Disorders of The Elbow: Medial: Eugene Mcnally

7 Disorders of the Elbow: Medial
Eugene McNally
CHAPTER OUTLINE
COMMON FLEXOR ORIGIN ENTHESOPATHY ULNAR NERVE COMPRESSION

ULNAR COLLATERAL LIGAMENT MEDIAN NERVE COMPRESSION
NEURAL COMPRESSION
partial tears and ultimately tendon separation from the

COMMON FLEXOR ORIGIN epiphysis (Fig. 7.2). Acute changes, particularly due to
ENTHESOPATHY trauma, may also involve the pronator teres muscle. Chronic
changes include calcification and bony irregularity repre-
Tendinopathy of the common flexor origin (CFO) is less senting enthesopathy at the attachment.
common than its extensor counterpart. The presenting fea-
tures are similar, although the sporting and occupational
associations are different. There is a particular sporting asso- Practice Tip
ciation with golf and the term golfer’s elbow has come into
common use. Other names, such as medial tennis elbow and There is a close association between CFO tendinopathy and
ulnar neuritis, and in many patients the symptoms overlap.
flexor–pronator sprain, are also applied.
Key Point This is because the floor of the cubital tunnel receives
some fibres from the dorsal aspect of the CFO and conse-
Flexor–pronator sprain is a useful term and it draws quently tendinopathy of the CFO may also irritate the
attention to the common association with injury to the overlying ulnar nerve. As symptoms may be difficult to dif-
pronator teres muscle, which overlies the CFO. ferentiate on clinical grounds, an assessment of both of
these structures should be carried out in patients presenting
with medial elbow pain. The differential diagnosis also
includes injuries to the ulnar collateral ligament (UCL),
Pain is worse on resisted flexion, as opposed to extension median neuropathy and pronator teres.
with common extensor origin (CEO) tendinopathy.
The ultrasound findings are similar to CEO tendinopa-
thy. As has been previously discussed, the configuration of ULNAR COLLATERAL LIGAMENT
CFO is different from that on the extensor side.
Stability of the elbow joint depends on intact bony and liga-
mentous structures. Medial stability depends on soft tissue
Practice Tip integrity throughout the majority of the flexion/extension
range, as bony structures only provide stability at less than
The musculotendinous junction is more proximal so the overall 20° and more than 120°. The medial collateral ligament
ultrasound appearance is of a more muscular or fleshy complex is composed of three components, the most
appearance compared with the CEO (Fig. 7.1). important of which is the anterior limb, which is generally
referred to as the UCL. Anatomically the ligament arises
on the under surface of the medial epicondyle as a fan
This more general hyporeflectivity must not be misinter- shaped attachment and inserts onto the sublime tubercle
preted as tendinopathy. Signs of tendinopathy include loss of the ulna.
of the normal fibrillar structure of the true tendinous There has been considerable study of the biomechanics
portion of the CFO. Increased Doppler is a common and of throwing, particularly in North America where throwing
useful sign to draw attention to the diseased area. More sports play such an important role in late childhood and
advanced signs include tendon delamination leading to adolescence. The overhead throwing sequence is divided
78
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CHAPTER 7 — Disorders of the Elbow: Medial 79
a a
CFO
CFO
Med Humerus
Epicondyle M
UC S I
L
L
b b
Figure 7.1 Coronal image of the medial elbow. There is loss of Figure 7.2 Coronal image of medial elbow. Further example of
reflectivity and increased Doppler activity in the proximal part of the epicondylitis with disordered reflectivity and increased Doppler.
CFO consistent with epicondylitis.
into a number of phases, with stress being placed on differ-

