Return To Play | Elbow Injuries

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– Injuries to the elbow are common in sports, typically due to acute trauma, overuse, or improper mechanics. These injuries are often caused by throwing or swinging motions in sports, such as baseball, golf, or pickleball. The experts at UPMC have studied elbow injuries in athletes for decades, developing injury prevention methods, thorough diagnosis, and individualized treatment plans. So, if you are an athlete suffering from elbow pain, look no further. UPMC has the team to help. Hi, I’m Charlie Batch. Yes, that Charlie Batch, if the name is familiar to you. And I’m here with Dr. Josh Szabo, an orthopaedic surgeon specializing in the elbow at UPMC. Doc, thanks for joining me today.

– Thank you for having me.

– How did you become interested in focusing in orthopaedics in surgery and sports medicine?

– Like so many, my interest was born as a patient. I was a 17-year-old freestyle mogul skier, and I had an injury to my right knee. Well, it turns out I was one of the first patients at UPMC Sports Medicine Center, and Dr. Freddie Fu reconstructed my knee. During that process, I lost my window of opportunity to be an Olympian, but learned about and understood the impact that medicine has on people’s lives. It’s because of this, I then pursued a career in medicine and led me to doing what I’m doing today. It’s astounding to think about what Dr. Fu has done and impacted lives. For me, he was my treating physician. He then was a mentor, and then he was a colleague.

– Why have you developed a strong interest in elbows?

– I was fortunate to do my fellowship training in Jackson, Mississippi, which is one of the centers for elbow arthroscopy. During that time, I did a research project on arthroscopic treatment of tennis elbow, or lateral epicondylitis, a common condition. In that research, we found that arthroscopic technique is as effective as open technique. And I got a chance to travel the country lecturing this, and I got a chance to also meet other elbow surgeons. And as a result, I went on to teach elbow arthroscopy, and I continue to do so right now.

– And what is elbow arthroscopy?

– That’s a description of the surgical technique we utilize to address pathology. So, historically, we would do things through an open technique: a large incision, expose everything. And in doing so, we’d have to violate tissue planes. Arthroscopy allows us to use poke-hole incisions, that even a pen can’t even fit into, to insert a camera with a light source and magnification. And then we have other access points, or portals, that then, we can introduce instruments into the joint and treat pathology. We don’t have to violate all the soft tissues, and usually it affords less pain and a quicker recovery. And it allows a great inspection of structures that we may not have seen.

– And what are some of the common conditions that you treat in athletes?

– There are a multitude of conditions that I’ll treat in an athlete. And the easiest way to break it down is to consider them by age. So my younger athletes, my adolescents, can have a disorder of the bone and cartilage, which is referred to as osteochondritis dissecans, or they can have growth plate injuries, where instead of injuring the ligament while they’re throwing, they injure the growth plate because the growth plate’s more weak than the ligament. Then, as the athlete matures, I’ll see a different injury pattern. And I’ll see the ligamentous injuries that we think of, like the Tommy John, or UCL, injury. You can see elbow dislocations, which the elbow is the second-most commonly dislocated joint in the body. And the later athlete will have tendon problems, such as golfer’s elbow, tennis elbow, or distal biceps ruptures. And even the older athlete can have arthritis, which can be successfully treated with elbow arthroscopy.

– And what type of athletes do you see most often, and why?

– Again, that becomes, it’s racket sports, it’s throwers, it’s volleyball players. You can see extreme athletes like motocross riders. We see collision sports such as rugby and football, is some of the athletes that we’ll see routinely.

– How is pitch count, specifically in baseball, related to elbow injuries?

– Well, studies have shown, especially in the 9- to 14-year-olds, the younger athletes, it’s important to protect their elbows from injury. So there’s been recommendations. So, for instance, we try to limit 75 pitches per game. Or, another way to calculate that is 15 batters per game to avoid injury, or a total of 600 pitches per season. We also recommend that they take three months off a year of throwing. Lastly, we talk about the sequence in which we teach throwers how to pitch. So, at 8 years old, we talk about teaching the fastball. At 10 years old, we talk about the changeup. Then, we skip up to 14 years old; that’s a curveball. And then, at 16, we talk about teaching them sliders. And this is all predicated on how their elbow matures and can endure the stresses that each pitch requires.

– Now, I know you mentioned pitch count, and you mentioned 75 balls per game. Now, is that from warmup to 75th pitch? Or is that only in-game pitches when you refer to 75-pitch count?

– It’s vigorous throwing. So, if they’re doing a lob toss, that shouldn’t be counted, but it’s for meaningful pitches.

