Thrower's Elbow is an injury to the medial collateral ligament (MCL) which is most commonly caused by overuse. Sports such as baseball, javelin, tennis, cricket, javelin and water polo have the highest incidence of this injury due to the valgus moment that is placed on the elbow during the late cocking and early acceleration phases of the throwing movement. Most cases of throwers elbow are seen in patients under 20 years old (64.6%), followed by patients between the ages of 20-30 (20.5%) and less commonly seen in patients aged 30-40 years (14.9%). This blog will discuss easy strategies that can help athletes to reduce their symptoms.
The MCL is a complex of ligaments composed of the anterior, posterior and transverse bands. The anterior band is primarily resisting valgus forces (forces which bend elbow towards the body) and contributes 55 to 70% of valgus stability of the elbow. The anterior band is comprised of two parts: the anterior non-isometric and posterior isometric bundles. When the elbow is flexed from full extension, there is a sequential tightening of these bundles preceding from anterior to posterior. The posterior band is shaped like a fan and is best defined when the elbow is flexed to 90°. It does not significantly contribute to valgus stability of the elbow except in terminal (near end range) flexion. Finally, the transverse band does not cross the joint line, yet exists as a thickening at the most caudal portion of the joint capsule. This band only contributes to small amount of elbow stability due to its origin and insertion on the ulna.
Athletes who present with an acute MCL injury typically describe a sudden onset of pain with throwing. In 50% of cases, the athlete will report hearing or feeling a ‘pop’ sensation in the elbow and is typically unable to continue throwing. An MCL tear has 3 different grades ranging from a small partial tear resulting to a complete rupture of the MCL. Athletes with a minor (grade 1) to moderate (grade 2) MCL tear can expect to return to sport/normal activity within 2 – 8 weeks if a rehabilitation program is followed. However, Athletes with a complete rupture of the MCL (grade 3) may require surgical intervention to repair the torn ligament and therefore require a longer rehabilitation timeframe.
The different grades can be described as:
Grade 1: a small number of fibres (<10%) are torn resulting in some pain but allowing full function with no instability.
Grade 2: a significant number of fibres are torn with moderate loss of function.
Grade 3: all fibres are ruptured resulting in elbow instability and major loss of function. Other structures may also be injured such as the cartilage and joint capsule of the elbow.
Let’s guide you through how we resolve lower back pain related to rowing here at Breathe using our Roadmap to Recovery:
Step 1. Pain Reduction
Step 2. Activation
Step 3. Movement
Step 4: Strengthening / Sports Performance
Pain reduction
In the early stages following the injury, the RICE principle should be followed.
Figure 2. Retrieved from: https://www.monhomeomonchoix.fr/en/news/homeopathy-the-athletes-ally/
The RICE protocol is most beneficial in the first 72 hours following injury or when inflammatory signs are present (e.g. pain without movement). As part of the initial management, it is important to cease aggravating activities such as throwing to prevent further tissue damage. Throwing should be ceased for at least 1-4 weeks as guided by your Physiotherapist. Depending on the grade of the injury, your physiotherapist may choose soft tissue techniques to break down and realign scar tissue and increase blood flow. They may also tape/brace your elbow to support the ligaments which helps facilitate healing.
Evidence has shown the risk factors that may pre-determine a MCL sprain such as:
increased BMI
limited glenohumeral internal rotation
preseason supraspinatus weakness,
throwing breaking pitches (curveballs and sliders)
throwing while fatigued
As a result, it is critical that your rehabilitation program is specific to you to facilitate injury prevention. Once you can perform basic range of motion movements with your elbow pain-free, it is important to begin activating the muscles to prevent muscle wasting.
Activation
During the activation phase, your physiotherapist will most likely prescribe you with isometric strengthening (exercises where you hold weight but don't move). These exercises will begin to target the underlying issues which led to your injury. You should not need the brace or strapping at this time, but you may notice that your muscles have shrunk (wasted) due to them not being used. The exercise program will focus on the gradual building of load which ultimately ends with a successful return to sport.