ent structures in each phase. The phases are an initial wind- Key Point
up, early and late cocking, early and late acceleration,
If medial instability becomes chronic the sequelae include
deceleration and follow through. Poor technique tends to
valgus extension overload, olecranon stress fractures, ulnar
lead to increased valgus forces, which in turn lead to tension neuritis and ultimately ulnotrochlear arthritis.
along the ulnar aspect of the elbow.
Key Point Injuries to the UCL include complete and partial rupture.
Complete rupture is easier to diagnose than partial injuries.
Knowledge of the point in the throwing cycle where Complete rupture may be proximal or distal, and partial
symptoms occur gives a useful clue to the most likely injury. rupture tends to be distal and may be limited to separation
of the joint surface of the ligament from the sublime tuber-
cle of the ulna (Figs 7.3, 7.4 and 7.5). Plain films are rarely
helpful, although they can occasionally identify an entheso-
Stress on the UCL is greatest in the late cocking phase. Tears phyte. Ultrasound and MRI are both used, and MRI arthrog-
of the UCL, shearing between the posteromedial olecranon raphy is superior to MRI for subtle injuries.
and adjacent posterior aspect medial epicondyle, and com- The ultrasound findings in UCL tear include disorganiza-
pression at the radiocapitellar joint may all follow. tion of the normal fibrillary structure, increased size and
80 PART 2 — ELBOW
Figure 7.3 Schematic diagram of proximal tear of the UCL. Figure 7.5 Schematic diagram of the partial tear of the distal ulnar
collateral ligament attachment. The ligament is lifted from the underly-
ing sublime tubercle allowing joint fluid or contrast to pass between
it and the underlying ulna. Fluid pas above and below the line of fluid
in the joint is referred to as the T-sign.
laxity. In the acute phase free fluid may be seen to traverse

the tear and exude from the joint into the surrounding soft
tissues. Partial tears are more difficult to detect but in addi-
tion to disorganization of the ligament on ultrasound, focal
pain is an important aspect of diagnosis.
Practice Tip
Strain of the UCL may only manifest as ligament dysfunction

and stressing the ligament is important to detect these more
subtle injuries.
The methods for stressing the ligament have already been

described in the techniques section.
Medial elbow distraction injuries may lead to compres-
sion injuries laterally. Tears of the UCL may be associated
with osteochondral compression injuries on the lateral side.
Although not strictly osteochondritis dissecans, a similar
Figure 7.4 Coronal schematic of tear of the ulnar attachment of the lesion may be apparent in the capitellum.
ulnar collateral ligament.
Practice Tip
Careful scrutiny of the medial ligament complex is suggested

when capitellar bone lesions are detected, and vice versa.
nerve generally loses some of its reflectivity and becomes

NEURAL COMPRESSION tender to examination, resulting in a positive Tinel’s sign.
Other signs within the compressed nerve include altera-
Nerve compression and contusion around the elbow are tions in echotexture, reduced movement and changes in
common. This is because the main nerve trunks are rela- perineural vascularity. The second important finding is the
tively superficial and are in close proximity to underlying cause at the level of compression. In many cases none is
osseous structures. This combination makes them vulnera- apparent, though clearly any soft tissue enlargement,
ble to acute injury from a direct blow or a fracture. In addi- whether it be due to tendinopathy, tenosynovitis or a syno-
tion, all three main nerve trunks pass through narrow vial extension from an adjacent inflamed joint, mass,
fibromuscular or fibroosseous tunnels around the elbow, tumour or haemorrhage, should all be considered. Most
where they can be compressed or impinged by repetitive present themselves as an obvious mass, but a few are subtle
traction/relaxation movement. All three also pass through (for example: in some cases, thickening of the margins of a
muscle tunnels, which are further potential sources of com- fibroosseous tunnel may be the cause for compression).
pression. The radial nerve passes between the two heads of These are difficult to detect, but the change in calibre of
supinator, the median nerve passes through pronator teres nerve helps to focus attention and comparison with the
and the ulnar nerve passes through the two heads of flexor other side may be helpful. The third finding is the effect of
carpi ulnaris. Muscles that are extremely active during the nerve compression itself, and this depends on whether
throwing are particularly prone to dynamic compression the nerve is sensory, motor or both. Loss of motion function
syndromes. results in muscle denervation. The early signs of these can
There are three principal ultrasound findings in nerve be subtle, particularly on ultrasound, and are easier to find
compression syndromes. The most important is an altera- on MRI. In the early stages, the muscle may enlarge and
tion within the nerve itself. It is narrowed at and dilated become oedematous. Both of these signs are difficult to
proximal to the level of compression (Fig. 7.6). The swollen detect unless the muscle is painful or comparison with the
asymptomatic side is made. In the later stages, muscle
atrophy occurs. The muscle fibres are replaced by fatty
tissue, resulting in a generalized increase in reflectivity (Fig.
7.7). This is an easier sign to detect on ultrasound. If there
is any doubt, MRI is excellent at detecting the early changes
of denervation.
ULNAR NERVE COMPRESSION
Ulnar nerve compression is the most common neural com-

