History

Taking a comprehensive history helps the physician to develop a differential diagnosis. The examiner should find out whether a single traumatic event or repetitive traumatic episodes caused the symptoms. Acute injuries include ulnar collateral ligament (UCL) rupture, medial epicondyle avulsion, biceps rupture, loose-body formation, acute mus-culocutaneous strain or tendon rupture, and acute subluxation of the ulnar nerve. Chronic injuries include UCL strain or rupture, valgus extension overload, musculocuta-neous strains, tendonapathies, and osteochondral defects that can progress to degenerative changes.1

The examiner should elicit the location of the pain. Dividing the elbow into four anatomic regions (i.e., lateral, medial, anterior, and posterior) helps to narrow the range of differential diagnoses.1-6 Symptoms in the lateral region of the elbow can indicate radiocapitellar chondro-malacia, osteochondral loose bodies, radial head fractures, osteochondritis dissecans (OCD) lesions, or posterior interosseous nerve entrapment. Symptoms in the medial region can indicate UCL strain or rupture, a medial epicondyle avulsion fracture, ulnar neuritis, ulnar nerve subluxation, medial epicondylitis, osteochondral loose bodies, valgus extension overload syndrome, or pronator teres syndrome. The differential diagnoses for symptoms in the anterior region include anterior capsular sprain, distal biceps tendon strain or rupture, brachi-alis muscle strain, and coronoid osteophyte formation. Finally, symptoms in the posterior region can indicate valgus extension overload, posterior osteophyte with impingement, triceps tendinitis, triceps tendon avulsion, ole-cranon stress fracture, osteochondral loose bodies, or ole-cranon bursitis.1

The examiner should query the patient about the presence and character of the pain, swelling, and locking and catching episodes. Sharp pain radiating down the medial portion of the forearm with paresthesias in the fifth and the ulnar-innervated half of the fourth digit indicates ul-nar neuritis. When these symptoms are associated with a snapping or popping sensation, ulnar nerve subluxation might be the underlying cause. Pain that occurs in the posteromedial portion of the elbow with intense throwing efforts and is associated with localized crepitus might indicate valgus extension overload syndrome.7,8 Pain localized in the posterior region of the elbow at the triceps tendon insertion can signal triceps tendinitis. Poorly localized, deep, aching pain in the posterior region of the elbow might be associated with an olecranon stress frac-ture.1 Sharp pain in the lateral region associated with locking or catching can result from loose bodies in the radiocapitellar joint due to radial head fractures and OCD lesions of the capitellum. Acute, sharp pain in the anterior region of the elbow can result from an acute biceps tendon rupture. Persistent, aching pain in the anterior re gion can indicate inflammation involving the anterior capsule.1

A patient whose symptoms are related to throwing or to an occupational stress should be asked to reproduce the position that causes the symptoms. Pain during the early cocking phase of throwing might result from biceps or triceps tendinitis. Pain during the late cocking phase can result from valgus stresses on the medial region of the elbow and can indicate UCL incompetency or ulnar neuritis. A thrower who reports pain in the posterior region of the elbow during the late cocking and acceleration phases of throwing and reports inability to "let the ball go" might have valgus extension overload syndrome. Pain during the late acceleration or follow-through phases might signal a flexor-pronator tendonapathy due to forceful wrist flexion and forearm pronation during these phases. In the skeletally immature patient, pain in the lateral region of the elbow during the late acceleration and follow-through phases often indicates radiocapitellar joint injuries, such as OCD lesions.

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