Muscles which cross the medial side of the elbow joint provide dynamic protection of the MCL due to the favourable alignment. These muscles include the flexor carpi ulnaris, which is the most important stabiliser, along with the flexor digitorum superficialis. These two muscles are optimally positioned to provide secondary valgus stability to the medial elbow. In particular, these muscles provide stability between 90 and 120° of elbow flexion which is the position during the cocking phase of throwing.
Some great activation exercises for MCL sprains are:
Isometric Wrist flexion: This requires the wrist flexors (flexor carpi ulnaris, flexor carpi radialis, palmaris longus and flexor digitorum superficialis) to contract isometrically to support the elbow.
Ball squeeze: Squeeze and hold a soft rubber ball. This will activate the wrist flexors as well as the finger flexors such as flexor digitorum profundus.
Isometric ulnar deviation: This exercise focuses on the activation of flexor carpi ulnaris which is the most important dynamic stabiliser of the elbow.
Wrist pronation-supination: The wrist pronators and supinators provide deep stability to the elbow. Use a light weight or resistance band to move from pronation to supination.
Movement
Now that you can activate muscles that support your elbow, it is time to progress the amount of load to challenge it further. In this phase, we will aim to increase the strength of the forearm flexors, pronators and supinators due to evidence showing that strengthening these muscles provide the most active protection of the MCL. Here are 3 great exercises to include in your rehabilitation program:
Reverse throws with resistance band: In a staggered stance, loop a TheraBand around your throwing arm and under the opposite leg. Raise your arm into the throwing position. Shift your weight backwards to mimic the throwing action while controlling the movement. This exercise will dynamically will challenge the flexor carpi ulnaris and flexor digitorum superficialis to resist the valgus forces produced throughout the movement.
Repeated throws against wall: Using a light ball (Soccer or tennis ball), repeatedly throw and catch while maintaining the arm in the cocked position. This exercise will challenge the active (e.g. muscles) and passive (e.g. ligaments) structures to react and control the valgus force.
Medicine ball throw: This exercise is a great way to build explosive power and increase your throwing speed. Step into a lunge position and push the medicine ball away like you are doing a normal throw/pitch. Due to the added load, the valgus forces will significantly challenge the passive and active structures so start with lighter weights and build your tolerance slowly.
Strengthening / Sports Performance
To avoid MCL-related elbow pain in the future, it is important to continue weekly strength and conditioning sessions in addition to regular throwing sessions. These sessions should aim to continually progress your strength and mobility by focusing on dynamic movements which replicate the throwing technique. The Throwers Ten Program is a very popular and well-researched program that incorporates the relevant muscles required for throwing as well as other muscles from the kinetic chain. Always speak to your Physiotherapist about which program would be the best for you and your goals.
Reference:
Brukner, P., & Khan, K. (2017). Brukner & Khan's clinical sports medicine : injuries (5th edition). McGraw-Hill Education Australia.
Carr, J. B., Wilson, L., Sullivan, S. W., Poeran, J., Liu, J., Memtsoudis, S. G., & Nwachukwu, B. U. (2022). Seasonal and monthly trends in elbow ulnar collateral ligament injuries and surgeries: a national epidemiological study. JSES Reviews, Reports, and Techniques, 2(1), 107–112.
Park, M. C., & Ahmad, C. S. (2004). Dynamic Contributions of the Flexor-Pronator Mass to Elbow Valgus Stability. Journal of Bone and Joint Surgery. American Volume, 86(10), 2268–2274.
Saper, M. G., Pierpoint, L. A., Liu, W., Comstock, R. D., Polousky, J. D., & Andrews, J. R. (2018). Epidemiology of Shoulder and Elbow Injuries Among United States High School Baseball Players: School Years 2005-2006 Through 2014-2015. The American Journal of Sports Medicine, 46(1), 37–43.