A Peculiar Case of Elbow Pain

Abstract

HISTORY: 12 year old male baseball player presented with insidious onset of right shoulder and medial elbow pain over the previous year. First noticed the pain when he was throwing baseballs. He was a right-handed thrower and the pain began in his shoulder then progressed to the elbow. Initial presentation to the orthopedic clinic was after 2 months of complete rest where he attempted to return to baseball but could not throw due to pain. PHYSICAL EXAMINATION: A focused right upper extremity exam revealed full range of motion of the elbow. There was tenderness to palpation over the medial epicondyle and the ulnar collateral ligament. There was medial elbow pain with valgus stress and with Milking maneuver. There was no worsening of symptoms with resisted flexion of the wrist and no tenderness to palpation of the flexor/pronator tendons. Right shoulder with patient supine and abducted to 90 degrees revealed external rotation to 90 degrees on the right. There was also tenderness to palpation along the anterior and lateral humerus and decreased forward flexion and abduction range of motion as compared to the left upper extremity. DIFFERENTIAL DIAGNOSIS: Little leaguer’s shoulder, Little leaguer’s elbow, stress fracture, medial epicondylitis TESTS AND RESULTS: X-rays of the right shoulder showed widening of the humeral physis. X-rays of the right elbow showed widening of the medial epicondylar physis INITIAL WORKING DIAGNOSIS: Little leaguer’s elbow, little leaguer’s shoulder TREATMENT AND OUTCOMES: The athlete was held out of activities for 4 weeks. At follow up visit shoulder pain had completely resolved. The elbow was still giving him a lot of pain and for this reason a MRI arthrogram was done which showed avascular necrosis of the trochlea. CT scan of the elbow was ordered for evaluation of the AVN which confirmed the disease of the trochlea and medial epicondyle apophysitis. Subsequent follow ups showed continued improvement in his pain and he was allowed to slowly progress back to activity. Full clearance was given 8 months after initial presentation. FINAL WORKING DIAGNOSIS: Avascular necrosis of the trochlea, little leaguer’s elbow