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The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player - MR, US and Sonoelastography Evaluation.

Łasecki M, Olchowy C, Pawluś A, Zaleska-Dorobisz U - Pol J Radiol (2014)

Bottom Line: It describes a broad range of pathologies and anatomical abnormalities.One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence.Simultaneously presence of two or more "snapping reasons" is rare but should be always taken under consideration.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, University of Medicine in Wrocław, Wrocław, Poland.

ABSTRACT

Background: Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography.

Case report: A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3-0.6% in males and 0-3-1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head.

Discussion: Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more "snapping reasons" is rare but should be always taken under consideration.

Conclusions: There are no sonoelastography studies describing golfers elbow syndrome, additional triceps band and ulnar neuritis. Our data suggest that the sonoelastography signs are similar to those seen in well described lateral epicondylitis syndrome, Achilles tendinitis and medial nerve neuralgia.

No MeSH data available.


Related in: MedlinePlus

T2 image (left) and T2 FS presents small fluid collection in the medial epicondyle area (arrow). The ulnar nerve is moderately enlarged (arrowhead).
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f1-poljradiol-79-467: T2 image (left) and T2 FS presents small fluid collection in the medial epicondyle area (arrow). The ulnar nerve is moderately enlarged (arrowhead).

Mentions: A 28-year-old semi-professional left-handed tennis player complained of recurrent pain in the posteromedial elbow area. Tenderness over the medial humeral epicondyle was noted two months prior to the examination of the patient. Golfer’s elbow syndrome was suspected, which occurs quite commonly and has a prevalence of 0.3–0.6% in males and 0.3–1.1% in women [2] and may be associated (approx. 50% of cases) with ulnar neuropathy [3]. However, the golfer’s test was negative and the patient was directed to the radiodiagnostic unit where he underwent an elbow X-ray and US in a private clinic. The X-ray was normal. The US revealed a small amount of fluid around the medial epicondyle. The image of soft tissues was described as “without any abnormalities”. The patient was prescribed anti-inflammatory drugs (diclofenac) and advised to spare the affected limb. After 6 weeks of rest, the patient returned to playing tennis, which caused all symptoms to recur within the following three weeks. Due to long-lasting pain that impeded his tennis play, the patient underwent a commercial MRI scan at our department. When golfer’s elbow is suspected, it is a good decision to introduce MRI after a negative US result. In a study by Miller et al. [4] the sensitivity of US in detecting medial epicondylitis ranged from 64 to 82%, while the sensitivity of MRI was between 90 and 100%. The study was performed on 1.5 T (Siemens) device using an examination protocol proposed by the ESSR Sports Subcommittee (PD TSE axial/coronal/sagittal and T2 TSE axial/coronal) with additional T1 sequences (axial/coronal). The scan showed tiny fluid collections near to the medial epicondyle (Figure 1). An unusual presence of the distal tendon of the medial triceps head was reported as an additional finding. The ulnar nerve was also slightly enlarged (7.5×3.1 mm). The described changes did not match the golfer’s elbow. Consequently, the snapping elbow syndrome was suspected. Unfortunately, this syndrome can be confirmed only in a dynamic examination. We contacted the patient and advised him to get another US examination, as it was possible that the previous US was conducted without dynamic evaluation of the anatomical relationships in the posterior-medial elbow. Our suspicion was not confirmed by the patient who claimed that the procedure had been carried out correctly. Before the procedure, the Golfer’s elbow test was performed and gave a negative result. However, we noticed a positive Froment’s sign. As far as we know, snapping triceps syndrome has never been evaluated in sonoelastography before.


The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player - MR, US and Sonoelastography Evaluation.

Łasecki M, Olchowy C, Pawluś A, Zaleska-Dorobisz U - Pol J Radiol (2014)

T2 image (left) and T2 FS presents small fluid collection in the medial epicondyle area (arrow). The ulnar nerve is moderately enlarged (arrowhead).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4269067&req=5

f1-poljradiol-79-467: T2 image (left) and T2 FS presents small fluid collection in the medial epicondyle area (arrow). The ulnar nerve is moderately enlarged (arrowhead).
Mentions: A 28-year-old semi-professional left-handed tennis player complained of recurrent pain in the posteromedial elbow area. Tenderness over the medial humeral epicondyle was noted two months prior to the examination of the patient. Golfer’s elbow syndrome was suspected, which occurs quite commonly and has a prevalence of 0.3–0.6% in males and 0.3–1.1% in women [2] and may be associated (approx. 50% of cases) with ulnar neuropathy [3]. However, the golfer’s test was negative and the patient was directed to the radiodiagnostic unit where he underwent an elbow X-ray and US in a private clinic. The X-ray was normal. The US revealed a small amount of fluid around the medial epicondyle. The image of soft tissues was described as “without any abnormalities”. The patient was prescribed anti-inflammatory drugs (diclofenac) and advised to spare the affected limb. After 6 weeks of rest, the patient returned to playing tennis, which caused all symptoms to recur within the following three weeks. Due to long-lasting pain that impeded his tennis play, the patient underwent a commercial MRI scan at our department. When golfer’s elbow is suspected, it is a good decision to introduce MRI after a negative US result. In a study by Miller et al. [4] the sensitivity of US in detecting medial epicondylitis ranged from 64 to 82%, while the sensitivity of MRI was between 90 and 100%. The study was performed on 1.5 T (Siemens) device using an examination protocol proposed by the ESSR Sports Subcommittee (PD TSE axial/coronal/sagittal and T2 TSE axial/coronal) with additional T1 sequences (axial/coronal). The scan showed tiny fluid collections near to the medial epicondyle (Figure 1). An unusual presence of the distal tendon of the medial triceps head was reported as an additional finding. The ulnar nerve was also slightly enlarged (7.5×3.1 mm). The described changes did not match the golfer’s elbow. Consequently, the snapping elbow syndrome was suspected. Unfortunately, this syndrome can be confirmed only in a dynamic examination. We contacted the patient and advised him to get another US examination, as it was possible that the previous US was conducted without dynamic evaluation of the anatomical relationships in the posterior-medial elbow. Our suspicion was not confirmed by the patient who claimed that the procedure had been carried out correctly. Before the procedure, the Golfer’s elbow test was performed and gave a negative result. However, we noticed a positive Froment’s sign. As far as we know, snapping triceps syndrome has never been evaluated in sonoelastography before.

Bottom Line: It describes a broad range of pathologies and anatomical abnormalities.One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence.Simultaneously presence of two or more "snapping reasons" is rare but should be always taken under consideration.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, University of Medicine in Wrocław, Wrocław, Poland.

ABSTRACT

Background: Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography.

Case report: A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3-0.6% in males and 0-3-1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head.

Discussion: Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more "snapping reasons" is rare but should be always taken under consideration.

Conclusions: There are no sonoelastography studies describing golfers elbow syndrome, additional triceps band and ulnar neuritis. Our data suggest that the sonoelastography signs are similar to those seen in well described lateral epicondylitis syndrome, Achilles tendinitis and medial nerve neuralgia.

No MeSH data available.


Related in: MedlinePlus