Is the ulnar nerve damaged in 'handball goalie's elbow'?

'Handball goalie's elbow' has been defined as pain in the elbow region due to repetitive forced hyperextensions of the elbow. Goalkeepers are the players most often suffering from hyperextension trauma to the elbow in European team handball. They may complain of radiating pain or numbness in the ulnar aspect of the forearm in addition to local pain in the elbow region. To detect any injury to the ulnar nerve that could explain the symptoms, we performed a neurological and neurophysiological study in goalkeepers with elbow pain. Nine goalkeepers, with a total of 15 'handball goalie's elbow', were included in this study. Neurological examination revealed a probable ulnar nerve lesion in one player. Neurophysiological and electromyographic examinations (10 examinations) were, however, normal in all players. Handball goalkeepers with elbow problems may suffer from symptoms suggestive of ulnar nerve affection, but serious or permanent injury to the ulnar nerve with wasting or paresis is unusual.

Osseous manifestations of 'handball goalie's elbow'.

The radiographic manifestations of musculoskeletal stress at the elbow associated with European team handball are reported in 46 amateur handball players with 74 elbows injured by blocking shots. All the 92 elbows were evaluated by clinical and radiological examinations using the 18 asymptotic elbows as a control. Lateral and anterioposterior radiographs were obtained of both elbows in addition to stress radiographs with manual valgus force. The mean age of the athletes was 23.0 (range 16-44) years. The players had an athletic experience of 11.6 years (range 3.5-34). Their elbow pain had at inclusion lasted for 43 +/- 42) (range 2-252) months. Their symptoms were located in all four parts of the elbow and in different combinations: anterior (6), posterior (23), medial (38), lateral (17), and in the whole elbow (3). No major bony lesions were found. Minor abnormalities were observed (21%), including loose bodies (7), traction spur formation (1), and minor arthritic changes (7) in addition to medial instability (12). Manual instability stress test was not useful and should be performed with a stress device. 'Handball goalie's elbow' does not lead to major osseous manifestations.

Hyperextension trauma to the elbow joint induced through the distal ulna or the distal radius: pathoanatomy and kinematics. An experimental study of the ligament injuries.

Loads applied to the forearm result in hyperextension of the elbow. The pathomechanics of hyperextension trauma with load applied to the distal radius and ulna were studied in 10 macroscopically normal cadaver elbow joint specimens to reveal patterns of injury with radial traction (n = 5) compared to ulnar traction (n = 5). The mean age of the donors was 60.8 years (range 33-74). Kinematic testing was performed in an experimental 3D-kinematic loading apparatus. The extension range of motion increased by 20.9 degrees +/- 2.9 degrees after joint loading. Hyperextension loads induced joint laxity during flexion of less than 60 degrees. In both groups, the changes were significant in joint flexion during forced valgus and external rotation, but were not significant in flexion during forced varus and internal rotation. In both groups, the same four lesions were produced: 1) Anterior capsule rupture, 2) L-formed rupture of the origin of the pronator muscle with elongation of the anterior bundle of the medial collateral ligament, 3) partial rupture of the lateral collateral ligament and 4) small cartilage damage to the posterior or anteromedial edge of the ulna. In conclusion, hyperextension trauma to the elbow joint induced through the distal ulna or the distal radius produced the same pattern of injury as reported in hyperextension of the elbow with traction to the forearm when free rotation of the radius relative to the ulna was allowed.

Hyperextension of the elbow joint: pathoanatomy and kinematics of ligament injuries.

