A 23-year-old man acutely dislocates his shoulder for the first time while kayaking. The location and quality of elbow pain can generally localize the injury to one of the four anatomic regions: anterior, medial, lateral, or posterior. 5.0 (3) See More See Less. Shoulder & Elbow - Adhesive Capsulitis (Frozen Shoulder) Listen Now 15:40 min. (SBQ06BS.44) He has had 2 anterior dislocations of his throwing shoulder, both of which were able to be reduced on the pool deck. In many cases, overuse injuries develop when an athletic movement is repeated often during single periods of play; when these periods of play (including games and practices) are so frequent, the body does not have enough time to rest and heal. A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. A small percentage of patients who present with lateral elbow pain and are thought to have lateral epicondylitis on initial presentation actually have an entrapment neuropathy of the radial nerve.15,23, For both syndromes, patients typically present with a history of repetitive forearm supination and pronation (e.g., carpenters, mechanics) and have insidious, poorly localized pain in the forearm. Note, in partial tears this test can still be normal. The elbow and shoulder are flexed to 90, forearm is supinated. She elects arthroscopic treatment. Superior labrum tear from anterior and posterior (SLAP), Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA), Partial articular-sided supraspinatus tendon avulsion (PASTA). It is also worth noting that some of these examination techniques may overlap with more than one disease process. The elbow joint is where three bones in the arm meet: the upper arm bone (humerus) and the two bones in the forearm (radius and ulna). The medial joint space of the symptomatic elbow should be compared with the asymptomatic side for the amount of opening, the subjective quality of the end point while a valgus force is applied across the joint, and pain. Orthopaedic Knowledge Online Journal 2004. (OBQ08.45) Patients with septic olecranon bursitis present with pain, swelling, warmth, and erythema over the olecranon; roughly one-half will have a fever. He was subsequently treated in the emergency department and discharged home. 340 plays. can show increased T2 signal, and displacement out of the bicipital groove. A positive test is apprehension when the elbow is terminally extended from a flexed position with voluntary and involuntary guarding or complete dislocation. [1][2] Medial epicondylitis, also known as golfers elbow or throwers elbow, refers to the chronic tendinosis of the flexor Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. Overhand throwing places extremely high stresses on the elbow. These unique motions, along with a wide range of dynamic exertional forces, predispose the elbow and its structures to significant injuries, particularly with repetitive motions. Increasing the glenoid bony support and excursion distance prior to dislocation. For example, it may take the athlete 6 to 9 months or more to return to competitive throwing after UCL reconstruction. A positive test is pain or laxity on the affected arm compared to the contralateral limb. is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid. What treatment do you recommend? This results in valgus pronation stress with the radial head forcibly pushed against the capitulum of the humerus 1,2. This stress causes impingement of the olecranon tip in the olecranon fossa, which may cause osteophyte formation and a fixed flexion deformity over time. What is the most common finding during surgery for traumatic anterior shoulder instability? (OBQ09.136) His medical history is significant for Crohn's disease which is controlled medically with prednisone therapy during flares. A patient undergoes an MRI arthrogram for recurrent shoulder instability. However, he feels the shoulder is still unstable and cannot return to play at his desired level. Call our friendly team today on 020 3195 2442 He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. A positive test is apprehension, instability, or pain, Elbow Valgus Stress Test. References (ED setting) Beaty JH, Kasser JR. (OBQ18.233) It controls the muscles of the hand and provides sensation to the small and ring fingers. Throwing mechanics can be evaluated in order to correct body positioning that puts excessive stress on the elbow. The elbow: Physeal fractures, apophyseal injuries of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures. Web(OBQ11.78) A 66-year-old male presents with a three-month history of increasing right shoulder pain. The examiner should stabilize patients elbow in 90 flexion with one hand on