Working Diagnosis:
Left elbow posterolateral impingement involving the distal lateral triceps tendon

Treatment:
After meeting the patient, the surgeon and patient elected a conservative approach that involved non-operative management. The approach included prescription strength anti-inflammatories with Meloxicam, local steroid cocktail injection with bupivacaine and triamcinolone to the affected hypertrophic soft tissue, and a period of rest from throwing activities. Eight months after his initial surgical consultation, the patient was not interested in proceeding with surgery. Given that the patient had great response to the initial cortisone injection, he decided to continue with the injections and have repeat imaging after his baseball season ends.

Outcome:
The patient had good compliance with outpatient appointments and therapies. The team that treated this patient included the primary sports medicine specialist, the physical therapist, and the orthopedic surgeon. MSK ultrasound imaging revealed a left hypertrophic radiocapitellar plica. A non-operative approach was selected for his treatment plan, including local steroid injections into the joint space. Overall, the patient tolerated the local steroid injections well and had his second injection eight months later. Repeat imaging will be ordered at the conclusion of his baseball season.

Author's Comments:
Elbow pain is a very common joint complaint with a variety of etiologies. Plica are often benign, asymptomatic and have no known function.1 Elbow plica may cause clinical symptoms in the elbow joint after they become hypertrophied or inflamed from repetitive activities or trauma. Symptomatic elbow plica may strike at any age but it is not a common radiographic finding among the pediatric population.2 In this case report, we are presenting a case of symptomatic left lateral hypertrophic elbow radiocapitellar plica in a 16 year old baseball thrower.

Editor's Comments:
This case illustrates a less commonly encountered diagnosis of a common patient concern--elbow pain in a pitcher. The case was well managed with attempts at conservative care and when those did not resolve the symptoms, more advanced imaging and consultation was needed.

References:
1. Cerezal L, Rodriguez-Sammartino M, Canga A, et al. Elbow synovial fold syndrome. Am J Roentgenol. 2013. doi:10.2214/AJR.12.8768
2. Meyers AB, Kim HK, Emery KH. Elbow plica syndrome: Presenting with elbow locking in a pediatric patient. Pediatr Radiol. 2012. doi:10.1007/s00247-012-2407-1
3. Garcia-Valtuille R, Abascal F, Cerezal L, et al. Anatomy and MR imaging appearances of synovial plicae of the knee. Radiographics. 2002.
4. D.B. H, N. S, C.W.A. P, et al. Ligaments and plicae of the elbow: Normal MR imaging variability in 60 asymptomatic subjects. Radiology. 2010. doi:http://dx.doi.org/10.1148/radiol.10092163
5. Ruch DS, Papadonikolakis A, Campolattaro RM. The posterolateral plica: A cause of refractory lateral elbow pain. J Shoulder Elb Surg. 2006. doi:10.1016/j.jse.2005.08.013
6. Sanghi A, Ly JQ, Bush RJ, Folio LR. Case for diagnosis. Elbow synovial fold syndrome. Mil Med. 2007.
7. Lee H Il, Koh KH, Kim JP, Jaegal M, Kim YK, Park MJ. Prominent synovial plicae in radiocapitellar joints as a potential cause of lateral elbow pain: clinico-radiologic correlation. J Shoulder Elb Surg. 2018. doi:10.1016/j.jse.2018.04.024
8. Clarke RP. Symptomatic, lateral synovial fringe (plica) of the elbow joint. Arthroscopy. 1988. doi:10.1016/S0749-8063(88)80077-X
9. Antuna SA, O'Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001. doi:10.1053/jars.2001.20096
10. Ruiz De Luzuriaga BC, Helms CA, Kosinski AS, Vinson EN. Elbow MR imaging findings in patients with synovial fringe syndrome. Skeletal Radiol. 2013. doi:10.1007/s00256-012-1523-1
11. Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. Am Fam Physician. 2014. doi:10.1016/S1003-6326(14)63234-9
12. Steinert AF, Goebel S, Rucker A, Barthel T. Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint: A report of three cases and review of literature. Arch Orthop Trauma Surg. 2010. doi:10.1007/s00402-008-0798-0
13. D.H. K, R.A. G, N.S. E, L.A. Y, F.W. J. Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers. Am J Sports Med. 2006. doi:10.1177/0363546505281917

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