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An orthopedic diagnosis identifies a tissue that has failed. Patients engage in activities, play sports, pursue hobbies, develop postures, and traumatically injure themselves to end up in your office.  The patient’s age can help narrow the list of potential tissue failures.

Proper diagnosis and subsequent treatment will vary based on your understanding of tissue maturation, and more specifically, growth plates. Understanding tissue injury based upon age will make you more efficient in practice and improve your clinical effectiveness. Watch this quick three-minute video about how pitching impacts the elbow differently, depending upon the patient’s age.

 

Have you ever diagnosed a 10-year-old with tendinopathy?

After this blog, you may reconsider.

*The remainder of this blog will dive deeper into repetitive stress injuries as they relate to orthopedic diagnoses.  We will use the example of a baseball pitcher, but keep in mind, this is a similar process for every developing athlete, regardless of pain location.

Patient # 1: 13-year-old baseball pitcher

Tissue injury happens at the weakest point in the kinetic chain—often defined by patient age. Ossification centers at the elbow fuse at different times:

  • olecranon age 11
  • lateral epicondyle age 13
  • medial epicondyle age 16

Youth sports specialization (and subsequent overuse) usually occurs during this period, predisposing patients to growth plate injuries. (1) Disruption of ossification centers is the most common overuse injury involving the pediatric skeleton. The junction of the physeal-metaphyseal region of any growing bone is “the most vulnerable structure to overuse injuries observed in the young pediatric athlete.” (2

Suspected Diagnosis # 1:

Medial Epicondyle Avulsion Fracture

Typical signs and symptoms : 

  • Medial elbow pain usually associated with increased pitch count or training intensity
  • Tenderness to palpation
  • Decreased throwing velocity

Patient # 2: 17-year-old baseball pitcher

As our patient becomes skeletally mature, their growth plates fuse and bone is no longer the weakest link. Vulnerability shifts from the physis to the interface between the medial epicondyle and ulnar collateral ligament. “Tendons and ligaments now become the weakest structures of the joints, and in the medial elbow, continued distraction forces applied during throwing may result in significant tears of the medial ulnar collateral ligament itself following skeletal maturity.” (4)

Suspected Diagnosis # 2:

Ulnar Collateral Ligament Sprain

Typical signs and symptoms include:

  • Medial elbow pain and tenderness
  • Decreased throwing velocity
  • Positive Moving Valgus Stress Test

Moving Valgus Stress Test

The “moving valgus stress test” reports 100% sensitivity and 75% specificity for UCL laxity. The test is performed by maximally flexing the elbow. The examiner applies a valgus torque to the elbow during rapid elbow extension. Apprehension, pain, or instability, usually from 70 to 120 degrees of flexion, signifies a positive result. (5)

Moving Valgus Stress Test

The “moving valgus stress test” reports 100% sensitivity and 75% specificity for UCL laxity. The test is performed by maximally flexing the elbow. The examiner applies a valgus torque to the elbow during rapid elbow extension. Apprehension, pain, or instability, usually from 70 to 120 degrees of flexion, signifies a positive result. (5)

Patient # 3: 35-year-old baseball player

Repetitive elbow flexion and pronation create a strain on the common flexor origin, resulting in irritation. Recurrent valgus stress from the pitching motion is thought to be a principal trigger for medial epicondyle pain due to excessive stretch and eccentric overload. Skeletally mature populations often suffer from degenerative tendinopathies rather than acute inflammatory responses. Tendinopathies begin from repetitive overloading & micro-tearing and culminate with a disorganized healing process that fails to regenerate a “normal” tendon. Repetitive activity without appropriate rest results in a failed healing response.

Suspected Diagnosis # 3:

Medial Epicondylopathy

Typical signs and symptoms include:

  • Medial elbow pain and tenderness
  • Positive Golfer’s Elbow Test

Golfer's Elbow Test

Perform this test on a seated patient with their palms resting on their knees. The clinician grasps the patient’s hand and elbow and simultaneously supinates the hand while extending the wrist and elbow. Reproduction of pain suggests medial epicondyle involvement. 

Rule Out

Cubital Tunnel Syndrome: patients frequently report paresthesia or pain extending distally from the medial epicondyle to the fourth or fifth digit. Nocturnal symptoms are common. Likely positive ulnar nerve tension test, possible Tinel sign at the elbow. (6)

In Summary

Treatment for apophysitis includes prevention of the inciting activity, wrist braces that limit motion, ice, soft tissue therapy, and oral analgesia. (7) These measures help alleviate the acute inflammation associated with apophysitis and tendinitis but do little to alter the long-term course of tendinopathies. Conversely, a comprehensive management approach for chronic tendon pain will likely require measures to stimulate a controlled inflammatory reaction, i.e., instrument assisted soft tissue manipulation, eccentric rehabilitation, ESWT, dry needling, etc.

An evidence-based chiropractor’s primary clinical objective is to diagnose patients—not merely treat them. Understanding treatment pathways are critical, but the ability to diagnose precedes the ability to treat effectively.  There are nuances to every case; as each patient is a case study of “one.”  However, age may be an overlooked variable in patient diagnosis.  Understanding tissue maturation and load management will allow you to become more efficient with your time, and more effective with your clinical care.

Be sure to check out the condition references in your ChiroUp account for in-depth evaluation, treatment, & management when treating elbow pain (and 95 other conditions.)

Looking for another way to become more efficient with your time? 

You’re going to want to check out ChiroUp’s condition report builder

In a matter of seconds, you can send condition-specific reports to your patients with their entire treatment plan, ADLs, & exercises. You can probably imagine how much time that will save you from explaining & re-explaining. 

Want to see this resource in action?

Get started with your free trial today!

References
  1. Klingele KE, Kocher MS. Little league elbow: valgus overload injury in the paediatric athlete. Sports Med. 2002;32(15):1005–1015.
  2. Jaimes C, Chauvin NA, Delgado J, et al. MR imaging of normal epiphyseal development and common epiphyseal disorders. Radiographics 2014;34(2): 449–71.
  3. Kobayashi K, Burton KJ, Rodner C, et al. Lateral compression injuries in the pediatric elbow: Pan- ner’s disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12(4): 246–54.
  4. Kijowski R, Tuite MJ. Pediatric throwing injuries of the elbow. Semin Musculoskelet Radiol 2010;14(4):419–29.
  5. O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med 2005;33(2): 231–9.
  6. Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med. Jan 1996;15(1):65-83.
  7. Lawrence JT, Patel NM, Macknin J, et al. Return to competitive sports after medial epicondyle fractures in adolescent athletes: results of operative and nonoperative treatment. Am J Sports Med 2013;41(5):1152–7

About the Author

Dr. Brandon Steele

Dr. Brandon Steele

DC, DACO

Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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