the lateral epicondyle. Pain and decreased strength with resisted gripping and with wrist supination and extension are often present.22, There is some controversy about whether radial tunnel syndrome and posterior interosseous nerve syndrome are two separate entities or a continuum of the same condition. (OBQ18.210) The patient's occupation and recreational activities can be important clues to diagnosis. Elbow On the inner and outer sides of the elbow, thick ligaments (collateral ligaments) hold the elbow joint together and prevent dislocation. Superior labrum anterior to posterior (SLAP) repair, Open approach for bone grafting of humeral defect with allograft, Open repair of humeral avulsion of glenohumeral ligament (HAGL) lesion, Arthroscopic Bankart repair and Remplissage procedure. 24% (851/3530) 5. The point of maximal tenderness usually resides over the anterior radial head. Additional treatment options may include: Physical therapy. The abnormal bone growth of VEO is apparent in these illustrations of the back of the elbow and inner side of the elbow. He works as a lawyer and has been treating the pain with non-steroidal anti-inflammatory drugs with little improvement. In the case of ulnar neuritis, the athlete will frequently experience numbness and tingling of the elbow, forearm, or hand as described above. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. (OBQ11.19) Golfers Elbow Test. What other pathology, besides the Bankart lesion, is likely contributing to this patient's recurrent instability? Elbow injuries in throwers are usually the result of overuse and repetitive high stresses. In some cases, an injection of platelet-rich plasma (PRP) can be beneficial in patients with partial tearing of the UCL. Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. As with other musculoskeletal problems, the keys to diagnosing elbow pain are a history to include mechanism of injury or exacerbating movements, and a focused physical examination. Musculoskeletal ultrasonography is more operator-dependent than MRI but allows for an inexpensive dynamic evaluation of commonly injured structures. Although distal biceps tendon ruptures are rare, comprising 3% of all tendon ruptures, distal biceps tendinopathy is more common.3 This condition presents with an insidious course of anterior elbow pain, especially with resisted flexion and resisted supination of the forearm. Proper conditioning, technique, and recovery time can help to prevent throwing injuries in the elbow. Injuries of the UCL can range from minor damage and inflammation to a complete tear of the ligament. (SBQ05UE.87) A patient sustains the injury seen on the radiograph in Figure A. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments. They may also evaluate the athlete's shoulder. Webcombination of forearm supination, axial loading, valgus (posterolateral) stress, and elbow extension causes progressive failure of the lateral collateral ligament complex and anterior capsule, may not be helpful in the setting of recurrent instability and LUCL attenuation as visualizing ligament difficult due to oblique course. All rights reserved. This is called an anterior transposition of the ulnar nerve. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. The conjoined tendon passing through the subscapularis becomes a supportive sling. (OBQ07.80) The physical examination of the elbow should include a standardized exam approach as well as a series of special tests to help diagnose the cause of the patients elbow pain. instability with valgus stress notes more severe involvement. In most cases of UCL injury, the ligament can be reconstructed using one of the patient's own tendons. The MRI images are seen in Figures A and B. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Sports Injuries: Prevention, Diagnosis, Treatment and Rehabilitation, Sports Injuries: Prevention, Diagnosis, Treatment and Rehabilitation. 25-year-old with first time acute traumatic dislocation, 78-year-old with a rotator cuff tear arthropathy with superior escape, 24-year-old with chronic dislocation and large engaging Hill-Sachs lesion, 30-year-old with an acute bony Bankart fracture-dislocation, 27-year-old with a chronic anterior dislocation and inverted pear-shaped glenoid. History of contralateral shoulder dislocation, Young age (<20-years-old) at time of dislocation. She has significantly limited right shoulder active and passive range of motion (ROM) in all planes but full left shoulder active and passive ROM. His current radiograph is shown in Figure A. It can occur both at the medial and lateral epicondyle with medial epicondylitis occurring less frequently than lateral epicondylitis. Lateral