Recently, I wrote a blog on medial collateral ligament (MCL) injuries in teenage pitchers. The throwing motion puts a lot of stress on the elbow. There’s significant tension on the inside of the elbow, potentially leading to MCL injuries. The other side of this coin is that there’s also a lot of compression on the outside of the elbow. Injuries can occur here as well, when the compressive overload injures the cartilage and bone in this area. This is called osteochondritis dissecans (OCD). In essence, the excessive compression injures the blood supply to the elbow, causing the bone supporting the outside of the elbow to die. This is analogous to a heart attack of bone. In a heart attack, the blood is cut off from the heart, killing part of it. In a stroke, the blood is cut off from the brain, killing part of it. In a bone, when the blood supply is cut off, part of the bone dies, leading to OCD. In the elbow, this most commonly happens in the area of bone known as the capitellum.
OCD causes pain, swelling, and stiffness of the elbow, and often leads to arthritis. In addition, the dead bone and cartilage can break off and form loose bodies that lead to painful locking and catching. It’s a very serious problem.
The best way to treat early OCD, before loose body formation, is to rest the elbow. No throwing, using the arm to bear weight or heavy lifting for 6 months. If that fails to quiet the symptoms, or if there are loose bodies from fragmented bone and cartilage, elbow arthroscopy is often helpful. Elbow arthroscopy can remove loose bodies and smooth down loose cartilage edges that may get caught between the bones of the elbow during motion. In addition, ‘micro-fracture’ can be used to treat the area of OCD. This is similar to what many professional athletes have done to focal areas of arthritis in their knees and ankles. A sharp awl is used to punch small holes in the affected area of bone to hopefully stimulate a healing response that can lead to the production of new cartilage. While the new cartilage formed from micro-fracture is not normal, and not as good as natural cartilage, it may be enough to stop the pain, swelling and the progression to arthritis. After a brief period of splinting to rest the elbow down surgery, motion is encouraged to help the cartilage mature. There is no heavy elbow use for 6 months.
If symptoms persistent for over 6 months following surgery, if the OCD lesion is large, or if the outside rim of bone (that helps stabilize the joint) is lost from the OCD, then a second procedure is indicated. In this procedure, living bone and cartilage is taken from the outside of the knee and placed into the area of the elbow affected with OCD. The hope is that the transplanted cartilage will heal and allow the elbow to function normally. If not, the natural history of OCD is that 50% of patients will continue to have pain and swelling and go on to develop arthritis.
Therefore, as for MCL tears, the best treatment is prevention. Parents, protect your teenage pitchers. Follow the pitch counts religiously. Rest painful elbows. Otherwise, many of the best pitchers will have their careers ended due to injury before they graduate high school. Remember: teenage athletes are more vulnerable to overuse injuries than adult athletes. A little patience and rest in the short run can prevent the end of a promising career in the long run.