Javelin Thrower's Elbow


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Definition

Javelin throwers elbow is a sprain or injury to the medial ulnar collateral ligament (UCL) of the medial elbow, which is easily susceptible to injury. As the injury is commonly seen in javelin throwers, it is named as javelin throwers elbow.

Description

Javelins Thrower’s Elbow is mostly caused by overuse.

The pain begins when the elbow is subjected to a valgus force, which is bigger than the tensile properties of the ulnar collateral ligament (UCL). UCL stretching is provoked by poor technique of throwing the javelin. Poor technique consists of throwing with insufficient shoulder abduction (90° - 100°), where the elbow is too low resulting in a valgus force on the joint. Since the UCL is the principal structure opposing this motion, it will be the primary site of injury. Athletes participating in throwing sports, or overhead sports in general, are at higher risk of being diagnosed with this injury.

First sign of injury is sharp pain while throwing the javelin and aching pain at the medial elbow there after that very soon begins to interferes with the performance of the athlete.

A second type of "javelin elbow" occurs in expert throwers and is the result of hyperextension of the elbow at the end of the throw, causing an injury to the tip of the olecranon. These symptoms resolve with rest, but are known to re-occur.

Epidemiology/Etiology

The onset of the injury can be a direct trauma, but is more likely to be insidious due to the accumulation of repetitive sub-threshold valgus forces on the UCL. This will generally result in a sharp pain during the throw and/or an ache at the medial elbow after a heavy and exhausting session. The pain will increase in proportion to the amount and intensity of throwing with the performance of the athlete. 

This injury is commonly caused by a lack of competence of throwing the javelin. In general, there are two ways of throwing the javelin:

1. Round arm, which causes strain on the medial collateral ligament,
2. Over arm, which can lead to roughening and new bone formation at the tip of the olecranon or even might result in avulsion of the tip. 

Signs and Symptoms

1. Swelling around the elbow joint, especially the medial aspect of the elbow joint
2. Reduced range of motion at the elbow joint
3. Tenderness along the medial aspect of the elbow
4. Medial elbow pain
5. Decreased power during throwing activities

Recognizing this injury promptly can lead to better treatment outcomes and decrease the risk of permanent damage or persistent functional disability.

Inspection

Resting position of the elbow and carrying angle of the elbow have to be appraised. The normal carrying angle is 11° of valgus in men and 13° of valgus in women. An increased valgus angle may indicate the body is accommodating for the repetitive stress of valgus instability. Furthermore, it is important to note the presence of an effusion, scars, developmental abnormalities or signs of previous traumas.

Clinical Examination

• Range of motion (ROM) is important to assess the injury. Let the patient perform flexion, extension, supination and pronation.
• Detect the end feel of these movements and any associated pain. A soft end feel in extension may indicate a soft tissue contracture of the arm flexor apparatus. A bony end feel in terminal flexion on the other hand may indicate anterior bony osteophytes or loose bodies.. 
• It is mainly the valgus stress test of the elbow that will reproduce the pain.
• Other pathologies around the medial elbow, such as golfers elbow or avulsions, have to be excluded.

Differential Diagnosis

For a good treatment of this injury you must understand the differential diagnosis of medial elbow pain is very important to diagnose medial collateral ligament injury as well as the treatment of other medial elbow injuries.

• Medial epicondylitis (Golfer's Elbow)
• Ulnar nerve entrapment
• Cervical radiculopathy
• Ulnar collateral ligament injury
• Ulno-humeral arthritis
• Presence of medial osteophytes
• Medial epicondyle avulsion fracture
• Cubital tunnel syndrome

Physiotherapy Management

The PEACE and LOVE principle has approved by clinicians and researchers in many trials in managing acute soft tissue injuries.

• In the acute phase of the injury, PEACE approach could help in providing relief:
  • Protect: Unload or restrict movement to minimize bleeding and prevent aggravation of the injury. To support and protect the passive ligamentous system in the beginning of the rehabilitation period, an elbow brace or a sleeve could be recommended.
  • Elevate: Raise the injured limb above the heart to reduce swelling.
  • Avoid Anti-inflammatories: Do not use anti-inflammatory medications
  • Compress: Apply external pressure with taping or bandages to help reduce swelling and hemorrhage.
  • Educate: Learn about the benefits of active recovery and appropriate management strategies for your specific injury. Note on using ice in the acute phase: The role of ice in muscle injury recovery has different opinions. Traditional studies show that applying ice can help reduce pain and swelling right after an injury, while the newer evidence claim that prolonged icing may slow the body’s natural healing response.
• In the sub-acute phase of recovery, after the pain and soreness decrease, use an active approach based on the LOVE principle:
  • Load: Gradually introduce controlled exercises and movement within pain limits to restore function and strength.
  • Optimism: Maintain a positive and realistic outlook on recovery, as psychological factors significantly impact healing.
  • Vascularisation: Engage in activities that increase blood flow to the injured area, such as pain-free cardiovascular exercise and targeted muscle work.
  • Exercise: Progressively increase the intensity and type of exercises to rebuild strength, mobility, and stability in the affected area and surrounding musculature.
• In the advanced rehabilitation phase of the injury, it is time to increase the load on the elbow joint. It is vital to remember that pain is still persistent and before you returning to throwing javelin or other more intense activities, one should commence strengthening of the upper limb. During this time, patient is suppose to slowly return to throwing but at a reduced intensity.

Early Stage Exercises

If pain and stability of the elbow allow, a gradual and progressive return to throwing may be initiated. Caution should be taken to assure a safe recovery of the strength of the medial collateral ligament. Since poor throwing technique is the main contributing factor to this injury, implementing technique changes is of upmost importance. The correct method is that the shoulder is abducted higher (120°-130°) so internal rotation of the arm can bring the elbow forward early in order to reach a position directly in front of and above the shoulder. From there, powerful extension of the elbow will transmit the necessary force to the javelin without endangering the UCL. Rehabilitation finishes when the patient can complete a throwing motion with no pain or discomfort. 

Patients whose symptoms do not improve conservative treatment or patients with loose cartilaginous bodies, avulsion fractures or osteochondritis dissecans (Osteochondritis Dissecans of the Elbow) should be referred to their orthopaedic specialist. Surgical management Surgery of the medial collateral ligament is necessary when: - a throwing athlete has a complete UCL tear, - diagnosed partial tear that has failed to improve with conservative management, - symptomatic non-throwing athletes after a minimum of three months of non-responding conservative care. When surgery is necessary, two techniques are available: direct repair of the ligament or reconstruction. The latter is the most widespread used surgical modality.