Working Diagnosis:
Osteochondritis Dissecans of Capitellum

Treatment:
The patient was referred to orthopedic surgery due to the instability of the OCD lesion. She underwent arthroscopic surgical debridement and microfracture without complication. She started range of motion exercises 2-days post-operatively and completed 3-months of physical therapy.

Outcome:
After completing physical therapy she was subsequently released from the care of her orthopedic surgeon. She returned to painless full range of motion of her right elbow. She started participating in orchestra again and playing viola approximately 3-months post-operatively. She was restricted from high impact physical activity for a total of 6-months post-operatively.

Author's Comments:
This is the first documented case to our knowledge of an OCD in the capitellum of a fine arts performer without a history of trauma. It brings to question whether other factors aside from trauma and repetitive axial loads are involved in the development of OCD lesions. These potential causes include obesity or underlying endocrine or vascular abnormalities which lead to avascular necrosis of the subchondral bone. Although capitellar OCD lesions are seen in gymnasts and baseball players, it is rare to find one in a fine arts performer such as a violinist, prompting our investigation into other etiologies of OCD lesions.

Editor's Comments:
It is widely accepted that repetitive microtrauma contributes to capitellar OCD lesions. These OCD lesions are more commonly seen in athletes participating in activities that cause valgus stress on the elbow such as overhead throwing or tumbling, as the repetitive radiocapitellar compression leads to osteochondritic changes in the capitellum. Playing the viola requires repetitive flexion and extension of the elbow when going from the frog to middle to tip points on the bow leading to repetitive compression of the radiocapitellar joint. While the force of this repetitive compression in violists is less than in high-impact sports, one study of violinists has looked at the internal loads of the bow arm during certain bowing techniques at a variety of speeds and found that the quantity of load was affected by the tempo and the quality of the load was affected by the musician's individual characteristics. It would be interesting to know the tempo of the music she had recently been practicing and if there was a change in the type of music she was playing prior to the onset of the pain. Her body habitus may have contributed to the quality of her playing as well leading to increased load on the elbow.

Just as it is important for athletes to play their sport with proper mechanics, musicians need to play their instrument with proper mechanics in order to prevent acute and overuse injuries. Despite some variability between musicians, every string instrument is played within certain physical limits, and playing an instrument outside these limits can lead to problems. It would be important for the current patient to work with her instructor to ensure proper mechanics, in particular of her bow arm, to help her right arm joints move more effectively and efficiently to reduce the risk of injury.

References:
Gadinsky NE OBrien MJ Osteochondritis dissecans of the capitellum Management in the throwing athlete Operative techniques in sports medicine 2020 28 2 150734

Kelleher Campbell KR and Dickey JP 2013 Biomechanical Research on Bowed String Musicians A Scoping Study Medical Problems of Performing Artists 28 4 212 to 218

S Duprey B Michaud and M Begon 2017 Muscular activity variations of the right bowing arm of the violin player Computer Methods in Biomechanics and Biomedical Engineering 20 sup1 S71 to S72

Schoonderwaldt E The player and the bowed string Coordination of bowing parameters in violin and viola performance J Acoust Soc Am 2009 126 5 2709 to 2720

Yagisan N Karabork H Goktepe A Karalezli N Evaluation of three dimensional motion analysis of the upper right limb movements in the bowing arm of violinists through a digital photogrammetric method Medical problems of performing artists 2009 24 4 181 to 184

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