+ What are the key components of this patient’s history and physical examination?

Relevant History:

• Onset, location, duration, radiation, quality, intensity, aggravating/alleviating factors?
• Was there any recent injury or prior injury to that arm?
• Any numbness, tingling, weakness, fever/chills, neck pain, or pain elsewhere in the limb?
• Was/is there any pop/swelling/discoloration to the elbow?
• What position does the patient play?
• If he is a pitcher, does he have a pitch count/limit?
• What is the patient’s dominant hand? Is the pain in the patient’s throwing arm or other arm?
• What is his performance and training schedule/regimen like? What kind of league does he play in?
• Has he been worked up or treated for this problem yet? If so, what has been done? Consultations, imaging, therapy, medications, injections, etc.?
• Past medical/surgical history?
• Social history? Supportive family?
• Sports history? Is baseball his only sport? What else does he play?
• Does he enjoy sports/baseball/his team/etc?
• What are his future career and athletic plans?
• How is he doing in school? What kind of grades does he get?
• What medications does the patient take?
• Allergies?

Relevant Physical Examination:

• Vital signs
• Inspection of bilateral upper limbs
• Palpation of bilateral upper limbs including elbows
• Range of motion of bilateral shoulders and elbows
• Manual muscle testing, sensation, reflex testing of bilateral upper limbs
• Special testing: Empty can, Neer, Hawkins, Speed, Yergason, Hook, varus/valgus stress testing of elbow in slight flexion and full extension, Tinel at medial elbow, milking maneuver, grip strength, distal interphalangeal joint flexion strength of digits 2,3 vs. 4,5; brachial artery, ulnar artery, radial artery pulse check, Hoffman, Spurling

+ Challenge Question

• Why do you want to test isolated flexion strength of the distal phalanges?

+ Challenge Answer

• This would be one way to test the patient’s neurologic status in that limb. With elbow injuries can come the presence of peripheral nerve injury or entrapment, which may manifest as numbness, tingling, pain, or weakness in the affected limb. By testing DIP flexion in digits 2-5, I am testing the anterior interosseous nerve (digits 2,3) compared to the ulnar nerve (digits 4,5). If I detect weakness in one set of digits vs. the other, it will help diagnose if a nerve injury is present, which will need to be treated.

+ Anything else you would like to know about the history?

• No, thank you. That will be all.

+ What is your differential diagnosis for his right elbow pain?

• Right medial collateral ligament/ulnar collateral ligament (UCL) sprain, medial or lateral epicondyle stress fracture, valgus extension overload syndrome (VEO), medial epicondylitis (Golfer’s Elbow), lateral epicondylitis (Tennis Elbow), common flexor tendon strain, common extensor tendon strain, medial or lateral epicondyle avulsion fracture, distal biceps tendonitis/tear, median nerve injury, ulnar nerve injury, right shoulder injury/rotator cuff tear, cervical radiculopathy.

+ What workup would you arrange for this patient?

• Right elbow x-rays (AP, lateral)
• Diagnostic ultrasound scan of right elbow if I possess the skills to perform this scan in this scenario. If not, I may refer out for this
• MRI right elbow

+ What else would you order?

• Nothing else at this time. Thank you.

+ Your workup reveals the following:

• Right elbow x-ray: normal
• Diagnostic ultrasound scan: excessive widening of the medial elbow joint space with valgus stress testing when compared to the lateral elbow during varus stress testing.
• MRI right elbow: partial tear of the right ulnar collateral ligament (UCL)

+ How would you manage this patient?

• I would counsel and educate the patient on the diagnosis, management plan, and prognosis. I would start with rest, ice, and oral NSAIDs as needed. The patient would need to refrain from pitching activity for several weeks while the ligament heals. I would start gentle, progressive physical therapy to rehabilitate the ligament and correct pitching mechanics once the patient is able to participate without pain. If the patient fails physical therapy I would offer a referral to an orthopedic surgeon for UCL repair or reconstruction.

+ What are the implications, and how would your management change if the patient complained of numbness and tingling in the medial forearm and digits 4,5 with impaired strength of distal interphalangeal joint flexion in digits 4,5, first dorsal interosseous, and abductor digit minimi?

• I would suspect electrodiagnostically significant ulnar nerve injury at the elbow in this case, which would warrant an EMG/nerve conduction study of the right upper extremity as well as likely a referral to an orthopedic surgeon for ulnar nerve transposition. The surgeon may elect to perform UCL repair/reconstruction at that time as well, given the patient’s high-level pitching and anticipated future in college/professional athletics.

+ What actions would you take upon discovering this?

• I would inquire and discuss with each of these patients the particulars of their training regimens, league schedules, pitch counts (or lack thereof), play schedule, return to play protocols, coaching strategies and beliefs, and the presence of any other injuries that they have noticed in their leagues. With the patient and their parents’ permission I would reach out to the coaches of these players to discuss my findings and my concerns about overuse injuries in their athletes.

• I would inquire about the coaches’ thoughts regarding these injuries and their overrepresentation in my clinic, and would ask the same questions above to the coaches. My goal would be to come to a mutual understanding and action plan for how to prevent further accumulation of injuries in this baseball population in order to protect these players. I would also seek guidance from national youth sports organizations regarding baseball players and their sporting activity. I would ask all parties if they have any questions for me, and of course remind them that I am here to assist with any sport-related injuries that may occur to these players.

+ What is your response?

• I am so glad to hear that you are doing better without pain! 95 mph is very impressive! You have a bright future ahead of you. May I ask you to clarify what you mean by “anabolics”?

+ The patient responds:

• Oxandrolone. It’s similar to testosterone. All the pros take it. You pretty much have to take it in order to compete and make it to the big leagues. It’s the reality of competitive sports. My brother says it’s going to be legal soon, so I wanted to stay ahead of the game. It’s clearly working!

+ Your response?

• I commend your competitive spirit. As I said, you no doubt have a bright future ahead of you. However, I am concerned about your health and safety. Anabolic steroids are unfortunately very dangerous and should only be used in a supervised medical setting for certain medical conditions, prescribed by a trained physician. Does anyone else know that you are taking anabolic steroids?

• Patient: I haven't told anybody yet.

+ You continue, saying...

• Unfortunately anabolic steroids have a number of health risks associated with them, including the risk for heart attack. I don’t say this to scare you, but to educate you on the risks. I do strongly advise that you abstain from using performance-enhancing drugs such as anabolic steroids to help with athletic performance. I know you are concerned about having a competitive disadvantage to other players, but in reality, nowadays steroid usage is a lot less common than you might think. How do you feel about discussing this with your parents? Do you feel supported by them and comfortable enough to talk about this with them? I want you to know that I am always here to help you through your athletics, and your health, safety, and sports performance are important to me. What questions do you have for me today? Is there anything else I can help to explain or clarify?

• Note: If a patient confides in you that they use anabolic steroids, this can be a difficult discussion and even a difficult set of decisions for the physician to make. In reality you can always check state and national laws regarding anabolic steroid or illegal substance use and what your actions must be from a legal standpoint. In this case, the most important thing to highlight is the act of maintaining a relationship of trust between you and your patient. You don’t want to shame the patient and make them discharge themselves from your care. You want to be source of guidance for the patient and someone whom they feel safe talking to. You should also encourage they develop a healthy line of communication with their parents.