Less Common Causes of Elbow Pain Tyler Crawford, MD May 11, 2006.

Less Common Causes of Less Common Causes of Elbow PainElbow Pain

Tyler Crawford, MDTyler Crawford, MD

May 11, 2006May 11, 2006

Pain in the throwing athletePain in the throwing athlete

Usually medialUsually medial

Usually (85%) during acceleration phaseUsually (85%) during acceleration phase

Etiology: Ulnar collateral ligament tears, Etiology: Ulnar collateral ligament tears, ulnar neuritis, flexor-pronator ulnar neuritis, flexor-pronator strain/tear/tendonosis, medial epicondyle strain/tear/tendonosis, medial epicondyle avulsion, valgus extension overload avulsion, valgus extension overload syndrome, olecranon stress fractures, syndrome, olecranon stress fractures, OCD, loose bodiesOCD, loose bodies

Cain EL. Amer J Sports Med 2003; 3(4):621-635

Ulnar Collateral LigamentUlnar Collateral Ligament

Most important to exclude an injury to the Most important to exclude an injury to the ulnar collateral ligamentulnar collateral ligament

Anterior band from the medial epicondyle Anterior band from the medial epicondyle to the sublime tubercleto the sublime tubercle

Injury usually not a difficult clinical Injury usually not a difficult clinical questionquestion

Munshi M. Radiology 2004; 231:797-803


Ulnar Collateral LigamentUlnar Collateral Ligament

Kijowski R Skeletal Radiol(2005) 34:1-8

T2 FS T2 FS

Partial tear Complete tear

Valgus extension overload Valgus extension overload syndromesyndrome

Repetitive high loads during throwing may Repetitive high loads during throwing may lead to anterior band UCL attenuation & lead to anterior band UCL attenuation & failurefailure

Carry angle (nl 11 men and 13 women) Carry angle (nl 11 men and 13 women) may increase to >15 degreesmay increase to >15 degrees

Valgus stress leads to “kissing lesion” Valgus stress leads to “kissing lesion” osteophytes on posteromedial osteophytes on posteromedial olecranon/trochleaolecranon/trochlea


Valgus extension overload Valgus extension overload syndromesyndrome

Subtle laxity may Subtle laxity may contribute to medial soft contribute to medial soft tissue and posterior tissue and posterior compartment osseous compartment osseous disordersdisorders

Posterior compartment Posterior compartment osteophytes and bodies osteophytes and bodies are the most common are the most common cause for surgery among cause for surgery among baseball playersbaseball players


Snapping ElbowSnapping Elbow

Subluxation of the medial head of the Subluxation of the medial head of the tricepstriceps

Subluxation of the ulnar nerveSubluxation of the ulnar nerve

Intra-articular factors, such as torn annular Intra-articular factors, such as torn annular ligamentligament

Synovial foldsSynovial folds

Intraarticular bodiesIntraarticular bodies

Fukase N, Skelet Radiol 2005 Jun 7

Synovial FoldsSynovial Folds

Commonly seen within the elbow as a Commonly seen within the elbow as a remnant of joint developmentremnant of joint development

May simulate intra-articular bodiesMay simulate intra-articular bodies

Normal anterior and posterior fat pads Normal anterior and posterior fat pads may mimic synovial foldsmay mimic synovial folds

Awaya H. AJR:177, Dec 2001


Synovial fold

Normal nodularity

Synovial Fold SyndromeSynovial Fold Syndrome

Patients present with locking or limitation Patients present with locking or limitation of full extension because of impingementof full extension because of impingement

Superoposterior plicae in the superior Superoposterior plicae in the superior olecranon recessolecranon recess

Both symptomatic and asymptomatic Both symptomatic and asymptomatic patients may have thickened foldspatients may have thickened folds



Chronic pain

T1 FS Arthrogram

GRE T1 FS Arthrogram

Pain Chronic pain

Radiohumeral Synovial FringeRadiohumeral Synovial Fringe

Arises from the embryonic joint septum and Arises from the embryonic joint septum and almost always present anteriorly and almost always present anteriorly and posteriorly.posteriorly.

Embryos rarely have a lateral fringeEmbryos rarely have a lateral fringe

Adults can develop a lateral fringe over time.Adults can develop a lateral fringe over time.

Enlargement, hardening, & lateral extension Enlargement, hardening, & lateral extension is likely a manifestation of underlying is likely a manifestation of underlying derangement or degeneration.derangement or degeneration.

Isogai S. J Shoulder Elbow Surg. 2001; 10:169-181

Synovial FringeSynovial Fringe

Duparc F. Surg Radiol Anat (2002) 24:302-307

DistributionDistribution

DorsalVentral

Lateral

50 Specimens

6 11

5

5

24

4 2 2 2


Synovial Fringe/Posterolateral Synovial Fringe/Posterolateral ImpingementImpingement

Athletes engaged in repetitive motions Athletes engaged in repetitive motions such as throwing or golfing are pronesuch as throwing or golfing are prone

Complain of pain, clicking or snapping, Complain of pain, clicking or snapping, swelling, or inability to fully extend.swelling, or inability to fully extend.

