Medial Elbow Pain Research Articles

Approach to Medial Elbow Pain in the Throwing Athlete.

Injury to the ulnar collateral ligament is the most common, significant injury affecting the medial elbow of the overhead athlete. However, there are many other significant sources of pathology that should be considered. This review seeks to present a broad range of conditions that providers should consider when evaluating the overhead athlete with medial elbow pain. Recent biomechanical studies have deepened understanding of the anatomy and function of the anterior bundle of the ulnar collateral ligament germane to the overhead athlete. Orthobiologics hold potential for expanding the role of non-operative treatment for ulnar collateral ligament injuries. In addition to injury to the ulnar collateral ligament, providers should be prepared to diagnose and treat valgus extension overload, proximal olecranon stress fracture, ulnar nerve pathology, common flexor - pronator mass injury, and, in adolescents, medial epicondylar avulsion, when managing medial elbow pain in the overhead athlete.

Medial Elbow Pain During the Return-to-Throwing Period After Ulnar Collateral Ligament Reconstruction in Pitchers.

Background:Ulnar collateral ligament reconstruction (UCLR) is common in the sport of baseball, particularly among pitchers. Postoperative return-to-sport protocols have many players beginning to throw at 4 to 5 months and returning to full competition between 12 and 16 months after surgery. Medial elbow pain during the return-to-throwing period often occurs and can be difficult to manage.Purpose:To evaluate the incidence of medial elbow pain and associations with outcomes and revision surgery during the return-to-throwing period after UCLR.Study Design:Case-control study; Level of evidence, 3.Methods:Between the years of 2002 and 2014, all pitchers who underwent UCLR at a single institution were identified. Charts were reviewed for incidence of medial elbow pain during return to throwing, return to sport, and subsequent operative interventions, including revision ulnar collateral ligament surgery.Results:Of a total of 616 pitchers who underwent UCLR during the study period, 317 were included in this study. Medial elbow pain was experienced by 45.1% (143 of 317), with a mean time of complaint of 9.75 months after surgery. The groups with and without pain did not differ statistically with regard to age (pain, 20.6 years; no pain, 20.9 years) or level of competition. Of those who experienced medial elbow pain, 10.5% did not return to sport; 5.6% underwent revision UCLR; and 19.6% underwent other operative procedures at the elbow. Among those who did not experience medial elbow pain when returning to throw, 8.7% did not return to sport, with only 1.7% undergoing revision UCLR and 6.9% undergoing other operative elbow procedures.Conclusion:Of the pitchers evaluated in the study, approximately half reported pain during the return-to-throwing phase after UCLR. Those who experienced medial elbow pain had a higher rate of subsequent surgical intervention.

Clinical Application of Real-Time Sonoelastography for Evaluation of Medial Epicondylitis: A Pilot Study

The aim of this study was to evaluate the diagnostic potential of real-time sonoelastography (RSE) in medial epicondylitis by comparing clinically diagnosed patients and patients without medial elbow pain. From July 2016 to December 2017, gray-scale sonographic findings (swelling, cortical irregularity, hypo-echogenicity, calcification and tear), color Doppler findings (hyperemia) and sonoelastographic findings (elastographic grade on a 3-point visual scale and strain ratio from two regions of interest) for 63 elbows of 56 patients were compared. Twenty-four patients with 29 imaged elbows were clinically diagnosed with medial epicondylitis, and 32 patients with 34 imaged elbows had no medial elbow pain. Cortical irregularity, hypo-echogenicity, calcification, elastographic grade and strain ratio revealed significant differences (p < 0.05). Among these, strain ratio had the highest diagnostic performance (area under the curve: 0.985). Real-time sonoelastography, which can obtain both elastographic grade and strain ratio, is valuable as a supplementary tool in the diagnosis of medial epicondylitis.

