Elbow Hyperextension Injury in Wrestling: Treatment Approach
For a wrestler with inner elbow pain and pain on arm extension after hyperextension injury, begin with conservative management including activity modification, ice, NSAIDs for short-term pain relief, and obtain radiographs to rule out fracture—if radiographs are normal and symptoms persist beyond 2 weeks, obtain MRI to evaluate for ligamentous injury, brachialis muscle rupture, or anterior compartment impingement.
Initial Assessment and Imaging
Obtain plain radiographs first to exclude fracture, particularly occult radial head, coronoid, or olecranon fractures that may not be apparent clinically 1. Inner elbow pain with hyperextension mechanism raises concern for:
- Medial collateral ligament (MCL) injury - the anterior bundle is particularly vulnerable to hyperextension forces 2
- Brachialis muscle rupture - can occur with hyperextension trauma and presents with anterior elbow pain and limited extension 3
- Anterior capsule rupture - consistently seen in hyperextension injuries 2
- Anterior impingement lesions - coronoid and olecranon impingement can cause persistent pain with extension 4
If radiographs are normal or indeterminate and you suspect soft tissue injury (ligament, tendon, or muscle), obtain MRI without contrast or ultrasound as equivalent next-step imaging options 1. MRI is particularly useful for evaluating the medial collateral ligament complex and brachialis muscle integrity 1.
Conservative Management Protocol
Start with these low-risk interventions immediately 5:
- Activity modification: Avoid repetitive wrist extension and movements that stress the medial elbow structures 5, 6
- Cryotherapy: Apply ice to reduce acute inflammation 5
- NSAIDs: Use for short-term pain relief during the acute phase 5
- Immobilization consideration: If this were a pediatric supracondylar fracture pattern, posterior splint immobilization provides better pain relief than collar-and-cuff in the first 2 weeks 1
Rehabilitation Phase
Once acute symptoms settle (typically 2-3 weeks), initiate eccentric strengthening exercises 5. For hyperextension injuries specifically, strength training targeting elbow flexors and extensors has shown effectiveness, with patients performing concentric and eccentric exercises at 80% of 1-RM, 8-10 repetitions, 3 times daily, 3 days per week 7.
Red Flags Requiring Urgent Evaluation
Watch for these concerning features that may require surgical consultation:
- Vascular compromise: Absent pulses or cold, pale hand requires emergent closed reduction 1
- Persistent mechanical symptoms: Locking or catching suggests intra-articular pathology 4
- Progressive loss of motion: May indicate anterior compartment impingement or capsular contracture 8
- Failure of conservative treatment after 6-8 weeks: Consider MRI if not already obtained and surgical consultation 5
Common Pitfalls
Do not assume this is simple "tennis elbow" - while lateral epicondyle tenderness with wrist extension activities suggests lateral epicondylitis 5, 6, the hyperextension mechanism and inner (medial) elbow pain point to different pathology involving the medial collateral ligament, anterior capsule, or brachialis muscle 3, 2.
Do not overlook anterior impingement - hyperextension injuries create both posterior and anterior compartment pathology, with anterior impingement of the coronoid being particularly common in athletes with repetitive hyperextension 4.
The hyperextension mechanism in wrestling creates a specific pattern: anterior capsule rupture, MCL injury (particularly the anterior bundle), and potential brachialis muscle involvement 2. This differs from the lateral epicondylitis pattern seen with repetitive wrist extension in racquet sports 5, 6.