Video: Knock on Wood| Webinar: ACR/CHEST ILD Guidelines in Practice
fa-facebookfa-linkedinfa-youtube-playfa-rss

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

  • Conditions
    • Axial Spondyloarthritis
    • Gout and Crystalline Arthritis
    • Myositis
    • Osteoarthritis and Bone Disorders
    • Pain Syndromes
    • Pediatric Conditions
    • Psoriatic Arthritis
    • Rheumatoid Arthritis
    • Sjögren’s Disease
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
    • Vasculitis
    • Other Rheumatic Conditions
  • FocusRheum
    • ANCA-Associated Vasculitis
    • Axial Spondyloarthritis
    • Gout
    • Lupus Nephritis
    • Psoriatic Arthritis
    • Rheumatoid Arthritis
    • Systemic Lupus Erythematosus
  • Guidance
    • Clinical Criteria/Guidelines
    • Ethics
    • Legal Updates
    • Legislation & Advocacy
    • Meeting Reports
      • ACR Convergence
      • Other ACR meetings
      • EULAR/Other
    • Research Rheum
  • Drug Updates
    • Analgesics
    • Biologics/DMARDs
  • Practice Support
    • Billing/Coding
    • EMRs
    • Facility
    • Insurance
    • QA/QI
    • Technology
    • Workforce
  • Opinion
    • Patient Perspective
    • Profiles
    • Rheuminations
      • Video
    • Speak Out Rheum
  • Career
    • ACR ExamRheum
    • Awards
    • Career Development
  • ACR
    • ACR Home
    • ACR Convergence
    • ACR Guidelines
    • Journals
      • ACR Open Rheumatology
      • Arthritis & Rheumatology
      • Arthritis Care & Research
    • From the College
    • Events/CME
    • President’s Perspective
  • Search

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  |  August 12, 2020

A dynamic view of the ulnar nerve with elbow flexion revealed complete dislocation over the medial epicondyle followed by the medial head of the triceps (MHTr) (see Figures 1, 2 and 3).

No sonographic evidence of snapping of either the ulnar nerve or the MHTr was found. The ulnar nerve on longitudinal view appeared to be normal without areas of compression or dilation.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

The patient was diagnosed with ulnar nerve instability and dislocation of the ulnar nerve and MHTr. It was postulated that upon sudden elbow extension while vigorously throwing a baseball, ulnar nerve relocation occurred, with the ulnar nerve traumatically impacting either against the outside medial epicondyle and/or in the ulnar sulcus, producing severe pain.

Three days later the patient underwent anterior subcutaneous ulnar nerve transposition, in which the ulnar nerve was removed from the cubital tunnel. The MHTr was unaltered to avoid affecting his pitching velocity.

Figure 2. A transverse view of the ulnar groove in partial elbow flexion. Note the ulnar nerve and the medial head of the triceps muscle are both subluxing toward the apex of the medial epicondyle.

Figure 2. A transverse view of the ulnar groove in partial elbow flexion. Note the ulnar nerve and the medial head of the triceps muscle are both subluxing toward the apex of the medial epicondyle.

Three months later the patient resumed throwing a baseball and was soon able to painlessly pitch a complete season for a professional baseball team. He is now 14 months out from surgery and remains symptom free. His fastball remained greater than 90 mph and his earned run average was 2.32.

Causes of Medial Elbow Pain

In this age group, causes of medial elbow pain include medial epicondylitis, MCL injury with or without elbow instability, ulnar neuritis, snapping ulnar nerve, snapping triceps, olecranon osteophytes, olecranon stress fracture and flexor pronator strain.1

Ulnar neuritis may be caused by entrapment in different locations, but most commonly under Osborne’s ligament.1 Such entrapment is called cubital tunnel syndrome.2

Snapping ulnar nerve occurs in elbow flexion (between 70º and 90º) when the ulnar nerve dislocates over the apex of the medial epicondyle. This is typically painful and often accompanied by a palpable and audible snap.3,4 Neurologic symptoms from the snapping ulnar nerve are rarely reported, with the most common symptom being localized pain.3

Figure 3. A transverse view of the ulnar groove in full elbow flexion. Note the ulnar nerve and the medial head of the triceps muscle have both dislocated over the apex of the medial epicondyle. Key: UN, ulnar nerve; MHTr, medial head of the triceps muscle; ME, medial epicondyle.

Figure 3. A transverse view of the ulnar groove in full elbow flexion. Note the ulnar nerve and the medial head of the triceps muscle have both dislocated over the apex of the medial epicondyle. Key: UN, ulnar nerve; MHTr, medial head of the triceps muscle; ME, medial epicondyle.

Page: 1 2 3 4 5 | Single Page
Share: 

Filed under:Conditions Tagged with:case reportdiagnostic imagingelbow painTommy John Surgeryulnar nerveulnar nerve instabilityulnar nerve relocation syndromeultrasonographyUltrasound

Related Articles

    Ortho Angle

    August 1, 2009

    Where rheumatology and orthopedics meet

    Using Ultrasound to Diagnose Carpal Tunnel Syndrome

    April 26, 2018

    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

    April 17, 2021

    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

    March 19, 2019

    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…

  • About Us
  • Meet the Editors
  • Issue Archives
  • Contribute
  • Advertise
  • Contact Us
fa-facebookfa-linkedinfa-youtube-playfa-rss
  • Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 1931-3268 (print). ISSN 1931-3209 (online).
  • DEI Statement
  • Privacy Policy
  • Terms of Use
  • Cookie Preferences