Prevention and Rehabilitation of Thrower’s Elbow
1. What is Thrower’s elbow?
Medial or inside elbow pain may be caused by performing repetitive badminton overhead smashing. These forceful strokes cause inside elbow stress on the elbow (or medial valgus stress), (Fleisig et al., 1996), and may have the following consequences: golfer’s elbow (flexor-pronator tear or tendinosis), nerve irritation (ulnar neuritis), or Ulnar Collateral Ligament (UCL) sprains or ruptures, (Bell, 2006). This ongoing stress on the elbow causes further damage by overloading the bony elbow structures at the back and cause loose bodies and more instability (Safran, 2004).
2. Risk factors to other players and how to prevention this injury
Badminton is explosive and consists of repetitive jumping and lunging. The player must perform fast directional changes with the racket-arm, doing combination of rapid arm throwing movements similar to baseball throwing or tennis serving. This causes excessive strain on the arm, (Faude et al., 2007). Male badminton players perform the smash frequently since this is a very effective way to score points. The inside elbow is stabilised against valgus stress, primarily by the UCL and to a lesser extent by the flexor-pronator complex (FPC), (Safran & Baillargeon, 2005). The UCL provides support against this valgus stress when the elbow is flexed between 20°-120°, and is under maximum stress when flexed at 70°. When the player plays frequently, the FPC becomes fatigued and cannot provide effective support to the inside elbow. This may result in micro-tears, inflammation and later cause FPC degeneration (tendinosis), (Ciccotti et al., 2004). While preforming the smash, valgus stress in the late cocking and early acceleration phase may produce medial sheering force of 300N, and 900N compression forces on the elbow. The UCL can only tolerate 64N safely, consequently it is prone to injury, (Flesig et al., 1995), especially with a faulty technique.
2.1 Faulty technique assessment within the kinetic chain
Faulty techniques can be identified by slow-motion video analysis of different strokes. Faulty techniques cause unnecessary strain on the body resulting in injury. By identifying the problem the coach can improve the technique, optimize force generation and reduce load on the elbow (Eygendaal et al., 2007). For example when excessive wrist flicking is performed during strokes, strain is caused on the FDC resulting in reduced force generation, (Sakurai & Ohtsuki, 2000). Skilled badminton players should use the shoulder and forearm rotation to produce force with lower energy cost to produce an effective smash, (Marshall & Elliott, 2000).
The kinetic chain describes a sequence of movements that follow-on from each other to produce the maximal amount of force, (Kibler et al., 2013). The legs produce force that is then transferred up the kinetic chain to the back, trunk, into the arm, and finally to the racket to produce a stroke. Video analysis can identify players with inadequate leg performance, reduced trunk rotation, poor core and scapular control, or incorrect sequencing of movements, which can then be corrected, (Wilk et al., 2012).
2.2 Fitness and skill
Fitness, skill, mental power, tactics, balance and coordination (neuro-muscular control (NMC)) are essential in badminton. Players train and play in an anaerobic energy system. Their anaerobic fitness should be tested regularly for optimum success during matches, (Chin et al., 1995). Skilled players reduce fatigue by resorting to the stored elastic energy of muscles (stretch-shortening cycle) of the shoulder rotators, (Genevois et al., 2013) and the forearm rotators, and the pre-stretching energy from quadriceps before jumping to perform the smash, (Tsai & Chang, 1998). This should be trained to increase efficiency.
2.3 High velocity versus gender
Baseball pitchers pitching with a higher ball velocity have an increased risk of elbow injury and receiving surgery, (Bushnell, 2010). Likewise, male badminton players perform frequent high velocity smashes. Males are able to do this due to a higher racket grip velocity and faster shoulder rotation, abduction and elbow extension to produce a faster smash, (Salim et al., 2010). UCL injuries are known to reduce shuttle accuracy and velocity, with lack of stamina and strength, (Safran, 2005), which may explain why AB’s performance was unsatisfactory in Malaysia.
