A Soccer Fan’s Pain In The Elbow

Abstract

HISTORY: A 35-year-old right-hand dominant male soccer fan presents with 3 days of acute right elbow pain. He began to experience progressive right lateral elbow pain while clapping exuberantly during a Seattle Sounders come from behind victory. He could recall no other trauma or inciting event. He had noticed some mild elbow soreness a few days preceding acute onset of pain. He endorsed elbow warmth and swelling as well as severe pain with any movement. He denied numbness, tingling, chills, fevers, fatigue, malaise. No prior history of rheumatic disease or gout. An x-ray obtained prior to presentation to our clinic showed small elbow joint effusion which the radiologist noted was suspicious for occult radial head fracture. PHYSICAL EXAMINATION: Swelling of right elbow with mild erythema. Decreased passive and active range of motion with elbow flexion, elbow extension, pronation, and supination. Tenderness to palpation overlying radial head as well as to olecranon bursa. Resisted wrist extension reproduced symptoms. Neurovascular exam was normal. DIFFERENTIAL DIAGNOSIS: 1. Occult radial head fracture 2. Lateral epicondylitis 3. Radial tunnel syndrome 4. Septic arthritis 5. Inflammatory arthropathy TEST AND RESULTS: X-ray: A small joint effusion suspicious for occult radial head fracture was noted. Ultrasound: Large elbow joint effusion tracking from the radiocapitellar joint deep to the triceps tendon insertion posteriorly. Common extensor tendon was intact. No swelling of the radial nerve visualized. Joint Aspiration: Joint aspiration revealed initially bloody then cloudy fluid. No organisms on gram stain or culture. Cell count revealed inflammatory joint aspirate containing over 50,000 WBCs of which 95% were neutrophils. Intracellular monosodium urate crystals were identified. FINAL WORKING DIAGNOSIS: Acute gout flare of right elbow TREATMENT AND OUTCOMES: Radiocapitellar joint steroid injection was performed due to ongoing pain despite oral NSAID use. Elbow pain resolved approximately 1 week after the injection. Dietary considerations were discussed. Patient advised to discuss uric acid lowering agents with PCP.