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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

Dislocation of the ulnar nerve (*) and an additional muscle band (arrow) over the medial epicondyle. (A) extended arm, (B) 45-degree flexion, (C) 90-degree flexion.
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f4-poljradiol-79-467: Dislocation of the ulnar nerve (*) and an additional muscle band (arrow) over the medial epicondyle. (A) extended arm, (B) 45-degree flexion, (C) 90-degree flexion.

Mentions: The examination (US and sonoelastography) was carried out using Toshiba (UIMV-A500A) 12 and 18MHz linear probes. Apart from the fluid, the only abnormality noticed in the classic elbow US protocol (ESSR protocol) was enlargement of the ulnar nerve to 19 mm2 with mild hyperemia inside (Figure 2). A normal ulnar nerve in the cubital tunnel should be less than 9–10 mm2 in size [5,6]. The immage suggested moderate neuralgia [6] which coincided with the McGowan [7] score of ulnar neuropathy. In the sonoelastographic examination, the nerve trunk was also stiffer than the one in the opposite hand. The common flexor tendon had a normal appearance. The additional band of the medial triceps head was less stiff as well (Figure 3). These two different pictures might be easily explained. The nerve trunk underwent an active inflammation leading to an increase in the intra- and extracellular pressure, causing the nerve to be stiffer. Although the muscle band had no signs of hyperemia, it included hypoechoic areas slightly hyperintense in T2-w images on MRI, suggesting a mucoid/lipoid degenerative process. It was unclear whether this was caused by a simple ulnar nerve sliding or a movement-dependent dislocation of the abnormal muscle band, although the second case seemed more probable. Determining the cause of such changes was crucial for introducing appropriate treatment. Failure to recognize dislocation of the ulnar nerve and/or the medial head of the triceps can result in persistent, symptomatic snapping after an otherwise successful operation [8]. We introduced dynamic evaluation. A simple study merely revealed slipping of the nerve. When the study was repeated and counter-resistance was applied to the forearm, it revealed an almost simultaneous slipping of the ulnar nerve and muscle band over the medial epicondyle, with compression of the nerve by the medial epicondyle during that process (Figure 4). Snapping sound, if present, was associated only with the dislocation of the muscle band. No other abnormalities were detected. The patient was instructed to visit a neurologist and orthopedic surgeon for further treatment.


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)

Dislocation of the ulnar nerve (*) and an additional muscle band (arrow) over the medial epicondyle. (A) extended arm, (B) 45-degree flexion, (C) 90-degree flexion.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

f4-poljradiol-79-467: Dislocation of the ulnar nerve (*) and an additional muscle band (arrow) over the medial epicondyle. (A) extended arm, (B) 45-degree flexion, (C) 90-degree flexion.
Mentions: The examination (US and sonoelastography) was carried out using Toshiba (UIMV-A500A) 12 and 18MHz linear probes. Apart from the fluid, the only abnormality noticed in the classic elbow US protocol (ESSR protocol) was enlargement of the ulnar nerve to 19 mm2 with mild hyperemia inside (Figure 2). A normal ulnar nerve in the cubital tunnel should be less than 9–10 mm2 in size [5,6]. The immage suggested moderate neuralgia [6] which coincided with the McGowan [7] score of ulnar neuropathy. In the sonoelastographic examination, the nerve trunk was also stiffer than the one in the opposite hand. The common flexor tendon had a normal appearance. The additional band of the medial triceps head was less stiff as well (Figure 3). These two different pictures might be easily explained. The nerve trunk underwent an active inflammation leading to an increase in the intra- and extracellular pressure, causing the nerve to be stiffer. Although the muscle band had no signs of hyperemia, it included hypoechoic areas slightly hyperintense in T2-w images on MRI, suggesting a mucoid/lipoid degenerative process. It was unclear whether this was caused by a simple ulnar nerve sliding or a movement-dependent dislocation of the abnormal muscle band, although the second case seemed more probable. Determining the cause of such changes was crucial for introducing appropriate treatment. Failure to recognize dislocation of the ulnar nerve and/or the medial head of the triceps can result in persistent, symptomatic snapping after an otherwise successful operation [8]. We introduced dynamic evaluation. A simple study merely revealed slipping of the nerve. When the study was repeated and counter-resistance was applied to the forearm, it revealed an almost simultaneous slipping of the ulnar nerve and muscle band over the medial epicondyle, with compression of the nerve by the medial epicondyle during that process (Figure 4). Snapping sound, if present, was associated only with the dislocation of the muscle band. No other abnormalities were detected. The patient was instructed to visit a neurologist and orthopedic surgeon for further treatment.

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