A case study: Javelin Thrower with Medial Elbow Pain with Median Nerve Involvement
Dr. RD Donkin M.Tech:chiro ICSSP
Sports Chiropractor in Private Practice Pretoria South Africa.
Affiliations: Chirosport SA
Literature Review
A review of the literature showed no reported incidences of medial elbow pain involving the median nerve in javelin throwers. elbow pain involving the median nerve in javelin throwersMedian nerve trauma is typically caused by deep penetrating injuries or blunt trauma or neuropathy (1). This is in stark contrast to the most common elbow injury in javelin throwers namely medial collateral ligament injury. This injury can be caused by increased valgus stress on the elbow resulting in damage to the ligamentous structures of the medial elbow (2).
Case History
This 19 year old right hand dominant javelin thrower presented with shooting right medial elbow pain and tingling in the forearm after competing in three competitions within a month. No one specific throw produced the pain but the elbow pain began the day after the third competition. The patient has been taking part in javelin for more than four years, but in the last year her training has for the first time included regular weight training and a more rigorous throwing routine.
She has previously not had any elbow pain before this incidence. Previous injuries include back and shoulder injuries which were effectively managed with conservative treatment and improved throwing technique. Patient was initially diagnosed with medial epicondylitis but after treatment no improvement in symptoms was noted.
Case History
This 19 year old right hand dominant javelin thrower presented with shooting right medial elbow pain and tingling in the forearm after competing in three competitions within a month. No one specific throw produced the pain but the elbow pain began the day after the third competition. The patient has been taking part in javelin for more than four years, but in the last year her training has for the first time included regular weight training and a more rigorous throwing routine.
She has previously not had any elbow pain before this incidence. Previous injuries include back and shoulder injuries which were effectively managed with conservative treatment and improved throwing technique. Patient was initially diagnosed with medial epicondylitis but after treatment no improvement in symptoms was noted.
Physical Examination
No obvious swelling, discoloration or deformity of the upper limb or elbow was noted. Passive elbow range of motion was full and pain free. Active elbow range of motion was full and pain free. Valgus stress test demonstrated no instability or pain over the medial collateral ligament. Pronator teres syndrome test did not reproduce her symptoms. Elbow joint play had a springy end feel and pain free. Wrist range of motion was full and did not reproduce the patient’s symptoms. Resisted elbow and wrist isometrics were painless and no loss of strength was demonstrated. Upper limb reflexes, myotomes and dermatomes were normal.
Differential Diagnosis
– Medial epicondylitis
– Medial collateral ligament injury (sprain or rupture)
– Ulnar nerve neuritis
– Cervical radiculopathy
– Pronator teres syndrome
– Medial epicondyle avulsion fracture
Special Tests
An ultrasound of the elbow was requested. The median nerve of the right arm was enlarged when compared to the median nerve of the right armmedian nerve of the left arm. On the symptomatic right arm the median nerve measured 2.1mm in anterior-posterior diameter compared to the 1.5mm on the left arm. The transverse diameter of the median nerve of both elbows was symmetrical. One of the nerve fascicles of the right median nerve was swollen. All other soft tissue of the right elbow was within normal limits.
Final Diagnosis and Outcome
A diagnosed median nerve injury at the elbow was reached.
A treatment approach using neural taping, wrist and elbow mobilisation, and rest with no throwing or gym activity for six weeks.
Return to Activity
After six weeks the patient returned to normal training which included javelin throwing, cardiovascular fitness training and strength training without re-occurrence of the symptoms.
Discussion
Medial elbow pain may be common in sports that involve throwing such as javelin. While a ligament, tendon or muscular injury may be suspected, the clinician should be on the lookout for nerve injury especially when symptoms that characterise nerve involvement are present.
Bibliography
1. Leit, M, Tomaino, M M. Median Nerve Palsy. Journal of the Academy of American Orthopaedic Surgeons Vol. 7, Number 11, 2009. Creighton RA
2. 1, Bach BR Jr, Bush-Joseph CA Evaluation of the medial elbow in the throwing athlete.
American Journal of Orthopaedics June;35(6):266-9 .2006.