Wrist Flexion Exercise Increases the Width of the Medial Elbow Joint Space During a Valgus Stress Test

The medial elbow is stabilized during valgus loading by the ulnar collateral ligament, the flexor pronator mass (FPM), and the radial head. Impairment of the FPM can occur as a result of repeated wrist flexion activity. The purpose of this study was to determine the effect of repeated elbow flexion exercise on medial elbow stability. Thirty volunteers were included in this study. Ultrasound images of the medial joint space of the nondominant elbow of the participants were collected during a valgus stress test. The images were collected before and immediately after a wrist flexion exercise protocol. The wrist flexion strength measure decreased (7.5%) after the exercise protocol (t = 3.840; P = .001). The medial elbow width increased between unstressed (mean ± SD, 2.8 ± 0.1 mm) and stressed (3.6 ± 0.1 mm) conditions (P < .001). The stress-by-fatigue interaction was significant (P = .048). The medial elbow width increased after fatigue (0.9 ± 0.09 mm) while remaining unchanged in the unstressed condition. This study found an effect of repeated wrist flexion exercise on decreasing the stability of the medial elbow. Future research needs to explore the mechanisms leading to the decrease in medial elbow stability and to identify the effect of FPM fatigue on the development of medial elbow pain associated with activities.

Reliability of anterior medial collateral ligament plication of the elbow

The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner. In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35-74.5] points; postoperative median OES was 17 [15.5-31.5] points; postoperative median MEPI was 65 [57.5-72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities. The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension. The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.

Poster 329: Large Ulnar Nerve Neuroma-in-Continuity Presenting as Medial Elbow Pain: A Case Report

PM&RVolume 10, Issue 9S1 p. S109-S109 Poster 329: Large Ulnar Nerve Neuroma-in-Continuity Presenting as Medial Elbow Pain: A Case Report Daniel Probst MD, Daniel Probst MD Washington University, Saint Louis, MO, United StatesSearch for more papers by this authorBerdale Colorado DO, MPH, Berdale Colorado DO, MPHSearch for more papers by this author Daniel Probst MD, Daniel Probst MD Washington University, Saint Louis, MO, United StatesSearch for more papers by this authorBerdale Colorado DO, MPH, Berdale Colorado DO, MPHSearch for more papers by this author First published: 26 September 2018 https://doi.org/10.1016/j.pmrj.2018.08.341Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume10, Issue9S12018 AAPM&R Annual Assembly AbstractsSeptember 2018Pages S109-S109 RelatedInformation

Differential Diagnosis of Medial Elbow Pain

Differential Diagnosis of Medial Elbow Pain

Outcome of non-operative treatment and physiotherapy for medial elbow pain in young baseball players

The cytochrome P450 aromatase is involved in the last step of sex hormones biosynthesis by converting androgens into estrogens. The human enzyme is highly polymorphic and literature data correlate aromatase single nucleotide polymorphisms to the onset of pathologies such as breast cancer and neurodegenerative diseases. The aims of this study were i) to study the influence of the mutations R264C and R264H on the structure-function of the enzyme also upon phosphorylation by selected kinases and ii) to compare the activity of the variants to that of aromatase wild type in two different cell lines.Far-UV circular dichroism spectroscopy, thermal denaturation experiments and CO-binding assay showed that the two polymorphic variants are correctly folded. Steady-state kinetics experiments showed that rArom R264C and R264H exhibit a 1.5 and 3.4 folds lower catalytic efficiency, respectively, when compared to the wild type protein.Since R264 is part of the consensus motif of PKA and PKG1, phosphorylation experiments were performed to study the effect on aromatase function. Phosphorylation by PKA caused a decrease in activity by 36.2%, 49.3% and 27.9% in the wild type, R264C and R264H proteins respectively. Phosphorylation by PKG1 was also found to decrease the activity by 30.3%, 30.5% and 15.4% in the wild type, R264C and R264H proteins respectively.Experiments performed on the three full-length proteins expressed in human MCF-7 breast cancer cells and rat ST14A neuronal cells showed that, depending on the cell line used, the activity of the proteins is different, implicating different cellular mechanisms modulating aromatase activity.This work demonstrate that R264 polymorphism causes an intrinsic alteration of aromatase activity together with a different consensus for phosphorylation by different kinases, indicating that estrogen production can be different when such mutations are present.These findings are significant in understanding the onset and treatment of pathologies in which aromatase has been shown to be involved.