Flexor-pronation test—not helpfulFlexor-pronation test—not helpful

Anconeous soft spot tenderness—most Anconeous soft spot tenderness—most helpfulhelpful

Kim D. Amer J Sports Med. 2006, Vol 34, Num 3, p. 438-444


Nerves

Fatty

Fibrous

Flexed Extended

PDHuang G. Eur Radiol (2005) 15: 2411-2414

12 yo boy with a snapping elbow12 yo boy with a snapping elbow


PD


PD T2*

Extension

Flexion

Lateral elbow painLateral elbow pain

Biceps Tendon AnatomyBiceps Tendon AnatomyAbove elbow, flat surface Above elbow, flat surface faces anterior.faces anterior.As the tendon courses As the tendon courses distally, it moves in a more distally, it moves in a more posterior and lateral position posterior and lateral position and twists 90and twists 9000, so that the , so that the anterior surface faces anterior surface faces laterally.laterally.Distal attachments to the Distal attachments to the radial tubercle and the radial tubercle and the fibrosus lacertus (bicipital fibrosus lacertus (bicipital aponeurosis)aponeurosis)

Chew ML. Radiographics 2005; 25:1227-1237

FABSFABS

FFlexed elbowlexed elbow

ABABducted shoulderducted shoulder

SSupination of the forearmupination of the forearm

Minimizes partial voluming effects

Improved visualization of insertion

Center of the magnet optimizes fat supression

FABSFABS


Biceps BrachiiBiceps Brachii

Injury typically seen in weighliftersInjury typically seen in weighlifters

Forced hypertension applied to a flexed Forced hypertension applied to a flexed and supinated forearmand supinated forearm

With complete tear, muscle may retract or With complete tear, muscle may retract or be held in place by the lacertus fibrosis be held in place by the lacertus fibrosis (bicipital aponeurosis)(bicipital aponeurosis)

Tear can be mimicked by a partial tear, Tear can be mimicked by a partial tear, tendonosis, and cubital bursitistendonosis, and cubital bursitis

Biceps tearBiceps tear

Melloni P. Eur J Radiol 54 (2005) 303-313.

PD T2

Complete tear bicepsComplete tear biceps

Intact lacertus fibrosus


Complete tear repairComplete tear repair


Partial tears of the biceps brachiiPartial tears of the biceps brachii

Increase signal within the distal biceps Increase signal within the distal biceps tendontendon

55% demonstrated bicipioradial bursitis55% demonstrated bicipioradial bursitis

Insidious onset was more common than an Insidious onset was more common than an acute traumatic onset of painacute traumatic onset of pain

No echymosis or loss of functionNo echymosis or loss of function

Partial tears of the biceps brachiiPartial tears of the biceps brachii

Williams BD. Skelet Rad (2001) 30:560-564.

Partial tear--FABSPartial tear--FABS

PDPD FS


Bicipitalradial bursaBicipitalradial bursaNo tendon sheath. No tendon sheath.

There is a paratenon There is a paratenon surrounded by the surrounded by the bicipitoradial bursa.bicipitoradial bursa.

Becomes more Becomes more compressed with compressed with pronation.pronation.

Shaf AY. Radiology 1999;212:111-116

Median

Bicepstendon

Bursa

Deep radial nerve

Superficial Radial n.

Interosseous b

Bicipitoradial BursaBicipitoradial Bursa

Chung C. Clin Ortho:383, pp. 162-174

Short head Long

Bursa

Bursography


Long

Bicipitoradial bursitisBicipitoradial bursitisMass in cubital fossa Mass in cubital fossa Most have painMost have painSome experience impairment in motionSome experience impairment in motionIf there is extensor muscle weakness, look If there is extensor muscle weakness, look for compression of the deep and for compression of the deep and superficial branches of the radial n.superficial branches of the radial n.Etiologies include RA, partial tear of the Etiologies include RA, partial tear of the biceps tendon, and repetitive traumabiceps tendon, and repetitive trauma


Bicipitoradial bursitisBicipitoradial bursitis


No contact with adjacent nerves

Displaces radial d. and s. branches in a woman who presented with forearm pain, a mass, and extensor m. weakness.

Superficial

Deep

Cubital TunnelCubital Tunnel

Deep borders are the medial epicondyle, Deep borders are the medial epicondyle, the trochlea and the posterior band of the the trochlea and the posterior band of the ulnar collateral ligamentulnar collateral ligament

Roof is the arcuate or Osborne’s ligament, Roof is the arcuate or Osborne’s ligament, a retinaculum between the ulnar and a retinaculum between the ulnar and humeral heads of the flexor carpi ulnaris humeral heads of the flexor carpi ulnaris muscle—extends from the olecranon to muscle—extends from the olecranon to the medial epicondyle the medial epicondyle

Cubital tunnelCubital tunnel

Posterior recurrent ulnar a.

Arcuate ligament

Ulnar n.

Kim YS. Skelet Radiol1998.; 27:419-426.