2.4 Playing frequency and reduced upper limb range of motion (ROM)
Overuse injuries are usually quite common at the beginning of a new season when preseason conditioning was ineffective, or more towards the end of the season when the players are fatigued, (Jorgensen & Winge, 1990). Players that participate in competitions for longer than 8 months in the year are at risk of injury, (Shanley & Thigpen, 2013). Frequent, excessive volumes of overhead strokes reduce soft tissue flexibility, for instance: dominant shoulder inward rotation (IROM), (Wilk et al., 2011), and total shoulder rotation range of motion (TROM), that may cause additional stress on the inside elbow and UCL, (Eygendaal, 2007; Garrison et al., 2012). TROM and IROM are indicators of soft tissue restriction, (Couppe et al., 2014).
During excessive playing, elbow extension ROM reduces due to a flexor contracture or scarring that requires mobilisation, (Wilk et al., 2004). Identifying and improving restricted flexibility may promote upper limb biomechanical force production and translation with-in the kinetic chain, (Kibler, 2013).
Educating players about the importance of limiting excessive overhead activity, proper warm-up and maintaining flexibility whilst training may reduce injury, (Wilk, 2004). Screening and injury prevention programmes should be performed throughout the year to benchmark wrist, elbow and shoulder strength and ROM, monitor fitness and improve strength, endurance and flexibility to support the demands of badminton, (Ellenbecker et al., 2010; Shanley & Tightpin, 2013).
Medial elbow pain should be assessed by taking a thorough patient history, physical assessment and imaging. Medial epicondylitis is indicated by pain and weakness with resisted wrist flexion and pronation. By pressing slightly below and to the front of the medial epicondyle causes pain, (Ciccotti et al., 2004). If numbness or weakness of the small and ring finger is present, nerve conductive tests needs to be performed to rule out ulnar neuritis, (Ciccotti, 2004). Alternatively referred pain from the neck may also be the cause, (Lee & Lee-Robinson, 2010). The ‘Milking manoeuvre’ test identifies valgus instability, (O’Driscoll et al., 2005). Dynamic ultrasound or MRI arthrogram is used to identify UCL injuries, flexor-pronator tears, tendinosis or calcification, (Azar et al., 2000; Nazarian et al., 2003).
Due to the sudden onset of pain and lack of performance, a UCL sprain is suspected. An initial non-surgical UCL rehabilitation consisting of an initial protected phase, intermediate phase, advance strength training phase and RTS is advised, (Modified guidelines: Wilk, 2012).
3.1 Initial protective phase
- Reduce inflammation and pain
- Promote ligament healing
- Regain optimum pain free ROM
- Avoid muscle atrophy
1. Discontinue badminton with ‘active rest’. Avoid any further injury to the medial elbow structures for example heavy lifting and gripping. The kinetic chain needs to be taken into consideration and strong emphasis should be on core, scapular stability and shoulder strengthening, (Ellenbecker et al., 2009).
2. Treatment for the FPC: Ice and anti-inflammatory medication, transcutaneous electrical nerve stimulation, (Chesterton et al., 2009), and Cyriax treatment, (Trudel et al., 2004, Kohia et al., 2008) may reduce pain. Low intensity ultrasound increases protein synthesis, (Haker & Lundeberg, 1991), and laser treatment improves cell function, (Oken et al., 2008). Platelet rich plasma promotes UCL and FPC healing, (Halpernet et al., 2012; Podesta et al., 2013). Isometric elbow and wrist flexor and extensor exercises should be performed to avoid any further muscle wasting. Gentle stretching of the wrist flexors and pronators should be performed, (Wilk, 2004).
3. Elbow joint mobilisation: the physiotherapist may use Grade I-II mobilisation techniques and gradually progressing to Grade III-IV in weeks 3-4, to reduce pain and improve ROM (Maitland, 1987; Wilk, 2004).