Ulnar neuropathy and medial elbow pain in women's fastpitch softball pitchers: a report of 6 cases

Elite-level women's fastpitch softball players place substantial biomechanical strains on the elbow that can result in medial elbow pain and ulnar neuropathic symptoms. There is scant literature reporting the expected outcomes of the treatment of these injuries. This study examined the results of treatment in a series of these patients. We identified 6 female softball pitchers (4 high school and 2 collegiate) with medial elbow pain and ulnar neuropathic symptoms. Trials of conservative care failed in all 6, and they underwent surgical treatment with subcutaneous ulnar nerve transposition. These patients were subsequently monitored postoperatively to determine outcome. All 6 female pitchers had early resolution of elbow pain and neuropathic symptoms after surgical treatment. Long-term follow-up demonstrated that 1 patient quit playing softball because of other injuries but no longer reported elbow pain or paresthesias. One player was able to return to pitching at the high school level but had recurrent forearm pain and neuritis 1 year later while playing a different sport and subsequently stopped playing competitive sports. Four patients continued to play at the collegiate level without further symptoms. Medial elbow pain in women's softball pitchers caused by ulnar neuropathy can be treated effectively with subcutaneous ulnar nerve transposition if nonsurgical options fail. Further study is necessary to examine the role of overuse, proper training techniques, and whether pitching limits may be necessary to avoid these injuries.

Medial elbow pain.

Medial elbow pain is uncommon when compared with lateral elbow pain.Medial epicondylitis is an uncommon diagnosis and can be confused with other sources of pain.Overhead throwers and workers lifting heavy objects are at increased risk of medial elbow pain.Differential diagnosis includes ulnar nerve disorders, cervical radiculopathy, injured ulnar collateral ligament, altered distal triceps anatomy or joint disorders.Children with medial elbow pain have to be assessed for ‘Little League elbow’ and fractures of the medial epicondyle following a traumatic event.This paper is primarily focused on the differential diagnosis of medial elbow pain with basic recommendations on treatment strategies.Cite this article: EFORT Open Rev 2017;2:362-371. DOI: 10.1302/2058-5241.2.160006

Symptomatic medial humeral epicondylar fracture non-union- rare presentation of a relatively common injury

BackgroundSymptomatic non-union of medial humeral epicondylar fractures is a limited entity. Some studies recommend surgical excision of the fragment, but the results are controversial. The purpose of this study is to evaluate the outcome of open reduction and internal fixation of a medial epicondyle non-union fragment. Materials and methodsA retrospective study was conducted in all the patients, who were operated in our hospital between the year 2010 and 2015 for symptomatic medial humeral epicondyle non-union. Inclusion criteria were open reduction and internal fixation of symptomatic medial epicondyle non-union and minimum one year of follow-up from time of surgery. Exclusion criteria included other associated musculoskeletal disorders of the affected limb. Open reduction and internal fixation of the fragment was done in all patients and the ulnar nerve was decompressed and anteriorly transposed in cases where symptomatology was present. Outcome was assessed with radiograph, range/arc of motion, Visual analogue pain scoring and two functional outcome tools. ResultsStudy sample consisted of 14 patients, with mean age at presentation of 14.9 years (range 6 to 50 years) with mean time since injury of 7.7 months (range 3 to 24 months). Patients presented with medial elbow pain and prominence, limited range of motion, valgus instability, and ulnar nerve compression. After open reduction and internal fixation, at a mean of three years after surgery (range 1.5 to 5 years), patients reported an improvement in visual analogue pain score from a mean of 7.29±1.3 to 0.21±0.4, and the difference was statistically significant (p=0.001). Mean postoperative Quick DASH (Disability of Arm, Shoulder, and Hand) score was 5.21±7.2. Mean Mayo Elbow Performance Score was 96.7±6.1. Improvement in arc of motion was statistically significant (p=0.001). Radiographic union was achieved in all patients except one who had fibrous union. Functional elbow range of motion was achieved in 13 out of 14 cases (92.8%) and ulnar nerve recovered in five patients and one patient required tendon transfer. ConclusionOpen reduction and internal fixation of symptomatic medial humeral epicondyle non-union gives excellent clinical and functional outcome in the majority of cases.

Ulnar Nerve Neuropathy Secondary to “Snapping Triceps Syndrome”

Cubital tunnel syndrome is the second most common compression neuropathy of the upper extremity and the most common point of compression for the ulnar nerve. We present a case of ulnar nerve compression neuropathy at the elbow secondary to an abnormal subluxating medial head of triceps. A 37-year-old right hand dominant male presented with a history of bilateral medial elbow pain and ulnar distribution hand numbness. During his left cubital tunnel release surgery, the abnormal anatomy was noted. Initial subfascial anterior transposition was insufficient and had to be revised to a subcutaneous transposition intraoperatively. Failure to recognize the contribution of triceps abnormalities can lead to incomplete resolution following surgery. Surgeons should be wary of uncommon findings and adjust their approach appropriately.

