Elbow Pain - CrossFit

Abstract

HISTORY: A 29-year-old male CrossFit and surfing instructor with a history of left ulnar shaft fracture treated nonoperatively presented with a 9 month duration of chronic, intermittent, left, sharp and burning elbow pain since injuring himself weight lifting. Bicep flexion and thumb rotation caused pain radiating to the elbow. He endorsed numbness of the left hand that led to an ER visit 9 months ago. His tingling resolved prior to our visit and he denied shoulder or neck pain. He has been seen previously by a Hand Specialist, was offered a steroid injection, and presented to us for further evaluation. PHYSICAL EXAMINATION: The patient exhibited no obvious atrophy of the forearm, but trace atrophy at the left medial triceps. He had full flexion and extension equal bilaterally, with slightly decreased supination on the left as compared to the right side. He was tender to palpation over the distal biceps, but nontender in the antecubital fossa. There was mild crepitus with resisted supination and pronation on the lateral epicondylar region. Radial head was minimally tender to palpation. He had elbow pain with resisted elbow flexion in neutral and supination more so than pronation. No skin changes were appreciated and no obvious elbow effusion. Distal neurovascular exam was grossly intact. DIFFERENTIAL DIAGNOSIS: 1. Distal biceps tear 2. Bicipitoradial bursitis 3. Ulnar shaft fracture 4. Radial head fracture 5. Osteochondritis dissecans of the capitulum TEST AND RESULTS: Elbow MR arthrogram (obtained 3 weeks ago) demonstrated a very small partial thickness tear of the ulnar collateral ligament, minimal radial cartilage loss, and a partial thickness tear of the distal biceps with prominent bicipitoradial bursitis. FINAL/WORKING DIAGNOSIS: Left partial thickness distal biceps tear AND associated bicipitoradial bursitis TREATMENT AND OUTCOMES: 1. Patient elected to avoid steroid injections and pursue conservative management involving physical therapy and topical NSAIDs 2. Pain continued intermittently. Further work up 1 year later included CT elbow showing mild left ulnohumeral joint osteoarthritis with small ossific joint loose bodies and healed proximal left ulna shaft and coronoid process fractures 3. Elbow pain may be subsequent to malalignment from an old Monteggia fracture