and medial epicondylitis are two of the more common diagnoses and often occur as a result of occupational activities. Started in 1995, this collection now contains 7146 interlinked topic pages divided into a tree of 31 specialty books and 738 chapters. Her MRI is depicted in Figure A. Because it takes time for the compressive or traction neuropathy to result in a positive electrodiagnostic study, false-negative results can occur if the testing is performed before symptoms have been present for six to eight weeks.12,18. Reproduced with permission from Ahmad CS, ElAttrache NS: Elbow valgus instability in throwing athletes. medial (ulnar) collateral ligament (MCL) overview. His medical history is significant for Crohn's disease which is controlled medically with prednisone therapy during flares. What is the pathophysiology of her diagnosis and what other findings would most likely be observed? Athletes with VEO experience swelling and pain at the site of maximum contact between the bones in the back part of the elbow. A positive result is defined as pain between 70 and 120 degrees of flexion.11 A video of the moving valgus stress test is available at http://www.youtube.com/watch?v=plk7G2s8V30. can give dynamic test of bicep instability. The doctor will also assess muscle bulk and appearance, and will compare the injured elbow with the opposite side. Though return to play is not guaranteed, the procedure has helped professional and college athletes continue to compete in a range of sports. The milking maneuver (Figure 5) can provide additional information on the possible presence of a UCL injury. Plain radiography is the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and joint effusions. Hyperpronation Test. History often includes repeated elbow flexion with forearm supination or pronation, such as in dumbbell curls. Weakness in extensor muscles dorsally can also be seen. 40-year-old woman with antinuclear antibodies with knee and shoulder pain. After a full evaluation, you determine she has adhesive capsulitis, and is in the early stiffening stage. Figures C and D are the CT scan and 3D reconstruction of the injury. It is uncommon for many of these injuries to occur in non-throwers. Below is the preoperative MRI from 1 year ago. (OBQ09.133) Humeral avulsion of the glenohumeral ligament (HAGL lesion) stabilization and EMG/NCV studies, Immobilization in sling with external rotation and EMG/NCV studies, Anterior labral periosteal sleeve avulsion (ALPSA) stabilization, Transfer of the infraspinatus tendon and greater tuberosity to the humeral head. All rights reserved. post-traumatic (following proximal humerus fracture or immobilization for other upper extremity injury), post-surgical (following rotator cuff repair or axillary dissection for malignancy), inflammatory process causing fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus, fibroblasts/myofibroblasts with abundant Type III collagen present, stiffness may be first manifestation of diabetes and warrants further workup, increased risk with older age, increased duration of DM, autonomic neuropathy, history of MI, contribute to stability of the glenohumeral joint, act as check reins at extremes of motion in their non-pathologic state, inferior glenohumeral ligament (IGHL) complex with the following components, a triangular region between the anterior border of supraspinatus and the superior border of subscapularis, Gradual onset of diffuse pain (6 wks to 9 months), Decreased ROM affecting activities of daily living (4 to 9 months or more), Gradual return of motion (5 to 26 months), Capsular contraction and fibrinous adhesions, Increasing contraction, synovitis resolving, variable character and severity of pain, loss of motion dependent on the stage of disease at presentation, freezing- insidious onset of pain at rest and with movement, difficulty sleeping, frozen- pain lessens but significant motion limitations affecting ADLs, thawing- pain is gone and motion improves but less than normal, note any muscle atrophy or scars denoting prior surgery, document all motion planes and compare to contralateral side, pain throughout motion arc or at terminal motion depending on stage of disease, impingement, biceps, and SLAP maneuvers often positive, rotator cuff testing may be limited given loss of motion, Metabolic panel and endocrine labs (TSH, A1c), must be obtained to evaluate for osteoarthritis, posterior dislocation, or surgical hardware, not necessary for diagnosis but can evaluate for other pathology, physical therapy program of gentle, pain-free, should be supervised and last for 3-6 months, failure to improve with non-operative modalities, controversial