Author: Joshua Brandon, MD
Co Author #1: Roy Lemaster, M.D., CAQSM
Senior Editor: Carolyn Landsberg, MD
Editor: Adam Lewno, DO

Patient Presentation:
A 17-year-old, right hand dominant, level nine competitive female gymnast presents to the sports medicine clinic with medial right elbow pain and numbness radiating distally four weeks after falling onto her right arm.

History:
At the time of her injury, the patient was performing a roundoff when her foot slipped, propelling her forward, with subsequent reflexive placing of right hand out to brace herself while falling. Upon contact with the ground, she twisted her arm and felt a pop with immediate intense pain through her elbow. She noticed immediate warmth and swelling. Given the fear of dislocation, EMS was called for transportation to the local hospital. While en-route, the ambulance hit a bump in the road with the patient feeling a shift in elbow with subsequent decrease in her pain.

Right upper extremity X-ray was performed on arrival to ED, which did not show evidence of a fracture or dislocation. She was advised to follow-up in seven to ten days if there was continued pain. At that time, it was thought the patient had dislocated her elbow with spontaneous reduction prior to arriving at the ED.

Within the sports medicine clinic, the patient complained of continuous 3/10 right elbow discomfort at rest which increased to a 6/10 with movement, as well as radiating numbness into her fingertips. Even with taking over the counter pain medications, her symptoms were not improving. Her elbow swelling had decreased minimally. As the patient continued to complain of elbow pain one month out from her original injury with minimal improvement, a right elbow MRI was obtained.

Physical Exam:
Right Upper Extremity (elbow):
Inspection- Normal carrying angle, no deformity, no redness. Mild swelling at lateral surface of elbow.
Palpation- No induration. Tenderness at medial epicondyle ( flexor/pronator insertion) and lateral epicondyle (extensor/supinator insertion).
Range of Motion- Passive/active extension limited to 5 degrees and passive/active flexion limited to 100 degrees due to pain and swelling.
Stability- Valgus stress test showing 1+ ulnar laxity.
Neurological- strength: flexion and extension 4/5.

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