According to an epidemiologic study (Scand J Med Sci 1996/ 6: 297-302) the mechanism of "handball goalie's elbow" may be forced hyperextension. The pathomechanics of hyperextension were studied in nine macroscopically normal male cadaver elbow joints. The mean age of the donors was 43.2 years (range 25 to 61 years). Kinematic tests were performed with an experimental three-dimensional kinematic loading apparatus. Hyperextension loads induced joint laxity during flexion of less than 50 degrees. The kinematic changes were significant in joint flexion during forced valgus and external and internal axial rotation, but were not significant in flexion during forced varus. No instability was found with flexion beyond 90 degrees. The hyperextension loads produced four lesions: (1) anterior capsule rupture; (2) L-shaped rupture of the pronator/flexor origin with elongation of the anterior part of the medial collateral ligament; (3) occasional incomplete rupture of the lateral collateral ligament; and (4) small fragments of cartilage near the posterior edge of the ulna in one of the specimens. One or more of these lesions may be responsible for the symptoms in "handball goalie's elbow."

The effect of strength training on 'handball goalie's elbow'--a prospective uncontrolled clinical trial.

'Handball goalie's elbow' is defined as pain due to repetitive forced hyperextension of the elbow. Strength training has been suggested for prevention and rehabilitation of this injury. The present study examines the effect of a strength-training programme after 24 months in a prospective uncontrolled clinical trial in goalkeepers with 'handball goalie's elbow'. Concentric and eccentric elbow exercise loads at approximately 80% of one repetition maximum (1-RM) were carried out 8 to 10 times 3 times a day, 3 days a week. Muscle strength was measured for flexion and extension of the elbow and wrist, and pro- and supination of the forearm. Sixteen amateur goalkeepers (10 men and 6 women) with 25 (12 right and 13 left) injured elbows (16 male and 9 female) were evaluated. Their mean age was 21.0 (range 16-35) years and their elbow pain had at the time of inclusion lasted for 28.9 (range 3-54) months. The players were tested at inclusion and after 24 months. The strength tests showed improvement in all the tested motions. The subjective status of the goalkeepers was excellent in 9, good in 9, and fair in 7. The study indicates that specific strength training may be effective in rehabilitation of 'handball goalie's elbow'.

Combined hyperextension and supination of the elbow joint induces lateral ligament lesions. An experimental study of the pathoanatomy and kinematics in elbow ligament injuries.

An epidemiological study suggested that the injury mechanism of 'handball goalie's elbow' may be hyperextension. The pathomechanics of hyperextension combined with supination was studied in ten macroscopically normal, male, cadaveric elbow joint specimens. The age of the donors was 28.8 years (range 18-45 years). Extension loading of the elbow was performed in an experimental three-dimensional (3D)-kinematic loading apparatus. The degree of extension increased by 16.7 degrees +/- 8.7 degrees after loading. Hyperextension loads induced significant joint laxity in joint flexion (< 50 degrees) during forced valgus, external and internal rotation, respectively, but not during forced varus. The hyperextension trauma produced three lesions: (1) anterior capsule rupture, (2) avulsion of the proximal insertion of both the medial and the lateral collateral ligaments, and (3) occasional single rupture of the lateral collateral ligament. The lesions indicate that combined hyperextension and supination represent a possible mechanism leading to 'handball goalie's elbow'.

Mechanics of the anterior drawer and talar tilt tests. A cadaveric study of lateral ligament injuries of the ankle.

We analyzed the changes in lateral ligament forces during anterior drawer and talar tilt testing and examined ankle joint motion during testing, following an isolated lesion of the anterior talofibular ligament (ATFL) or a combined lesion of the ATFL and calcaneofibular ligament (CFL). 8 cadaver specimens were held in a specially designed testing apparatus in which the ankle position (dorsiflexion-plantarflexion and supination-pronation) could be varied in a controlled manner. Ligament forces were measured with buckle transducers, and joint motion was measured with an instrumented spatial linkage. An anterior drawer test was performed using an 80 N anterior translating force, and a talar tilt test was performed using a 5.7 Nm supination torque with intact ligaments, after sectioning of the ATFL, and again after sectioning of the CFL. The tests were repeated at 10 degrees dorsiflexion, neutral, and 10 degrees and 20 degrees plantarflexion. In the intact ankle, the largest increases in ATFL force were observed during testing in plantarflexion, whereas the largest increases in CFL force were observed in dorsiflexion. Isolated ATFL injury caused only small laxity changes, but a pronounced increase in laxity was observed after a combined CFL and ATFL injury.