pression syndrome around the elbow. It is particularly
common in throwing sports and occupations where elbow
movement is prevalent as it is under increased tension
during the throwing motion. Pressure within the cubital
tunnel increases with flexion, and increases any natural ten-
dency to compression. This is particularly so in the late
cocking phase of throwing. Ulnar nerve disease may present
a
with aching pain and discomfort over the medial elbow and
forearm. Transient numbness and paraesthesia can occur
UN over the medial aspect of the forearm and hand. Athletes
may complain of clumsiness or heaviness in their throwing
arm, with easy fatigue and loss of throwing speed.
Osborne’s Ligament The cubital tunnel lies on the posterior aspect of the
Ulnar Nerve medial epicondyle, between it and the olecranon.
Key Point
Humerus The floor of the cubital is formed by the joint capsule, the
fibres from the posterior bundle of the UCL and the CFO,
so it is unsurprising that there is a strong relationship
between symptoms of epicondylitis and ulnar nerve
P
I S compression.
A
b
Figure 7.6 Long-axis parasagittal image of posteromedial elbow The roof is formed proximally by a retinaculum called
showing a dilated ulnar nerve above compression within the cubital Osborne’s ligament and distally by a fibrous aponeurosis of
tunnel. the isthmus between the two heads of flexor carpi ulnaris,
82 PART 2 — ELBOW
UN Med H
Triceps
is
al
hi
ac
Br
Pronator Teres Atrophic
Pronator Teres Humerus
M
A P
L
b
Figure 7.8 Axial image of posteromedial elbow. Note the dilated

b ulnar nerve (UN) proximal to compression within the cubital tunnel.
Figure 7.7 Axial image of distal forearm anterior. Side-to-side com-

parison demonstrating atrophy of the pronator quadratus muscle.
This is secondary to compression of the anterior interosseous nerve,
a branch of the median nerve.
the neural bundles of the ulnar nerve are hyporeflective
against a background of bright perineural connective tissue.
The appearance has been likened to a tendon, although
called the arcuate ligament. The space within the cubital nerve fibres are generally larger and are continuous com-
tunnel naturally decreases with elbow flexion as the aponeu- pared with smaller and discontinuous tendinous fibres. The
rosis of the flexor carpi ulnaris becomes taut. During flexion fibres of the ulnar nerve form themselves into a tight, well-
and extension the ulnar nerve also needs to elongate by defined bundle, unlike the more ill-defined radial nerve.
some 5 mm. The combination leads to further increased The ulnar nerve should be traced from the brachial plexus
compression/traction. Thickening of the retinaculum, the through the arm, elbow, forearm, and into Guyon’s canal
presence of an anomalous anconeus epitrochlearis muscle and beyond. Lying the patient supine, with the arm abducted
and fleshy enlargement of the arcuate ligament may all facilitates this. Such extensive coverage is possible with MRI
make compression worse. but is more time-consuming. Sonopalpation can also be used
Ulnar nerve compression may also arise from trauma or to elicit the equivalent of a clinical Tinel’s sign, when symp-
chronic valgus extension overload, when osteophytes may toms are invoked as the probe passes over the area of neural
form on the medial margin of the olecranon and impinge compression.
the adjacent ulnar nerve. Less common causes include com- The commonest ultrasound finding is swelling of the
pression at the arcade of Struthers, a thick fascial band nerve above the level of the compression (Fig. 7.8). The
running between the intermuscular septum and medial calibre of the nerve should be assessed proximal to, within
triceps, and the fascial bands between the two heads of the the proximal part of the tunnel, within the distal part of
flexor carpi ulnaris and the deep flexor–pronator aponeu- the tunnel and distal to the tunnel (Fig. 7.9) and compared
rosis. The nerve may also be compressed by a space-occupying with the contralateral side. There is normally a reduction in
lesion, scarring, posteromedial arthritis or synovitis. the calibre of the nerve as it enters the tunnel. Normal
The ultrasound examination of the ulnar nerve relies pre- values have not been established as they have for carpal
dominantly on the transverse plane. Like nerves elsewhere, tunnel syndrome and it should be appreciated that the
Brachialis Medial head