Medial Elbow Pain - Young Baseball Pitcher

HISTORY: A 14-year, 2-month old male right-handed baseball pitcher presented with chronic right medial elbow pain over 18 months, with no inciting injury/trauma. Initially he had mild right medial epicondylitis on magnetic resonance imaging (MRI) which resolved with rest and physical therapy. Still his right elbow pain recurred when throwing, ultimately failing conservative measures. Our collaborating orthopaedist then referred him to us for ultrasound and nonsurgical management. At his initial visit with us, he reported no pain at rest. He last had elbow pain one month earlier while doing lighter outfield (non-pitching) throws. PHYSICAL EXAMINATION: Afebrile with normal blood pressure and pulse. Normal muscle bulk and appearance for his age. Focused right elbow examination showed normal range of motion and no pain with flexion/extension. No locking or swelling. He did have laxity of his right elbow with valgus stress. DIFFERENTIAL DIAGNOSIS: 1. Valgus extension overload. 2. Osteochondritis dissecans. 3. Olecranon stress fracture. 4. Medial epicondyle avulsion fracture. 5. Medial apophysitis. 6. Medial epicondylitis. 7. Ulnar collateral ligament (UCL) sprain or tear. 8. Ulnar neuritis/subluxation. TESTS AND RESULTS: Initial MRI 18 months prior showed no UCL injury, but rather fluid at the flexor pronator mass consistent with medial epicondylitis. New MRI showed a partial right UCL tear at the proximal insertion. No full tear, fracture, or other connective tissue injury. Under ultrasound, laxity of the right UCL and pathology consistent with the partial UCL tear was seen, with no fracture, loose bodies, or epicondylitis. FINAL WORKING DIAGNOSIS: Partial UCL tear at the right elbow. TREATMENT AND OUTCOMES: We injected platelet rich plasma (PRP) under ultrasound to the pathologic site of the right UCL. The boy then proceeded with our 12-week PRP rehabilitation protocol tailored to throwing athletes. At 8 weeks post-injection, ultrasound showed interval healing with reduced laxity of the right UCL. At 16 weeks post-injection, ultrasound revealed virtually complete healing with no laxity of the right UCL. The boy eventually returned to throwing full pitching distance without pain, emphasizing the potential utility of PRP injection in pediatric/adolescent athletes with musculoskeletal injuries.

Valgus Instability of the Elbow Due to Medial Epicondyle Nonunion: Treatment by Fragment Excision and Medial Collateral Ligament Reconstruction.

The medial epicondyle nonunion becomes symptomatic valgus instability with medial elbow pain and joint instability due to dysfunction of the medial collateral ligament (MCL), thus requiring surgical treatment. The purpose of the present study is to report the clinical result of the fragment excision and ligament reconstruction by free tendon graft in the treatment of symptomatic medial epicondyle nonunion. A retrospective study of five consecutive patients was performed. All five patients had signs and symptoms of valgus instability of the elbow. The mean period of nonunion was 25 years, and their injuries progressed asymptomatically until symptoms developed in adulthood after a second injury. All patients were treated by fragment excision and MCL reconstruction. At the final follow-up, no patients exhibited pain or instability. The mean joint range of motion was 0o of extension and 138o of flexion, with an MEPS of 100 points in all patients. By ligament reconstruction for MCL insufficiency and removing the bone fragments avoided irritation by the bone fragments, pain and instability disappeared, good range of motion was restored, and excellent outcomes were achieved in all patients. We believe that fragment excision and MCL reconstruction should be considered as the treatment option for symptomatic medial epicondyle nonunion of the humerus.

Radiological analysis of the medial epicondyle in the adolescent throwing athlete.

Injuries to the medial structures of the elbow due to overhead throwing games are well documented. However, variations of medial epicondyles are not well described, especially in athletes with fused medial epicondyles. In this study, we evaluated variations in the medial epicondyle of baseball players who were aged 15-17 years and had fused epicondyles. In this cross-sectional observational study, 155 skeletally mature baseball players with unilateral medial elbow pain and 310 elbow radiographs were reviewed by two independent reviewers. The medial epicondyles were categorised into three groups: normal, elongated or separated. Among the 155 patients, 65 (41.9%) had normal epicondyles, 41 (26.5%) had elongated epicondyles and 49 (31.6%) had separated epicondyles. The medial epicondyle was larger on the dominant arm for 125 (80.6%) patients; the mean surface area on the dominant arm was 222.50 ± 45.77 mm2, while that of the non-dominant arm was 189.14 ± 39.56 mm2 (p < 0.01). Among the three categories of medial epicondyles, separated epicondyles had the largest surface area, followed by elongated and normal epicondyles. Medial epicondyles in adolescent throwing athletes can be categorised into three different groups according to their shape (normal, elongated and separated). We observed a correlation between the shape and the surface area of the medial epicondyle in adolescent throwing athletes, with separated medial epicondyles having the largest surface area. Further studies and follow-up are needed to determine the prognostic value and clinical significance of these morphological variations.