– OK. So how can athletes help prevent elbow injury?

– First, preparation’s the key. So, you have to be prepared to participate in that activity, and you have to understand the kinetic chain. So, for example, a pitcher, the motion starts with their feet, goes through their legs, and then it goes through the hips and core, so those have to be strong. Then, it’s transmitted through their shoulder, and onto their elbow, and out to their hand to throw the ball. So that kinetic chain is only as strong as its weakest link. Specific to pitchers, we often see that their shoulder can have a problem; then, that leads to the traumatic elbow injury, such as the Tommy John injury. So we have to be cognizant of that. The other things that we’ve got to concern ourself with prevention are avoiding overuse, proper training and coaching with their techniques, and then we have to consider early intervention for injuries. Because if we recognize injuries early, we may treat them effectively and obviate the need for surgical intervention.

– And you mentioned Tommy John. That term is thrown out a lot. For people who are watching this, what does Tommy John mean?

– Tommy John’s the first person that underwent elbow surgery and then returned back to sport. It was done in California, and what it refers to is the ulnar collateral ligament on the medial side of the elbow. And that’s what pitchers, when they have injuries, that’s the ligament they injure. So it’s been synonymous with UCL injuries or Tommy John.

– Now, we don’t want to get to the point of surgery, and we’ll get to that point first. But what does nonsurgical treatment look like for you?

– The first thing I tell them is don’t do things that hurt. So it’s activity modification. Then, it’s about restoring the soft tissues and balances, making sure that kinetic chain, every link is very strong. That can be done through physical therapy. It can be facilitated by their athletic trainer and assisted by also overseeing by their coach. And then they get back to sport and return.

– Now, when you get to the point of determining that surgery is needed, what’s actually involved with that?

– No. 1, you have to see where the athlete is in their season, and you have to see and address the pathology, and then consider at what level you want to intervene. When it comes to surgery, you have to understand all the pathology that you’re dealing with. Life abhors a vacuum. So, you have to realize it may not just be the ligament. There could be an extra piece of bone in the elbow and treat everything accordingly. Then you carry out the surgery itself, and then you do the aftercare and rehabilitation to return them back to sport.

– Now, we’re talking about post-op. What does that look like for an athlete if they needed elbow surgery?

– Well, postoperatively, athletes, it can be a traumatic experience because most of them have not experienced an injury to date. So, you have to be careful and take them through that process. Surgery itself is there to restore the anatomy, whether it’s the repair or reconstruction, using tissues to augment that. And then, in the early phase, you want to protect that repair in the surgery that was performed. You want to restore their motion, then you want to restore their function, and then you want to work on sport-specific movements in getting them back ready in preparation. But, also, you have to work on identifying any factors that may have led them to their injury and make sure those are remedied. And, lastly, it’s the return to play. And that’s also a big step in getting them back.

– Now, how do you know that a athlete is ready to return to play?

– Oftentimes the athlete will tell you, but they’re not always the best and most reliable source. And this becomes a group effort in a team, like we have in UPMC. You have to ask the physical therapist who’s rehabilitating them. No. 1, I have to examine them and make sure everything is proceeding as expected. The athletic trainer can provide insight, as can the coach. And then once that’s ready, the decision can be made among the team to get them back to return.

– When you see that gleam and that smile that they have on their face, you know they’re ready to return, is that one of the most rewarding factors of your job?

– Absolutely. That’s why I do what I do and why I love it. I’ve got one of the coolest jobs in the world, and seeing that smile, seeing their confidence return, alleviating their pain and restoring their function, and allowing them to participate in the sport that they enjoy is so fulfilling and rewarding for me.

– Dr. Szabo, appreciate the great information that you shared with us today, and thank you for joining us.

– Thank you for having me; it was wonderful.

– From either acute trauma or overuse-type elbow injuries, proper diagnosis and treatment are vital to a quick recovery and return to play. If you are experiencing elbow discomfort or become suddenly injured, seek the care you need at UPMC Sports Medicine. To learn more about common elbow injuries and how the team of experts can help you get back to throwing that game-winning pass, visit

About Sports Medicine

An athletic lifestyle carries the potential for injury. Whether you’re an elite athlete or a weekend warrior, UPMC Sports Medicine can help. If you are looking to prevent, treat, or rehabilitate a sports injury, our multidisciplinary team of experts can help you get back into the game. If you are seeking to improve your athletic performance, we can work with you to meet your goals. We serve athletes and active people of all ages and experience levels. Our goal is to help you keep doing what you love. Visit our website to find a specialist near you.