Ulnar nerve triceps
Humerus
a Normal anatomy b Partially subluxed nerve

Weak but intact Osborne's ligament
FCR
c Subluxed nerve d Subluxed nerve and triceps
UN Single click Double click
Figure 7.10 (A) Normal pattern. The ulnar nerve is constrained by

FDP FDS Osborne’s ligament. (B) Lax Osborne’s ligament. The ulnar nerve
moves anteriorly but does not sublux. (C) The ulnar nerve has dislo-
cated anteriorly. In most cases the patient is unaware. In some, a
palpable and audible click is felt. (D) In a few patients a double click
is reported. This is due to subluxation of both the ulnar nerve and
medial or accessory head of triceps.
Figure 7.9 Axial image posteromedial elbow. The normal nerve lies
below the two heads of flexor carpi ulnaris.
head of the triceps or accessory triceps also subluxes (Fig.
7.10). Subluxation is also more frequent when there is gen-
eralized soft tissue laxity (Figs 7.11 and 7.12). Although
subluxation is not infrequent in the asymptomatic popula-
contralateral nerve may also appear compressed without any tion, repeated subluxation or even frank dislocation may
symptoms. lead to friction neuritis. Subluxation is also thought to exag-
Secondary signs within the compressed nerve include gerate the effects of other causes of neural compression.
alterations in echotexture, reduced movement and changes
in perineural vascularity. If an artery accompanies a particu-
lar nerve through its fibroosseous tunnel, changes in flow MEDIAN NERVE COMPRESSION
characteristics compared with the contralateral side may be
helpful in indicating that localized compression is present. Median nerve compression at the elbow is considerably less
common than ulnar nerve compression. The commonest
cause of median compression is at the wrist, within the
Practice Tip
carpal tunnel.
In addition, examining the elbow in different positions may
cause pressure changes to augment the findings in nerve Key Point
compression.
The commonest cause of median nerve compression above
the elbow joint is due to a supracondylar process, and
In some individuals, the cubital retinaculum/Osborne’s below the elbow it is due to compression between the two
ligament is absent. This allows the nerve to sublux during heads of pronator teres.
flexion. The tendency is exaggerated if there is a prominent
medial head of triceps or bony anomalies of the medial
epicondyle. Subluxation may be accompanied by an audible The supracondylar process is an anomalous bony spur
click or even a double click where a hypertrophied medial arising from the medial aspect of the humerus. The spur
84 PART 2 — ELBOW
a a
Med H
Triceps
UN UN
Med H
lis
ia Triceps
ach
Br
is
al
chi
B ra
Humerus
M Humerus
I S M
L A P
L
b b
Figure 7.11 Transverse image of posteromedial elbow. The ulnar Figure 7.12 On flexion, the ulnar nerve has dislocated anteriorly.
nerve is located within the ulnar groove. Its posterior relation is the
medial head of triceps.
itself can be identified on plain radiographs; however, bicipital aponeurosis (Fig. 7.15). Compression may also
neural compression requires the additional presence of occur from an accessory fibrous band associated with an
Struther’s ligament, a fibrous band extending from the spur anomalous third head of the biceps muscle, by the proximal
to the medial epicondyle. This forms a fibroosseous tunnel arch of the flexor digitorum superficialis muscle, by an
through which the median nerve and brachial artery pass. accessory head of the flexor pollicis longus (Gantzer
Compression at this level leads to pronator teres dysfunction muscle), anomalous vessels. Distension of the large bicipi-
and atrophy. Compression at or below the level of the elbow toradial bursa leads to radial nerve compression.
joint does not lead to pronator teres atrophy as the branch The major branch of the median nerve is the anterior
to that muscle arises above this level. Pronator syndrome is interosseous nerve and compression of this nerve causes
the most common compressive neuropathy just below the the Kiloh–Nevin syndrome. The nerve is motor and com-
elbow. In this condition, compression occurs between the pression leads to dysfunction of the flexor pollicis longus,
two heads of the pronator teres muscle (Fig. 7.13). Patients flexor digitorum profundus to the second and third digits
present with pain over the volar aspect of the forearm associ- and the pronator quadratus muscle. What is challenging
ated with numbness and paraesthesia in the median nerve about this condition is that the involved muscles are distal
distribution. The condition may be precipitated by aug- to the elbow.
mented training and muscle hypertrophy, and symptoms
are made worse by repetitive movements of the forearm
(Fig. 7.14). Sports that entail pronation and supination are Practice Tip
particularly susceptible.
Several other potential sites of median compression may In patients presenting with wrist and hand syndromes related
be detected around the elbow. As it enters the antecubital to muscle weakness, a nerve compression syndrome at the
fossa, the nerve lies medial to the biceps tendon and bra- elbow should be considered.
chial artery, where it may be compressed by a thickened
s
rosi
neu
Apo Pronator
Median Teres
Biceps Nerve
a
Brachialis
A
LM Humerus
b P
Pronator
Teres Figure 7.14 Axial image of anterior elbow. The median nerve is
dilated just above the pronator teres.
Median
Nerve
A
S I Pronator
P Teres
Figure 7.13 Sagittal image of the anterior elbow. There is thickening

