Jan 29, 2015Two Elbows Needed
An All-American gymnast overcomes injuries to both her elbows.
By David Hill
David Hill is a former Assistant Editor at Training & Conditioning.
For most athletes with a dislocated elbow, medical repair and rehabilitation is a matter of restoring strength and flexibility to run, manipulate a stick, or catch and throw a ball. But what happens when the athlete not only has to bend the elbow, but have it support her entire body while it twists and flips? And what happens when both elbows are severely injured at the same time?
This was the challenge facing Seattle Pacific University gymnast Corrie McDaniel and the surgical and rehabilitation team working on her case. A USA Gymnastics All-American in the all-around and her team’s co-captain, McDaniel dismounted the uneven parallel bars while practicing on March 29, 2004, just before the USA Gymnastics Collegiate National Championships of her junior season, and landed hands-first on the floor with her arms fully extended.
Both elbows were clearly injured and she was taken to the hospital. At the emergency room, doctors determined her right elbow was dislocated. They sedated her and put it back in place. Damage to her left elbow was less severe, consisting of a left ulnar ligament sprain.
Team physician Christian Peterson, DO, then began analyzing her MRI and other test results for the precise nature and extent of McDaniel’s twin injuries. He found that, in the left elbow, the left radial collateral and ulnar ligaments were damaged. In the right elbow both ligaments were ruptured and she had a humeral fracture. A major question loomed: Would her elbows ever be able to withstand the rigors of gymnastics again? And if so, would it be possible to rehab both elbows in time for competition of her senior year?
“In many of their routines, gymnasts’ entire body weight is loaded on their arms,” says Jeanette Kotch, ATC, Assistant Athletic Trainer at Seattle Pacific who covers the women’s gymnastics team. “When they do a round-off back handspring, for example, they load their whole body weight on their arms and shoulders. We weren’t sure how much stability she would have in her elbows after this injury.
“Our greatest concern was with the bars,” continues Kotch. “When you’re swinging on the bars, you not only have the normal forces but also centrifugal force, and you have to load your body.”
Ideally, both elbows would be operated on. But that would leave McDaniel spending weeks with both arms immobilized, not a workable prospect for a pre-med student in the last semester of her junior year. “If you have surgery on both of your legs, you can be put in a wheelchair and get around,” says Kotch. “But with two immobilized arms, she wouldn’t have been able to take notes or take tests. She basically wouldn’t have been able to take care of herself. Redshirting wasn’t a real option, because she had plans to go to medical school after graduation.”
Furthermore, double surgery would likely make rehab more complicated and slower. “We had two elbows that potentially would need surgery,” says Peterson. “But we also thought about how she was coming up on her senior year and maybe her last chance ever to compete at a high level. We only had so much time to rehabilitate her, so we ended up operating on the side that was a little worse and not operating on the other side.” The left elbow would be rehabbed along with the rebuilt right one, and taped when it showed instability as McDaniel worked out and competed.
On May 3, 2004, Peterson reattached the damaged ligament to the bone in McDaniel’s right elbow. After six weeks in a cast, she began her rehab with Waymen Wong, DPT, MTC, Physical Therapist at Advanced Manual Therapy and Sports Rehabilitation in Seattle. McDaniel had actually been working with Wong on a shoulder condition she’d suffered only a few weeks before the elbow injuries. The shoulder wasn’t debilitating, but it lacked posterior stability and caused a popping sensation. Wong had begun strengthening the muscles around it, and working with McDaniel meant he would be able to understand the full scope of her upper extremities rehab.
The first job was to revascularize the injured region, accomplished through open-chain radial deviation exercises, gripping exercises, wrist extension, finger flexion, dumbbell ulnar and radial deviation, and pronation and supination exercises. Wong tackled a deficit of elbow extension and flexion with a gradual approach, avoiding stretching that could weaken the ligaments, in favor of gentle exercises at the end range. McDaniel did bicep curls and tricep exercises without weight or band resistance at first, then added weight incrementally as her range grew.
