History

Taking a comprehensive history helps the physician to develop a differential diagnosis. The examiner should determine whether a single traumatic event or repetitive traumatic episodes caused the symptoms. Acute injuries to be considered include ulnar collateral ligament (UCL) rupture, medial epicondyle avulsion, biceps rupture, loose-body formation, acute wrist extensor or flexor origin muscle strain or tendon rupture, and acute subluxation of the ulnar nerve. Chronic injuries include UCL strain or rupture, valgus extension overload, musculotendinous strains, tendonopathies, and osteochondral defects that can progress to degenerative changes.1,2

The examiner should inquire about the location of the pain. Dividing the elbow into four anatomic regions (lateral, medial, anterior, and posterior) helps to narrow the range of differential diagnoses.1-7 Symptoms in the lateral region of the elbow indicate radiocapitellar chondromalacia, osteochondral loose bodies, radial head fractures, osteochondritis dissecans lesions, or posterior interosseous nerve entrapment. Symptoms in the medial region can indicate UCL sprain 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 of the anterior region include anterior capsular sprain, distal biceps tendon strain or rupture, brachialis muscle strain, and coronoid osteo-phyte formation. Finally, symptoms in the posterior region can indicate valgus extension overload, posterior osteophytes with impingement, triceps tendonitis, triceps tendon avulsion, ole-cranon stress fracture, osteochondral loose bodies, or olecranon bursitis.1,2

The examiner should ask 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 paresthesia in the fifth and the ulnar-innervated half of the fourth digit indicates ulnar neuritis or cubital tunnel syndrome. 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 and is associated with localized crepitation might indicate valgus extension overload syndrome.8,9 Pain localized in the posterior region of the elbow at the triceps tendon insertion or poorly localized, deep, aching pain in the posterior region of the elbow at the triceps insertion can signal triceps tendonitis. Poorly localized, deep, aching pain in the posterior region of the elbow can also be associated with an olecranon stress fracture.1,2,10 Sharp pain in the lateral region associated with locking or catching can be the result of loose bodies in the radiocapitellar joint from a radial head fracture or osteochondritis dissecans lesions of the capitellum.11,12 Acute, sharp pain in the anterior region of the elbow can be caused by an acute rupture of the biceps tendon. Persistent, aching pain in the anterior region can indicate inflammation involving the anterior capsule.

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 be the result of biceps or triceps tendonitis. Pain during the late cocking phase caused by valgus stresses on the medial region of the elbow 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 and reports an inability to "let the ball go" might have valgus extension overload syndrome. Pain during the late acceleration or follow-through phases may signal a flexor-pronator tendonopathy 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

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