Biomechanics of ankle ligament reconstruction. An in vitro comparison of the Broström repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique.

We wanted to use biomechanical testing in a cadaveric model to compare the Broström repair, the Watson-Jones reconstruction, and a new anatomic reconstruction method. Eight specimens were held in a specially designed testing apparatus in which the ankle position (dorsiflexion-plantar flexion and supination-pronation) could be varied in a controlled manner. Testing was done with intact ligaments and was repeated after sectioning of the anterior talofibular ligament and the calcaneofibular ligament and after a Broström repair, a Watson-Jones reconstruction, and a new anatomic reconstruction were performed. An anterior drawer test was performed using an anterior translating force of 10 to 50 N, and a talar tilt test was performed using a supination torque of 1.1 to 3.4 N-m. The forces in the anterior talofibular ligament and calcaneofibular ligament were measured with buckle transducers, and tibiotalar motion and total ankle joint motion were measured with an instrumented spatial linkage. The increase in ankle joint laxity observed after sectioning of both the anterior talofibular and calcaneofibular ligaments was significantly reduced by the three reconstructive techniques, although not always to the level of the intact ankle. Joint motion was restricted after the Watson-Jones procedure compared with that in the intact ankle. Unlike the Watson-Jones procedure, the ligament or graft force patterns observed during loading after the Broström repair and the new anatomic technique resembled those observed in the intact ankle.

Anomalous nerve anatomy at the wrist?

BACKGROUND AND AIMS: The common course of the ulnar and median nerve in the carpal tunnel has been described previously on two occasions. The aim of the study was to explain the cause of two main nerve trunks in the carpal tunnel found at an operation. MATERIAL AND METHODS: A patient was treated with open reduction and internal fixation for a volar Barton's fracture of the distal radius. Later, compression syndrome of the ulnar and median nerves developed. At operation, two nerves were found in the carpal tunnel. Electroneuromyography (ENMG) and magnetic resonance imaging (MRI) confirmed a divided median nerve. RESULT AND CONCLUSION: No anomaly of the ulnar nerve was confirmed. Deviation from the common clinical and ENMG picture of the carpal tunnel syndrome should result in thorough evaluation of possible anomalous nerve anatomy at the wrist. When at operation findings are suspicious of anomalous anatomy of the median or ulnar nerves in the carpal tunnel, Guyon's canal should also be explored to clarify the anatomy of the nerves. In cases with previous carpal collapse or other space occupying lesions we recommend division of the whole transverse carpal ligament in connection with a volar osteosynthesis, because the operative trauma may cause elevation of pressure in both the carpal and Guyon's canals.

High prevalence of elbow problems among goalkeepers in European team handball -- 'handball goalie's elbow'.

The aim of this study was to describe elbow problems among goalkeepers in team handball. A questionnaire was sent to the coaches of 449 senior and 32 junior teams in Norway in 1992. Of these, 304 coaches responded (63%) and their teams were included in the study. A total of 329 out of 729 goalkeepers (45+/-1.8%) and 166 out of 4120 court players (4.0+/-0.3%) were reported by their coaches to have current or previous symptoms from one or both elbows when playing handball. In response to a second questionnaire sent to all the goalkeepers (729; response rate 81%), 41+/-2.0% reported current elbow problems and an additional 34+/-2.0% reported previous problems. During a 2-year observation period from 1992 to 1994, 8.6+/-1.8% of the goalkeepers with previously healthy elbows experienced elbow problems. The typical complaint was recurrent pain and disability episodes, each with an acute onset, but with varying duration. The mechanism of injury for the goalkeepers appears to be repeated hyperextension traumas. We conclude that elbow pain and disability is a significant problem for a large number of goalkeepers in team handball. These problems may be described as a syndrome called 'handball goalie's elbow'.