The Ulnar Collateral Ligament Injury: Evaluation and Treatment.

➤ Medial elbow pain in the throwing athlete can result from a variety of sources, including medial epicondylitis, valgus extension overload, ulnar collateral ligament (UCL) insufficiency, ulnar neuritis, and others.➤ Initial treatment following a UCL tear involves a period of rest (no throwing or strenuous use of the elbow) followed by rehabilitation and a graduated throwing program.➤ UCL reconstruction (UCLR) has become the preferred surgical treatment method for patients with a symptomatic, deficient UCL who wish to return to sports.➤ Several modifications to the original technique described by Jobe et al. have been proposed, including a muscle-splitting approach, a docking technique, and the use of various grafts, including hamstring autograft and several types of allografts.➤ The timing of return to sport following UCLR varies from patient to patient, with some patients being able to return within 12 months and others taking &gt;18 months. Although the literature varies, typically &gt;80% of patients are able to return to the same level of sport following UCLR.

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Pitcher's elbow: medial elbow pain in the overhead-throwing athlete.

Overhead athletes subject their elbows to significant valgus stresses throughout the throwing cycle. A steady rise in the number of medial-sided elbow injuries over the years has lead to increased awareness regarding the pathophysiology of the "pitcher's elbow." As our understanding of the functional anatomy and throwing biomechanics has become more sophisticated, we have seen a concurrent improvement in the outcomes associated with managing these injuries. Despite this improvement, continued anatomical and biomechanical research is still needed to further optimize outcomes and return to sport.

Lateral and medial non-articular elbow pain

Lateral and medial elbow pain is frequently encountered in daily practice. Clinical assessment is essential to make the right diagnosis and formulate the appropriate treatment plan. Extra-articular causes for medial and lateral sided elbow pain often have overlapping symptoms with articular pathology, which can make discrimination between different causes difficult.In this paper the possible causes of extra-articular medial and lateral sided elbow pain will be discussed and an overview is given to help make the right diagnosis and apply the right treatment.

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Purpose To evaluate a combined imaging approach with both ultrasonography (US; conventional US and valgus stress US) and magnetic resonance (MR) arthrography in baseball players with medial elbow pain. Materials and Methods Institutional review board approval was obtained and the requirement for informed consent was waived. The study is compliant with HIPAA. Baseball players with medial elbow pain underwent US in addition to MR arthrography. Findings were assessed with each modality alone and both combined in this retrospective investigation. For the evaluation of ulnar collateral ligament (UCL) tears with stress US, the interval gapping of the medial elbow joint was measured between rest and valgus stress both at the injured and at the uninjured (contralateral) elbow. Surgical or arthroscopic correlation was available as the so-called gold standard. McNemar tests compared the accuracies of the imaging modalities. Results In this study, 144 baseball players had 191 findings of medial elbow pain, including 53 UCL tears. With stress US, joint gapping at the injured elbow greater than 1.0 mm compared with the contralateral elbow yielded a sensitivity, specificity, and accuracy of 96%, 81%, and 87%, respectively, for diagnosing UCL tears. With MR arthrography, the sensitivity, specificity, and accuracy for UCL tears were 81%, 91%, and 88%, respectively, and increased to 96% (P = .013, McNemar test), 99% (P = .023), and 98% (P < .001), respectively, when combined with US to a dual modality MR and US approach. For 31 patients with ulnar neuritis, the sensitivity, specificity, and accuracy increased from 74%, 92%, and 88%, respectively, with MR arthrography alone to 90% (P = .07, McNemar test), 100% (P < .001), and 98% (P < .001) combined with US. For the 59 myotendinous and the 48 osteochondral diagnoses, the sensitivity, specificity, and accuracy with MR arthrography alone were 93%, 93%, and 93%, and 94%, 98%, and 97%, respectively, with no additional diagnostic value from US. Conclusion The combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain. (©) RSNA, 2016.