T1

Cubital TunnelCubital Tunnel

Boles CA. AJR:174, Jan 2000Kim YS. Skelet Radiol1998.; 27:419-426.

Flexor carpi ulnaris

T1 T1 T1

FlexionFlexion

Kim YS. Skelet Radiol1998.; 27:419-426.

T1 T1


T1 T1

Ulnar nerve entrapmentUlnar nerve entrapment

Most frequent nerve at the elbow due to its Most frequent nerve at the elbow due to its fibro-osseous tunnelfibro-osseous tunnel

Ganglion, accessory muscle or abnormal Ganglion, accessory muscle or abnormal muscular insertion, pannus, osteophyte, muscular insertion, pannus, osteophyte, etc.etc.

Ulnar n. often thickened above and within Ulnar n. often thickened above and within tunnel, and tapering more distally tunnel, and tapering more distally


Ulnar n. entrapmentUlnar n. entrapmentT1 FS GRE


Ly JQ. J Clin Imag 29 (2005) 278-282

STIR

ganglion

Jeon IH. Skelet Radiol (2005) 34:103-107

Anconeous epitrochlearis

T1

T1

Sag STIR

Flexor carpi ulnaris h. and u. heads

Anconeus



Ol

Cubital tunnel syndromeCubital tunnel syndrome

22ndnd most common compression most common compression neuropathy of the upper extremity after neuropathy of the upper extremity after carpal tunnelcarpal tunnel

Causes include medial trochlear Causes include medial trochlear osteophyte, incongruity between trochlea osteophyte, incongruity between trochlea and olecranon, soft tissue mechanical and olecranon, soft tissue mechanical compression during flexion, and tractioncompression during flexion, and traction

Compression or traction?Compression or traction?

Cadavers without Cadavers without cubital tunnel stenosiscubital tunnel stenosisCubital tunnel Cubital tunnel decreases in size with decreases in size with flexionflexionExtra and intraneural Extra and intraneural pressures are lowest pressures are lowest at about 45 degreesat about 45 degrees

Gelberman RH. J Bone Joint Surg. 1998:80-A;4, 492-501.

Compression or traction?Compression or traction?Pressures rise quickly at flexion Pressures rise quickly at flexion greater than 90 degreesgreater than 90 degrees

Intraneural pressures rise faster Intraneural pressures rise faster and higher than extraneural and higher than extraneural pressurespressures

Ulnar n. cross-sectional area Ulnar n. cross-sectional area decreased as the cubital tunnel decreased as the cubital tunnel decreased without effacement of decreased without effacement of surrounding fatsurrounding fat

Suggests traction may be more Suggests traction may be more important than compression in important than compression in many symptomatic patientsmany symptomatic patients


Implications?Implications?

Decompressing the ulnar n. without Decompressing the ulnar n. without transposing it out of the cubital tunnel or transposing it out of the cubital tunnel or decompressing it through a medial decompressing it through a medial epicondylectomy would not likely treat any epicondylectomy would not likely treat any symptoms arising from traction.symptoms arising from traction.Lack of fat effacement within the cubital Lack of fat effacement within the cubital tunnel at imaging does NOT exclude tunnel at imaging does NOT exclude cubital tunnel syndrome, even in the flexed cubital tunnel syndrome, even in the flexed positionposition

Ulnar nerve dislocationUlnar nerve dislocation

Can be a cause of medial elbow pain or Can be a cause of medial elbow pain or snapping/catching sensationsnapping/catching sensation

Medial dislocation over the medial Medial dislocation over the medial epicondyleepicondyle

Absent arcuate ligament between the Absent arcuate ligament between the ulnar and humeral heads of the flexor ulnar and humeral heads of the flexor carpi ulnariscarpi ulnaris

Jacobson, JA. Radiology 2001;220:601-605


u

o

m e

m h t

ExtensionFlexion

m e

u

u

m h t

ol

Extension Flexion


Snapping triceps syndromeSnapping triceps syndrome

Medial subluxation/dislocation of both the Medial subluxation/dislocation of both the ulnar nerve and the medial head of the ulnar nerve and the medial head of the triceps over the medial epicondyletriceps over the medial epicondyle

Difficult to distinguish clinically from ulnar Difficult to distinguish clinically from ulnar nerve dislocationnerve dislocation

Isolated ulnar nerve translocation in the Isolated ulnar nerve translocation in the setting of snapping triceps syndrome will setting of snapping triceps syndrome will not stop the problem not stop the problem


Extension Flexion

u u

m e

m h tm h tm h t



Boles CA. AJR:174,Jan 2000







Huang G. Eur Radiol (2005) 15: 2411-2414



Jeon IH. Skelet Radiol (2005) 34:103-107

Kijowski R Skeletal Radiol(2005) 34:1-8

Kim D. Amer J Sports Med. 2006, Vol 34, Num 3, p. 438-444

Munshi M. Radiology 2004; 231:797-803


Less Common Causes of Elbow Pain Tyler Crawford, MD May 11, 2006.

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Transcript of Less Common Causes of Elbow Pain Tyler Crawford, MD May 11, 2006.