Upper limb throwing injuries

This session included presentations on: General biomechanics and aetiology; Shoulder throwing injuries: SLAP & biceps tendon; Radiology of impingement and SLAP; Throwing injuries of the elbow: ligament injuries and chronic overload; and Tennis wrist: the ulnar corner.

Despite sometimes having suboptimal biomechanics, many world-class tennis players have what is known as the ‘magic of a lively arm’, which describes precocious and easy power and performance, which seems to come from having the confidence to hit through the ball. The glenohumeral joint should only have 2–3 mm of translation of the humerus head with respect to its instantaneous axis of rotation in the glenoid; more than that causes excessive load and impingement. However, overhead athletes need large ranges of external rotation to accelerate their arm for maximum power, and these repeated actions often result in injury, such as SLAP lesions. Diagnosis is made by presentation, history and imaging [MRI with arthrogram (MRA)]. Most debate centres on the type 2 ‘detachment’ injury. The best approach is to start with rehab; repair, if necessary, can be done with a variety of suture materials and approaches (do not ‘strangle’ the biceps!). Follow with a sling and then rehab. The decision-making process should be guided by the patient’s needs and expectations and done as a collaborative team approach. Imaging is useful for impingement syndromes: plain radiography (bony lesions) and ultrasound (US) (bursa and rotator cuff), which allows guided steroid injections for external impingement; MRI/MRA for posterior superior Internal impingement; and US/MRI and MRA can be useful for anterior superior types, especially subtle lesions and biceps pulley lesions. CT arthrograms are useful for post-operative review.

In the elbow, posteromedial elbow impingement syndrome or valgus extension overload syndrome (VEOS) can be debilitating in throwing athletes. It is due to a slight laxity of the joint, causing the posterior olecranon to hit the posterior trochlea, which may happen with or without injury of the medial ulnar collateral ligament (MUCL). It is crucial to determine if the patient has MUCL instability or not. Treatment involves removal of the bone causing the impingement, which can be done well by arthroscopy.

In the wrist, ulnar corner [involving the extensor carpi ulnaris (ECU) and the triangular fibrocartilage complex (TFCC)] is at risk of damage in modern day tennis, particularly with the more common use of the double-handed backhand. Diagnosis by MRI and dynamic US. ECU tendinopathy can be treated conservatively by rest, steroid injections and technique modification or ultimately surgery. Instability is more like to need surgery. Most TFCC problems will usually recover non-operatively.