually we start a return to throw about six to eight weeks, and we'll let them hit it about a month, and they do pretty well with that, so it's a big deal. And then we have our medial instability, and primarily overhead athletes, again, everybody wants this surgery. We already saw this about the medial ulnar collateral ligament, and then the moving valgus stress test is your best exam, although there's some other ones, we'll show you one. This is an exam under anesthesia, this was after dislocation, so really very unstable, not quite that much, but those are the tests. If you have this injury, especially in a football player, basically they can play with rehabilitation and a brace for short term, you really don't need to fix it. If they're a multi-sport athlete, and they're gonna play baseball, throw the javelin, do other things, then you need to think about some of these other options. So this is actually an NFL player that's very interesting, he had a dislocated elbow, popped a brace on just like you heard, played the rest of the season, didn't miss a game. Next season, playing without a brace, same thing happened, dislocated, back in a brace, played the rest of the season. The next year, which is where this picture comes from, had another injury, of course, out of his brace, and dislocated the elbow, but also completely toward the lateral side, so complex elbow dislocation, and avulsus triceps. So we did the lateral side and the triceps arthroscopically, but this is what the inside of the ligament looks like. And so when you talk about problems with that ligament, it almost never happens. It looks like, again, we'll go to the left screen, there's a little bit of changes here and here on the bone. This is what's left of the medial onocollateral ligament, it's obviously a proximal avulsion. That's the joint, but the joint actually looked great when you look in there. So there's no consequences if you wait a bit, other than you may have some bad looking tissue like this. So historically, Frank Jobe changed this injury from career ending to career playing. I mean, it's like a giant change in the treatment of elbow throwing injuries, and it's just an amazing thing. There's a lot of options, though. You can treat this with bracing and rehabilitation. Tom Noonan just had a good paper two years ago, about 85% with non-operative treatment, and there's a lot of different things that you can do for it. Let's run through these really quickly. In an NFL player, you're going to brace this and let him go back to playing as quick as possible. That ligament will heal in four to six weeks. It's an extra-articular ligament. It's not an ACL. It's a little tiny one millimeter thick, about a centimeter long ligament, so it's not actually that great a thing. It's not an ACL. Just put them on rehabilitation. If they really want something, put a PRP shot in. It makes parents feel better if they spend some money on their child, but they're going to get back to playing. I know you've got biologics talks later, so that's not a knock on it, it's just like magic. This is one of ours. It had a partial, near-complete proximal tear. We did a couple of PRP shots, and then when we looked at it, if you look back at this one where our arrow is, that looks like a normal medial ulnar collateral ligament. Most likely it would have done without the PRP, but the parents were convinced that that's what made the difference and went back to playing without a problem, so it does happen. Surgery's indicated non-operative treatment's been unsuccessful. They want to keep playing. They can rehabilitate it. From a non-professional athlete standpoint, the timing of the seasons are very important because most of these, again, are multi-sport athletes, and you have to figure out what's most important. It's usually whatever they're playing at the time, and then try to figure out what you want to do. You can repair it. You can repair it with a brace, and then you can do a reconstruction. We'll run through these really quickly. The medial ulnar collateral ligament's an extra-articular ligament. It's had all this magic attached to it for many years, but it's an extra-articular ligament. It should heal more like a medial collateral ligament in the knee as opposed to an ACL because it's got really good blood supply about the elbow, so non-operative treatment can be very effective. You can split the muscle if you have to operate on it, so it shouldn't be that big a deal. This is an acute injury, and so when we talk about what we can repair, this is the medial ulnar collateral. This is a proximal avulsion. Here's the joint, which looks normal. This is the anterior capsule, and then you can see it's not really attached to the sublime tubercle. Here attachment, here's off, a little bit of damage at the top, and so acute avulsions of either side or both ends, which you do see sometimes, can all be repaired without a problem, especially in a football player because there's not as much stress across it. If you tear the middle, we're not sure about that right now. There's some evidence that maybe we could repair that, but I really wouldn't trust that at all. So I scope all of these. About 50% of the time we find pathology. If you say, I don't want to scope it, it's not