Medial Elbow Pain - Recreational Athlete

Abstract

HISTORY: 22-year female recreational athlete with history of left elbow pain following a fall on outstretched arm during a running/cutting activity. She noted immediate local pain of 7/10 on VAS and swelling of the medial elbow and forearm. She was unable to fully extend the elbow. PHYSICAL EXAMINATION: Edema was noted at the medial elbow, extending into the medial forearm. Palpation of soft tissues, tendon and bony structures revealed significant point tenderness at the medial joint space and at the medial epicondyle. Limited active ROM with extension was noted due to pain. Valgus stress test was positive, with significant discomfort upon moderate loading. Due to significant pain complaints, further physical examination was suspended and clinician progressed to point-of-care ultrasound imaging of the medial elbow complex DIFFERENTIAL DIAGNOSIS: 1. Medical Collateral ligament sprain 2. Medial Collateral ligament disruption 3. Common Flexor Tendon Pathology 4. Pronator Teres Strain 5. Medial epicondyle avulsion fracture 6. Biceps tendon pathology TESTS AND RESULTS: Bilateral ultrasound Imaging of the medial elbow complex revealed disruption of the ligamentous fibers of the UCL anterior band at the joint line. A large hypoechoic gap in the UCL is present, denoting the presence of significant fluid. Gravity valgus stress loading revealed a joint gap of 0.76cm compared to 0.38cm of the uninvolved side. FINAL WORKING DIAGNOSIS: Full thickness tear of the anterior bundle of the medial collateral ligament TREATMENT AND OUTCOMES: Since the athlete did not participate in overhead throwing activities, conservative management approach was selected. ROM was limited 0-100 degrees initially to full ROM at 4 weeks post injury. Strengthening was initiated with initial emphasis on core and shoulder musculature, progressed to elbow and forearm musculature, including the flexor/pronator group as an active stabilizer against valgus forces. Patient was symptom-free at 4 months following injury, and ultrasound imaging revealed reduced valgus joint gapping. This case presentation illustrates the utility of ultrasound imaging in diagnosing MCL pathology, especially when physical examination is limited due to patient discomfort, and further illustrates the successful conservative management of a full thickness MCL tear.