ELBOW PAIN???15 YEAR OLD BASEBALL PITCHER.

Abstract

HISTORY A.15 year old high school baseball pitcher, who writes with his left hand and pitches with his right hand, presents with a one-year history of right elbow pain and stiffness. The onset of his symptoms was gradual. His pain is localized to the posteromedial and posterolateral aspects of his elbow. The symptoms are worsened after physical activities, especially after pitching. He has occasional episodes of clicking with the sensation of a loose object in his elbow in addition to episodic swelling and stiffness. His prior treatment had consisted of diminished pitch counts, physical therapy and ibuprofen without significant relief. PHYSICAL EXAMINATION Examination reveals no focal tenderness to palpation. A moderate joint effusion is appreciable. Range of motion testing reveals 15° lack of extension with 140° of flexion. The contralateral elbow has an arc of motion from 0° to 155°. He has full and painless forearm pronation and supination. Valgus stress testing is negative bilaterally. The rest of his upper extremity and neurologic testing was normal and symmetric. DIFFERENTIAL DIAGNOSIS Capitellar osteochontitis dessicans/Panner's disease. Synovial chondromatosis. Olecrenon stress fracture. Medial epicondyle physeal injury/flexor-pronator strain. Multiple epiphyseal dysplasia. Olecrenon apophysitis. Intraarticular loose body. Plica. Medial epicondylitis. TEST AND RESULTS Anteroposterior, Lateral and Oblique elbow radiographs:–officially read as no evidence of fracture, no significant joint effusion, normal appearing articular surfaces Elbow magnetic resonance imaging: –osteochondritis dessicans of the distal humeral trochlea with an intraarticular loose body FINAL/WORKING DIAGNOSIS Osteochondritis dessicans of the right elbow trochlea with an intraarticular loose body. TREATMENT AND OUTCOMES Arthroscopic loose body removal and synovectomy. Physical therapy for active and active assist elbow range of motion exercises. Restricted throwing. At three months postoperatively, he had an active range of motion of 10° to 145° and he was progressed to light overhead throwing. At 9 months followup he had a range of motion of 5° to 150° degrees and was asymptomatic with overhead throwing.