a problem, I really don't have any evidence that it makes a difference, but in a contact athlete like a football player, I think it really helps to look in there and look at the rest of the elbow. Sometimes you'll find a little loose piece in the back where they knocked a chip off or an associated tear on the lateral side. Once we finish that, this is prone. We just internally rotate the shoulder, put the hand on an arm board, and we have direct contact with the medial side of the elbow. If you look, the palm is up, so that's our position, 70 degrees in pronation. If you want to harvest your palmaris, it's right there. This is really easy to do, and then you don't have to have anybody holding the arm at all while you're working on it. So I think it's easier if you're used to doing it supine, then it's going to take a little bit to understand the difference. What I found also prone is the medial anabrachial cutaneous nerve, for whatever reason, stays further out of the way, so I don't have to deal with it. I hate that nerve, and so I don't have to do anything with it. So this is our repair. So it's about a three to four centimeter incision. Split the muscle. You're looking at the ligament. If we're just doing a repair, we'll make a split kind of along the middle of it. That's the bony avulsion right there in the pickups that I showed you. And then we'll put an anchor in, pass our stitches, and repair it. So these are our younger kids where we don't want to put an internal brace in. This is our 10, 11, and 12-year-olds where we really don't want any permanent implants. So we use something absorbable at the top, put some dissolving stitches in, and do our repair. You can also do it through bone tunnels. That's kind of what it looks like when we get all done, magic PRP to help. And then they do pretty well. We split them for about a week. We do a hinged elbow brace for about eight weeks, mostly because they like to do too much. Start them on therapy right away, because they all have a disconnected scapula. They all have bad core strength and hip strength. And we just work on everything to get them back. And usually three to four months, they're back playing. And these are old studies and they show good results. Internal brace has been a game changer. I think Jeff Dugas, there's a ton of credit for developing this. And it's really changed the game as far as on the collateral ligament injuries. This is another more chronic one. You can see the changes there, but that's the brace going in. And it really helps to span it. Don't make it too tight. And when you put it in or when you tension it, make sure you have a full arc of motion. The most common issue with this is you make that too tight, it's not meant to replace the ligament. It's just a support. So it has to be a little bit loose. John Conway says he measures before he puts a second anchor in, 15.5 millimeters on the tape and makes a mark. The mark is about two millimeters wide, so I'm not sure I can do a half a millimeter. But we measure 16, figure it's right in there somewhere to get a little bit extra. And then this is what it looks like when you put it back together. It's the same kind of recovery process. You start them on rehab really quickly. And our results were really good. Jeff has a great series on this. There's a lot of papers coming out. We've been doing it for about six years now, seven years, ever since it started. We looked at our first 40 patients, 37 out of 40 back to the same level of play before six months. The vast majority of them went back to playing baseball or full sports at four months out, which is really about as good as we can do for an elbow injury like this. And then the reconstruction, we all know about this, and there's a lot of techniques about that. This is a revision reconstruction. It's kind of tough. So rehab for that is about twice as long. So you're looking at nine to 14 months to get back. So it's quite a bit of time. So the results of that, of course, are very good. So conservative treatment for our football throwing athletes really works the best. Rarely you're going to need to operate on them unless they have some of the structural damage that we talked about or they're a multi-sport athlete, which is what we see. So I think that's the treatment of Troit, especially for single sport football athletes. Return to play to the same level of play is probably fastest with an internal brace if you have to operate on them. So I think that's the way to go in terms of those. Prevention's always a key. Design programs to protect them. You don't want to tailor your surgery to the patient. Don't be a one-trick pony and only do one operation. You want to have the whole gamut of surgeries available to you. And then early rehab is the best thing. So in football, medial edema injuries are more related to acute trauma rather than overuse. I think that's pretty rare. Fatigue and dyskinesia are less of a factor in football throwers, but it does happen. Prevention is education and conditioning. And there are lots and lots of treatment options available, far short of a classic Tommy John surgery, which is almost never necessary in a football quarterback. Thank you.

elbow injuries

baseball players

overuse

treatment options

prevention