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INTRODUCTION

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Throwing warmup pitches to start the bottom of the second inning, Hudson felt some tightness around his elbow. On the second pitch that inning, he felt that something was seriously wrong. His fastball dipped to about 85 mph, and he became hittable. He stayed in the game and completed the inning . . but that . . would be Hudson’s last pitch for another year.

Report on Major League Baseball pitcher Daniel Hudson’s return from two ulnar collateral ligament surgeries

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A well-functioning elbow is essential for upper limb use in sports. Elbow injuries may even interfere with an athlete’s everyday activities. Tennis was the classic cause of elbow pain, but the double-handed backhand has reduced the prevalence of ‘tennis elbow’ dramatically. Elbow pain remains a problem in golf and in sports such as volleyball and handball, which involve forceful elbow hyperextension.

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To approach elbow pain in clinical practice, consider which of the following categories describes your patient’s elbow pain:

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  • lateral elbow pain, with a particular focus on extensor tendinopathy

  • medial elbow pain

  • posterior elbow pain

  • acute elbow injuries

  • forearm pain

  • upper arm pain.

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ANATOMY

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The elbow is situated between two highly mobile joints, the shoulder and the wrist, and comprises three distinct articulations—the ulna-humeral, radio-capitellar and proximal radio-ulnar joints. The first two provide flexion (150°) and extension (0°) of the elbow and the third provides pronation/supination (85°/85°) of the forearm. The proximal radio-ulnar joint works in conjunction with the distal radio-ulnar joint at the wrist to achieve forearm pronation–supination. With the forearm in full extension and supination there will be a physiological valgus (carrying angle) of 9–14° in men or 12–17° in women. Any increase or loss of this physiological angle is a sign of pathology (instability, mal-union or overuse). Elbow stability is provided by the osseous anatomy, capsuloligamentous structure and musculotendinous units that cross the elbow.

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Ligaments

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The ligaments of the elbow are divided into lateral and medial collateral ligament complexes. The medial collateral ligament complex is composed of discrete bands; the lateral collateral ligament complex consists of complex ligament fibres.

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The medial collateral ligament complex (MCLC) is composed of the anterior oblique, posterior and transverse bands. The anterior band is the primary constraint against valgus stress, contributing 55 to 70% of valgus stability of the elbow. There are two elements of the anterior band: the anterior non-isometric and posterior isometric bundles. There is sequential tightening of these bundles proceeding from anterior to posterior when the elbow is flexed from full extension. The fan-shaped posterior band of the MCLC is a thickening of the capsule that is best defined with the elbow flexed at 90°. The posterior band does not contribute significantly to valgus stability of the elbow except in near terminal flexion. The transverse band (TB) does not cross the joint, but exists as ...

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