if done during freezing/inflammatory phase, after extensive therapy has failed (3 months), arthroscopy will spare subscapularis tendon with the advantage of releasing intra-articular and subacromial adhesions, daily progressive stretching exercises to point of pain, in-dwelling catheter for regional anesthesia often used to aid in therapy, steady force applied after full muscle paralysis achieved, fracture, dislocation, rotator cuff and labral tears, standard skin incisions with portal placement slightly higher than normal given contracted and thickened capsule, intra-articular structures may be obscured by adhesions and contractures, coracohumeral ligament can then be visualized and released, subacromial bursectomy and adhesions released as needed, no acromioplasty done, MUA may be done before or after release to increase to range of motion, perform inferior release near to glenoid rim, Proximal humerus fracture, dislocation, rotator cuff tears or brachial plexopathy, following overzealous manipulation with osteoporotic bone, After surgical treatment, gains in range of motion and improved function are maintained at long-term follow, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. Musculoskeletal ultrasonography allows for an inexpensive dynamic evaluation of commonly injured structures. (SBQ16SM.3) The pain can also usually be recreated with resisted wrist flexion.6, The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress during overhead throwing (Figure 3). Knees, as seen from front, showing normal valgus alignment of tibiofemoral articulation. There are both non-surgical and surgical treatment options.[4]. Uncommon etiologies of anterior elbow pain include intra-articular processes such as osteoarthritis, rheumatoid arthritis, and gout. It consists of two portions, an anterior and posterior united by a thinner intermediate portion. (OBQ06.59) For cubital tunnel, tapping or pressing against the cubital tunnel can recreate the symptoms if an ulnar neuropathy is present. MRI scans provide an excellent view of the soft tissues of the elbow and can help the doctor distinguish between ligament and tendon disorders that often cause the same symptoms and physical examination findings. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. A 17-year-old football player sustained an injury to his shoulder. Web(OBQ12.204) A 44-year-old left-hand dominant carpenter experienced immediate left elbow pain after trying to stop a heavy object from falling two days ago. This is an AAOS Self Assessment Exam (SAE) question. On physical examination, with the elbow flexed to 90 degrees, passive supination and pronation of the forearm should reveal a normal piston-like movement of the biceps muscle belly. In throwing athletes, the ulnar nerve is stretched repeatedly, and can even slip out of place, causing painful snapping. https://www.sportsmedreview.com/by-joint/elbow/, Incidence of Lower Extremity Injuries in the NFL on Grass versus Turf, Return to Play Following Achilles Tendon Rupture. Which of the nerves in Figure A is most at risk during the planned procedure? (OBQ10.77) What is the most common neurologic problem associated with a simple shoulder dislocation? Occasionally, separation of the osteochondral fragment may occur, resulting in a loose body. If an ulnar collateral ligament injury is suspected, the medial joint space of the symptomatic elbow should be compared with the asymptomatic side for the amount of opening, the subjective quality of the end point while a valgus force is applied across the joint, and pain. A 47-year-old woman presents with concerns of chronic right shoulder pain and stiffness without antecedent trauma. ankylosis. MRI. carpal instability: scapholunate dissociation, ulnar translocation. You may feel locking or catching from loose bodies. WebTraumatic Anterior Shoulder Instability, also referred to as TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery), are traumatic shoulder injuries that generally occur as a result of an anterior force to the shoulder while its abducted and externally rotated and may lead to recurrent anterior shoulder instability. Partial articular sided thickness rotator cuff tear (PASTA), Anterior labral periosteal sleeve avulsion (ALPSA), Humeral avulsion of the glenohumeral ligament (HAGL), Superior labral anterior posterior lesion (SLAP). SHAWN F. KANE, MD, JAMES H. LYNCH, MD, MS, AND JONATHAN C. TAYLOR, MD. Ulnar collateral ligament injuries occur in athletes participating in sports that involve overhead throwing. Diagnosis is confirmed by bursal fluid analysis.25 By contrast, patients with aseptic olecranon bursitis may present with a history of minor