“We didn’t do any stretching, because that’s not my approach when you’re trying to regain range of motion with tissue that has been ruptured or repaired,” Wong says. “You can stretch the ligament, but that will deform the collagen and weaken it. I just tried to exercise it a lot in the end range, so that it would remodel, respond to the stimulus, and lay down new collagen at the length and range. This would allow the collagen to keep its elasticity and strength without compromising the stiffness, which is important for its integrity.”
After three weeks, McDaniel moved into exercises designed to build stability and co-contraction across her elbow. Wong sought adduction from 90 degrees, stressing the ulnar side because McDaniel couldn’t yet rely on the reconstructed ulnar collateral ligament to keep the elbow from going into valgus.
“I had her do an ulnar deviation against the cable first, and then do a shoulder adduction, using the flexor carpi ulnaris to substitute for the stability that’s lost without the ulnar collateral ligament,” Wong says. “We did a lot of ulnar deviation exercises with shoulder adduction trying to facilitate that type of stability. She started with three kilograms of resistance and worked her way to four and then six kilograms.”
After a couple months, enough time to build up stability in the elbow, Wong started anew on the shoulder rehab. He had McDaniel perform wall pushups, dumbbell bench presses, and a full rotator cuff strengthening regimen. Dumbbell circles on her back, for instance, served both the shoulder and elbow.
Wong was impressed with McDaniel’s dedication. “I loved working with her because she was so enthusiastic about her exercises,” he says. “She spent at least three hours here three times a week, and that shows a lot of devotion.”
Though Wong was the main therapist at this point, Kotch remained involved. She monitored McDaniel for inflammation and administered ice, massage, and phonophoresis. As the summer of 2004 wound down, McDaniel returned to campus, and Kotch became more involved in her rehab.
As McDaniel’s elbows regained strength, the next challenge was to simulate gymnastics-specific movements. “We just started adding basic skills,” Kotch says. “The most basic is a handstand, so we started with that and built from there.”
At one point, she trained upside-down on a vertical-jump machine equipped with bands. “She would get on it in a handstand position and then pop up on her hands and do little push-ups,” Kotch says. Wong had McDaniel use a lat pull machine, hanging with her full body weight on it, and eventually added ankle weights to simulate the centrifugal forces in many gymnastics routines.
In late September McDaniel rejoined her teammates for preseason workouts, continuing some physical therapy but backing off to compensate for the gymnastics skill work. She was ready for her competition season by mid-January, but Kotch still watched the gymnast closely. McDaniel, Kotch, and Peterson talked about whether McDaniel would be able to compete on the parallel bars again, and concluded that it was unlikely. She did eventually try, but experienced too much pain to continue. That, coupled with the fact that the season was approaching and rehabbing for the event would take more time, ruled out the bars. Still, McDaniel would be a contender in other events.
“Our primary concern was whether she would be able to remain stable through the whole season,” says Kotch. “She had a history of inflaming the medial epicondyle, and we wanted to make sure she didn’t form any tendinitis or rupture those ligaments through any of her routines. I gave her guidelines to stop working out if she had any pain or swelling, immediately or delayed-onset. She was a good patient—very motivated, very compliant.”
At one point, McDaniel’s left elbow gave a bit during floor-exercise tumbling, and from then on, her elbows were taped. “In fact, one practice she went to the gym without being taped, and then she came into the athletic training room and said, ‘Yeah, that tape really works,'” Kotch says.
Not only did McDaniel compete in 2005, but she was named All-American in the beam and floor exercise, finishing third in both events at the April Collegiate National Championships. And the silver lining: After going through surgery and rehab with Dr. Peterson, the pre-med major got to shadow him this past year—a great preparation for medical school.
PROFILE: Corrie McDaniel
- Sport: Gymnastics
- School: Seattle Pacific University
- Injury: Right elbow dislocation, left elbow ulnar ligament sprain
- Comeback team: Jeanette Kotch, ATC; Waymen Wong, DPT, MTC; Christian Peterson, DO