of the median nerve proximal and compression at the point where it
passes between the two heads of pronator teres.
In the early stages muscle oedema may be difficult to iden-

tify on ultrasound. Although this condition is uncommon
in the absence of a mass or haematoma, it may occur in
athletes as a result of muscle hypertrophy of the forearm.
Other nerves to consider around the elbow are the
musculocutaneous nerve and the medial and lateral ante-
brachial cutaneous nerves. Injury is rare, but may occur as
a result of needle management for CFO disease. Compres- Figure 7.15 Schematic diagram of the course of the median nerve.
sion of the lateral antebrachial cutaneous nerves is occasion- The common cause of impingement is the distal arm against the
ally due to biceps tendinopathy, as the nerve passes close to supracondylar process. In the anterior elbow, it may become impinged
the enlarged tendon. This is referred to as the Bassett’s against the biceps aponeurosis or between the two heads of pronator
lesion. teres.
86 PART 2 — ELBOW
FURTHER READING Loftice J, Fleisig G, Zheng N, et al. Biomechanics of the elbow in sports.
Clin Sports Med 2004;23(4):519–30.
Cain EL, Dugas JR. History and examination of the thrower’s elbow. Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in
Clin Sports Med 2004;23(4):553–66. athletes. Clin Sports Med 2010;29(4):521–53.
Izzi J, Dennison D, Noerdlinger M, et al. Nerve injuries of the elbow,
wrist, and hand in athletes. Clin Sports Med 2001;20(1):203–17.

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7 Disorders of the Elbow: Medial

COMMON FLEXOR ORIGIN ENTHESOPATHY ULNAR NERVE COMPRESSION

partial tears and ultimately tendon separation from the

into a number of phases, with stress being placed on differ-

laxity. In the acute phase free fluid may be seen to traverse

Strain of the UCL may only manifest as ligament dysfunction

The methods for stressing the ligament have already been

Careful scrutiny of the medial ligament complex is suggested

nerve generally loses some of its reflectivity and becomes

ULNAR NERVE COMPRESSION

Ulnar nerve compression is the most common neural com-

Figure 7.8 Axial image of posteromedial elbow. Note the dilated

Figure 7.7 Axial image of distal forearm anterior. Side-to-side com-

Brachialis Medial head

a Normal anatomy b Partially subluxed nerve

Figure 7.10 (A) Normal pattern. The ulnar nerve is constrained by

Figure 7.13 Sagittal image of the anterior elbow. There is thickening

In the early stages muscle oedema may be difficult to iden-

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