4. Shoulder and arm strengthening: the concept of strengthening all components of the arm should apply. By strengthening the scapula stabilisers using high repetitions and low resistance endurance at varying speeds will be promoted. By applying manual resistance above the elbow, Serratus anterior, Trapezius and Rhomboids can be strengthened to provide stability, (Ellenbecker, 2009). Rotator cuff strengthening using manual resistance to activate the posterior cuff and scapular stabilisation during prone extension and horizontal abduction, (Wilk, 2013).
5. Lower limb and core strengthening: Leg press, squats and calve heel raises will promote force production in the lower limb kinetic chain. Additionally, progressing to lower limb plyometrics to increase the quadriceps elastic energy, improves power production with reduced fatigue during the single leg smash, (Tsai & Chang, 1998).
3.2 Intermediate phase
- Maximise elbow range of motion and flexibility
- Improve strength and endurance
- Improve stability
The elbow joint capsule has a tendency to form adhesions with scarring of brachialis muscle. This needs to be reduced to maximise elbow extension by means of a low load, light resistance extension stretch for a duration of 10-15 minutes, 4 times per day. The arm, in pronation and elbow extension (figure 1), is attached to an elastic band providing a long duration light loaded (LDLL) stretch, (Wilk, 2004). This aim is to reach full elbow extension ROM at 3-4 weeks.
Figure 1: LDLL stretching (from: Ellenbecker et al., 2009)
2. Elbow flexion and extension: progression to concentric biceps and triceps strengthening can be introduced, if no pain is present. Concentric (muscle- shortening) triceps contraction improves racket velocity during the acceleration phase and needs to be trained, (Fleisig, 1995). During elbow extension the whipping effect may cause overload. Biceps need to be strengthened in an eccentric way (muscle lengthening) to oppose this, (Eygendaal, 2007).
3. The FPC provides dynamic elbow stability (Davidson et al 1995) and must be gradually loaded with concentric and then progressive ongoing eccentric loading, using elastic bands and light weights, (Cook & Purdam, 2009; Ellenbecker, 2010; Lewis, 2013 ) and continued stretching (Ellenbecker et al., 2002).
4. Posterior shoulder structures: sleeper stretch and the modified side-lying cross-body stretch mobilise the posterior shoulder structures. This can also be performed while the player is lying down, fixating the scapula and performing horizontal adduction across the chest, (Ludewig & Reynolds, 2009; Wilk, 2012; Shanley & Thigpen, 2013).
5. Myofacial release of the posterior shoulder structures and the forearm may improve mobility of the upper limb, (Travell & Simmons, 1999).
6. Upper limb rhythmic stabilisation that promotes dynamic stabilisation and neuromuscular control (NMC) may be increased and progressed to isotonic exercises, (Wilk, 2013).
7. Core stability and trunk rotational exercises must be performed for example medicine ball trunk rotation and swissball core strength training. Leg and core exercises that enhance NMC and flexibility that is specific to the needs of this player, for example hamstrings flexibility, (Shanley & Thigpen, 2013).
3.3 Advanced phase
Criteria for progression:
- Full pain-free ROM without any tenderness or laxity
- Elbow flexor & extensor strength improvements
- Good NMC and proprioception
- To increase strength, power and endurance
- Improve NMC with progression to high speed drills
1. Progressive arm strength training: Thrower’s Ten isotonic programme should be followed to strengthen the upper limb with Theraband and dumbbells. This is a comprehensive programme to improve strength, endurance and power in preparation for overhead strokes, (Wilk, 2012).
2. Ongoing biceps and FPC eccentric training should be incorporated at varying speeds and loads.
3. Isokinetic training: Furthermore wrist and elbow isokinetic strength training can be implemented at speeds of 180’and 300’ per second for 15-20 repetitions to promote strength and endurance, (Ellenbecker, 1991; Ellenbecker, 2009). This includes concentric and eccentric training for the wrist flexors, pronators and eccentric elbow flexors in a protective capacity, (Lauder et al., 2012), as well as eccentric shoulder external rotation and concentric internal rotation, (Van Cingel et al., 2007).
