Elbow Pain in an Adolescent Pitcher

Abstract

HPI: Patient is a 16 year old right-hand dominant male baseball pitcher with past medical history of partial tear of the right UCL and OCD of the right lateral trochlea managed with casting 9 months prior. He presented to our clinic with insidious onset right posterolateral elbow and arm pain 2 months after returning to pitching in summer baseball in May. He described sharp pain in the right lateral elbow with radiation into the posterolateral arm exacerbated with push-ups and bench press. He noticed a painless popping sensation with elbow extension, but denied weakness or sensory changes. The pain was not specifically associated with baseball or pitching and was different from his previous pain. PHYSICAL EXAM: Mild tenderness at right common extensor tendon origin worsened with 5 push-ups and improved with rest. Mild tenderness at right posterolateral triceps border. Slight weakness of the right triceps with pain. Varus and valgus stress caused no pain, but there was asymmetry with minimally increased laxity during valgus stress on the right. Negative extensor wad stress tests including Cozens, middle finger extension and Mills. No pain with flexor-pronator stretching. No pain with resisted pronation or supination. DIFFERENTIAL DIAGNOSIS: 1. Triceps tendinitis 2. Lateral epicondylosis 3. Radial nerve irritation 4. OCD radiocapitellar joint 5. Intraarticular loose body 6. Stress reaction/stress fracture distal humerus 7. Bony tumor/infection TEST AND RESULTS: Right elbow non-contrast MRI- Bone marrow edema within the olecranon and distal humerus medially as a result of stress reaction from excessive valgus stress. Thickening of the UCL. Healed osteochondral lesion of the right elbow trochlea. FINAL DIAGNOSIS: Valgus overload stress injury to distal humerus TREATMENT AND OUTCOMES: 3 months of rest from pitching followed by throwing progression via a pitching rehabilitation program. The program consists of focused strength training (RTC, scapular stabilizers) followed by normalizing throwing mechanics with gradual return to pain free baseball. We discussed with the patient the harmful effects on single sports athletes, particularly pitchers. We recommended he watch his pitch counts closely in the future (he admitted he hadn’t been doing that) and take at least 2 months off of baseball during the year.