Author: Jack Italiano III, DO, RT(R)
Co Author #1: Jason L. Zaremski, MD Chief of Sports Medicine, Dept. of PMR Associate Program Director, PMR Residency Program Associate Professor of Sports Medicine Director, UF Health Throwing Clinic
Senior Editor: Justin Mark Young, MD
Editor: Dylan Rogers, DO

Patient Presentation:
The patient is a 15 year old male right hand dominant high school varsity swimmer with no past medical history who competes in free style and breast-stroke swimming meets. He presented with 4 months of right elbow pain. The pain was insidious in onset, non-radiating, and described as a "sharp pinch" along the anterior surface of the right elbow. The pain was exacerbated by lifting greater than 20 lbs and high intensity swimming. He reported no pain at rest and the pain was alleviated with cessation of activity. Pain was recorded as a 6/10 at its worst and a 0/10 at rest. He denied nocturnal pain, paresthesia's, night sweats, unintentional weight loss and any prior injury. He reported progression in pain severity over the two months prior to presentation, which prompted his evaluation.

History:
The patient swam year-round without any time off from sport. He also participated in a competitive, college preparation swim club 4-5 times per week for additional interval swim training. Training included free style, breast-stroke, butterfly, and back stroke techniques for 1-2 hours and swimming 4,000 - 6,000 meters each session. He reported weight lifting sessions at the gym multiple times a week for 1-2 hours prior to symptom onset. His regimen consisted of bicep curls, shoulder press, flys, push ups, and sit ups. He denied participating in a warm up, cool down, or stretching routine. Two months after symptom onset, he was diagnosed with COVID-19 infection, which did not require hospitalization. He took two weeks off from excessive training due to fatigue. He returned to full intensity swim training without any reintegration. His symptoms progressed with lifting and swimming throughout the season. He denied any history of nutritional deficiencies or dietary restrictions.

Physical Exam:
Right Elbow -
On inspection of the right elbow there was no swelling, ecchymosis, or deformity. There was point tenderness along the anterior distal humerus and distal biceps tenderness. No tenderness to the medial or lateral epicondyles, radial head, olecranon, or ulna. He was able to extend the elbow to 0 degrees and flex to 130 degrees. His muscle strength was 5/5 in flexion, extension, and grip. There was pain with distal humerus squeeze test, no pain with biceps hook test, and a negative Cozens and Moudsley test.

Right Shoulder-
On inspection of the right shoulder there was scapula winging present. Otherwise, no tenderness to palpation, normal range of motion, and no provoking special tests. The right wrist and left upper extremity examinations were benign.

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