4. Weight training: gym equipment may be introduced for bench-press, seated rowing and Latissimus Dorsi pull-downs, (Wilk, 2012).
5. Plyometrics must be carefully implemented without any discomfort, (Wilk, 2013; Ellenbecker, 2013). This can be done by wrist flicks and snaps (Figure 2). Distal arm strengthening with ball dribbling on the wall (Figure 3), and progress to internal shoulder rotation ball tossing (Figure 4), (Ellenbecker, 2013).
Figure 2: Wrist flicks (From: Ellenbecker, 2013)
6. Technique analysis: Video stroke technique analysis should be performed and errors should be corrected, (Wilk, 2004).
7. Interval badminton programme (IBP), (Wilk, 2004): by introducing the IBP, the phased return to sport is established and confidence promoted. Proper warm-up including flexibility should be introduced and consistently used in future, (Shanley & Thigpen, 2013). Correct stroke mechanisms as determined by the video analysis should be applied under the supervision of the coach. Efficient communication should exist between the athlete, coach and other rehabilitation professionals to ensure that effective progression is established and regression or re-injury is avoided.
Some discomfort during and after the implementation of the IBP is acceptable, however, the player needs to stop if pain is sharp and inform the physiotherapist, (Reinold et al., 2002). By using alternative days, the first week will be played at 50% of maximal stroke force during forearm and backhand while week 3-4 will be at 75% of maximum force with correct technique using forearm and backhand strokes. At week 3, power strokes are performed at 50% force. At 4-6 weeks 100% force of forearm and backhand strokes will be introduced with power strokes at 75%. Progressive amounts of each stroke will be performed. If this is successful, phased return to 3 games may be initiated. Again, gradual progression from 1.5 sets to full matches, without any elbow pain. The IBP must be introduced and progressed very carefully. If pain is present, the player needs to be reassessed and the management reconsidered, (Wilk, 2012).
Figure 3: Distal Arm Strength training with ball dribbling (From: Ellenbecker, 2013)
Figure 4: Internal shoulder rotation ball tossing (From: Ellenbecker, 2013).
3.4 Return to Sport may be considered after week 14
- Completed Thrower’s Ten programme, IBP and fitness testing.
- Pain free and full ROM, palpation & no laxity present
- Isokinetic ratios must be comparable to the non-dominant side. Comparative dominant elbow flexion strength should be 10-20% more while elbow extension ought to be 5-15% greater in elbow extension compared to the non-dominant side, (Wilk et al., 1993). Dominant side forearm pronation should measure 10-25% stronger, (Ellenbecker, 1991).
4. RTS Recommendations
If rehabilitation is successful, the player may compete after 12-14 weeks, with between-competition re-assessment to avoid re-injury, (Rettig et al., 2001; Wilk, 2004; Lavellee et al., 2013). Returning to competition will be on 17/06/14, with a phased return. The next competitions will be 14/10/14, 11/11/14 and 17/12/2014, to provide the player time to continue with further rehabilitation and avoid overloading. If, at 3 months of rehabilitation, ongoing medial elbow pain, UCL pathology or pain at 75% of hitting, is present, surgery should be considered, indicting an early season end, (Cain et al., 2010; Lavallee, 2013). The ‘Tommy John surgery’ rehabilitation is 11months, (Dodson et al., 2006).
Due to the excessive demand of badminton, all players are at risk, but especially males that perform a faster frequent smash, (Salim et al., 2010). Care should be taken to avoid overloading by participating too frequent in competitions, causing excessive fatigue. Good technique, warm-up and flexibility is important. Overhead activity should be limited. Regular screening that include assessing FPC symptoms or UCL laxity, should be performed.
Badminton players must perform all year round conditioning that includes strength training and fitness conditioning together with proper warm-up and stretching. The players should receive regular screening to assess shoulder and elbow ROM loss or FPC pain. Proper technique modifications may be helpful to avoid tissue overload, fatigue and complications.
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