Video: Every Case Tells a Story| Webinar: ACR/CHEST ILD Guidelines in Practice

An official publication of the ACR and the ARP serving rheumatologists and rheumatology professionals

Recurrent Medial Elbow Pain Following Successful Tommy John Surgery

Mark H. Greenberg, MD, RMSK, RhMSUS, A. Lee Day, MD, RMSK, James W. Fant Jr., MD, & Christopher G. Mazoue, MD  |  Issue: August 2020  |  

A 27-year-old, left-handed man was referred to our ultrasound clinic for left elbow pain.

History

The patient had been a pitcher on a Minor League Baseball team. Two years before, he developed sudden, severe medial elbow pain while pitching in a game. The pain was associated with some tingling down the left medial forearm. The pain precluded further pitching. Magnetic resonance imaging (MRI) revealed a major medial collateral ligament (MCL) tear.

ADVERTISEMENT
SCROLL TO CONTINUE

He subsequently underwent Tommy John surgery, in which his MCL was reconstructed using his own palmaris longus tendon. He did not have an ulnar nerve transposition during this procedure. He did well with rehabilitation after surgery until one year postoperative when, while pitching a live game, he developed recurrent left medial elbow pain.

He described the pain as a sharp explosion that occurred when the elbow was fully extended, but not with elbow flexion. The new pain differed from the pain of tearing his MCL in that he could continue to pitch (albeit with escalating exacerbation), and there was no sensation of popping, snapping or paresthesia with either flexion or extension of the elbow.

ADVERTISEMENT
SCROLL TO CONTINUE

Conservative follow-up treatment and rehabilitation did not improve the pain. Repeat MRI revealed an intact MCL autograft. An intra-articular corticosteroid injection was ineffective. He was released from the organization and presented to our ultrasound clinic seeking relief for his pain and hoping to resume his pitching career.

Exam

The examination revealed a well-healed incision over the left medial elbow. The medial epicondyle was nontender. No effusion was present, and his range of motion was normal. With elbow flexion, there was a suggestion of subluxation of the ulnar nerve outside the ulnar sulcus. On elbow extension, the ulnar nerve retracted back into the ulnar sulcus. No palpable snapping was noted on elbow flexion. A dynamic valgus stress test was negative. Left upper extremity muscle strength and sensation were intact.

Ultrasonography revealed the palmaris longus graft, which stretched from the medial condyle to the sublime tubercle of the ulna, was intact both statically and dynamically. No tears were noted. The ulnar nerve was 9 mm² in cross-sectional area, a normal value.

In elbow extension, ultrasonography revealed the ulnar nerve to be resting normally in the ulnar groove and without evidence of compression in the true cubital tunnel under Osborne’s ligament.

Figure 1. A transverse view of the ulnar groove in full elbow extension. The red arrow indicates the advancing edge of the MHTr.

Figure 1. A transverse view of the ulnar groove in full elbow extension. The red arrow indicates the advancing edge of the MHTr.

Related Articles

    Ortho Angle

    Where rheumatology and orthopedics meet

    Using Ultrasound to Diagnose Carpal Tunnel Syndrome

    Note: Updated May 2, 2018, to correct a link in the reference section. The error was introduced in editing. A 44-year-old Caucasian woman presented to the outpatient rheumatology clinic that had followed her for several years for rheumatoid arthritis. She was compliant with her regimen of hydroxychloroquine, etanercept and salsalate. Her chief complaint was worsening…

    Clockwise from top: Image A shows the periungual ulceration (arrow) of the fifth digit, as well as the prior amputation of the second digit. Image B shows a longitudinal ultrasound of the palmar aspect of the ulnar right wrist. In the center of the image, the ulnar artery is in view and color Doppler flow is visualized within the vessel until there is a reversal of flow demonstrated by color change, followed by severe attenuation of flow distally. Distal to the cessation of flow, the vessel appears hypoechoic due to proliferation of the intima to the point of occluding the lumen. Image C shows a transverse view at the level of white line in Image B, with endothelial proliferation seen around a central lumen of the artery (a), next to the vein (v) and ulnar nerve (n). Image D, shows a transverse view at the level of the black line in Image B, where the arterial lumen (a) is occluded.

    Insights Into Ulnar Artery Occlusion in Systemic Sclerosis

    A 51-year-old man with a history of limited systemic sclerosis with Raynaud’s phenomenon and pulmonary hypertension being treated with tadalafil and macitentan presented to a clinic with ulceration of his right pinkie. The patient had injured the finger two months earlier. He reported poor healing and the presence of a persistent ulcer since the injury….

    Insights on the Diagnosis & Treatment of Low Back & Hip Pain

    CHICAGO—Two experts presented insights on the diagnosis and treatment of low back and hip pain, including a refresher course on the mechanical structures involved, in Anatomy in a Day: Demystifying Low Back Pain and Lateral Hip Pain: New Patho-Anatomical Perspectives, a session at the 2018 ACR/ARHP Annual Meeting. Low Back Pain Avoid using such terms…