Elbow Pain In An Adolescent Baseball Player

HISTORY: 17 year-old male baseball player complaining of right elbow pain for 9 months that is gradually worsening. He is a right hand-dominant pitcher and has an intensive upper body workout schedule. There was no known trauma or inciting events to the area. The pain was initially intermittent with no swelling but is now described as a constant pain with moderate swelling. No fevers. Occasionally, his elbow will “lock”. Non-steroidal anti-inflammatory medications, resting, and icing the area have little to no effect. PHYSICAL EXAMINATION: Examination reveals diffuse tenderness and swelling at the right elbow joint with no erythema. He is unable to extend his elbow past 30 degrees with crepitus noted at terminal extension. He has full range of motion in all other planes of movement and can supinate and pronate without issue. Ligaments are otherwise intact. DIFFERENTIAL DIAGNOSIS: (1) Osteochondritis Dissecans (2) Little League Elbow (apophysitis) (3) Epicondylitis (4) Epicondyle Fracture (5) Ulnar Collateral Ligament Injury (6) Intraarticular Loose Body TEST AND RESULTS: Radiographs showed bony fragments of his capitellum measuring up to 1 cm. MRI of his right elbow showed osteochondritis dissecans of his capitellum with possible radial head involvement as well as multiple loose fragments with a moderate sized joint effusion. FINAL WORKING DIAGNOSIS: Osteochondritis Dissecans TREATMENT AND OUTCOMES: (1) Orthopedic surgery interventions: Right osteochondral allograft transplant of the capitellum, elbow arthroscopy, capsular release. (2) Physical therapy: Range of motion exercises for 4 weeks then advance to load bearing after 4 weeks post-op. (3) Active range of motion and functional use for activities, including resistance activities has improved. No increased pain post-treatment and progressing well. (4) Emphasis placed on in-home exercise program until plateau in status with orthopedics follow-up.