If the ulnar nerve moves out of the ulnar groove when the groove is palpated as the elbow is flexed and extended, subluxating ulnar nerve is the likely diagnosis. If 2 structures displace over the medial epicondyle with elbow flexion, the first will be the ulnar nerve and the second will be the medial head of the triceps—an indication of a snapping medial head of triceps.18
Imaging studies may require a second look
Imaging studies are sometimes used to further aid in diagnosis of elbow injury. However, standard elbow x-rays, including an anteroposterior view in full extension, an oblique view, and a lateral view at 90° flexion, can be deceiving, as they often appear normal in conditions causing medial elbow pain associated with overhead throwing.
Careful review of the images may be needed to rule out fracture and other conditions, keeping the following factors in mind:
- A supracondylar fracture is likely if the anterior humeral line that is drawn along the anterior surface of the humeral cortex (on a lateral view) does not transect the middle third of the midcapitellum.3,11,18
- Dislocation of the radial head is suggested if the radiocapitellar line (drawn through the center of the radial head and neck) does not transect the midcapitellum on a lateral view.3,11,18
- Intra-articular injury with a joint effusion is indicated when an enlarged anterior fat pad, which is slightly anterior to the distal humeral diaphysis, is visible (the “sail sign”) on a normal elbow radiograph.3,11,18
- A fracture is likely if a posterior fat pad (which lies in the olecranon fossa and is not usually visible unless an effusion elevates the fat pad away from the cortex) is visible on an elbow x-ray. 3,11,18
- A chronic UCL tear is suggested by heterotropic calcification of the UCL.19
It is useful to x-ray both the injured and the unaffected elbows in skeletally immature athletes to compare secondary ossification centers. Little League elbow demonstrates a widening of the medial epicondyle physis, for example, when the x-rays are compared.3 Secondary ossification centers of the elbow appear first at the capitellum (age 2), followed by the radial head (age 5), medial epicondyle (age 7), trochlea (age 9), and lateral epicondyle (age 11). Most ossification centers fuse between 14 and 17 years of age.3
Computed tomography arthrograms, magnetic resonance imaging (MRI), and ultrasonography are also used to identify UCL tears. MRI, which can reveal injuries to cartilage and tendons as well, is the most commonly used imaging technique for musculoskeletal diagnosis of the elbow.16,20
Treatment gets most athletes back on track
Most medial elbow injuries respond to conservative treatment—typically, with some combination of activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), icing, physical therapy aimed at flexor-pronator strengthening, and counterforce bracing.11 Medial epicondylosis and flexor-pronator strain injuries have an excellent prognosis, with more than 90% of patients back to their previous level of activity at 1 year. Initial treatment consists of a 2- to 3-week rest period, followed by a 6- to 12-week rehabilitation protocol.11
Randomized controlled trials have found limited evidence of short-term improvement in symptoms with corticosteroid injections compared with placebo or no treatment, local anesthetic, orthosis, physical therapy, and NSAIDs. However, corticosteroids were less effective than physiotherapy or oral NSAIDs in improving long-term outcomes.21 Despite a paucity of well-designed studies to prove their use, autologous blood, platelet-rich plasma, and botulinum toxin are sometimes used for refractory elbow pain.21
Treatment of Little League elbow consists of cessation of throwing for at least 4 to 6 weeks, with a gradual return to throwing and emphasis on proper throwing mechanics after the pain resolves. Most throwers are out of competition for 2 to 3 months, but fully recover with nonoperative management.21
UCL injuries, too, are initially treated with rest, NSAIDs, icing, bracing, and physical therapy, typically with 2 to 3 months of no throwing. Some patients also use a splint at 90° flexion at night and as needed for pain during the day. Patients whose symptoms last more than a year despite treatment may be candidates for arthroscopic debridement.11
Consider reconstruction when nonsurgical management fails
UCL reconstruction was introduced in 1974, when reconstruction was performed on professional pitcher Tommy John, who went on to win 164 games.4,9 The procedure has since undergone numerous modifications. Surgery is indicated for acute rupture, significant chronic instability, insufficient UCL tissue after debridement, or recurrent pain and valgus instability with throwing after rehabilitation.2,4,6,9
Reconstruction generally entails fixing a tendon graft through bone tunnels in the medial epicondyle of the humerus and sublime tubercle of the ulna to reestablish valgus stability. A recent systematic review of reconstruction methods found a 76% to 95% rate of excellent results, with patients returned to their prior level of activity at a mean follow-up of 1 year.22 Rehabilitation typically begins 7 days postop; throwing (without windup) may begin in 4 to 5 months, with a gradual increase in speed and force and a return to the game at 12 months.