trauma to the elbow and a boggy, nontender mass over the olecranon without redness, warmth, limited range of motion, or other signs of infection.26 Because aspiration of bursae can be associated with complications such as introducing infection, this should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases.24, Tendinopathy at the triceps insertion occasionally occurs in weight lifters or industrial workers in whom repetitive elbow extension against resistance is required. Which of the following interventions would best mitigate the chances of her developing the most common complication of surgical treatment? When he attempts to press his abdomen with his right palm, his right elbow drops back. A neurapraxic musculocutaneous nerve injury, An axonotmetic musculocutaneous nerve injury. If painful symptoms are not relieved by nonsurgical methods, and the athlete desires to continue throwing, surgical treatment may be considered. His shoulder MRI is shown in Figures A and B. A 38-year-old former professional football player complains of longstanding left shoulder pain. To avoid introducing infection, aspiration of olecranon bursitis should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases. (OBQ10.63) He undergoes arthroscopic Bankart repair and re-dislocates his shoulder within 1 month after surgery. Also searched were the Agency for Healthcare Research and Quality evidence reports, the Cochrane database, Essential Evidence Plus, the Institute for Clinical Systems Improvement, and the National Guideline Clearinghouse database. This content is owned by the AAFP. Elbow joint. A rehabilitation program directed by the doctor or a physical therapist will include a gradual return to throwing. Copyright 2022 Lineage Medical, Inc. All rights reserved. Which of the following provocative maneuvers indicates the most common associated pathology in this age cohort? An arthroscopic labral repair in isolation without a bony procedure would result in a higher failure rate if performed for which of the following imaging studies? About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an Orthopaedist. The initial doctor visit includes discussion about the athlete's general medical health, symptoms and when they first began, and the nature and frequency of athletic participation. Physical examination should focus on muscles innervated by the ulnar nerve distal to the cubital tunnel: the flexor carpi ulnaris, the flexor digitorum palmaris, the hypothenar eminence, and the intrinsic muscles of the hand. Shoulder & ElbowMultidirectional Shoulder Instability (MDI) 10/21/2019. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. A 25-year-old basketball player sustains an anterior shoulder dislocation during a game that is subsequently reduced with traction. A 17-year-old basketball player presents to your office with persistent shoulder soreness following a fall during a game 2 months ago. Ehlers-Danlos Syndrome, collagen disorders), often associated with atraumatic instability, global hyperlaxity confers an odds ratio (OR) of 2.68 for the development of anterior shoulder instability, individuals with global hyperlaxity have a 3x higher rate of recurrent instability, patients with global hyperlaxity are less likely to develop capsulolabral lesions, labrum contributes 50% of additional glenoid depth, Anterior static shoulder stability is provided by, Anteroposterior Translation Grading Scheme, Humeral head translation up to glenoid rim, Humeral head translation over glenoid rim with spontaneous reduction once force withdrawn, Humeral head translation over glenoid rim without spontaneous reduction. A 20-year-old female presents with recurrent anterior shoulder instability. Web(OBQ11.78) A 66-year-old male presents with a three-month history of increasing right shoulder pain. 4.7 (6) See More See Less. Although a change of position or even a change in sport can eliminate repetitive stresses on the elbow and provide lasting relief, this is often undesirable, especially in high level athletes. The bones, major nerves, and ligaments are highlighted. A 42-year-old female presents to your office with pain in the shoulder that has been present for 1 month, and she notes the shoulder is also becoming stiff. Webin athletes, may develop in response to large valgus forces on elbow. Physical exam shows full strength with wrist flexion, wrist extension, and pronation, but notable weakness with supination of the forearm. His MRI images are seen in Figures A-C. What would be the most appropriate treatment? Pitchers who throw with arm pain or while fatigued have the highest rate of injury. 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