Elbow Pain In A Gymnast - Page #4
 

Working Diagnosis:
Osteochondral lesion of the capitellum

Treatment:
No weight bearing activities (no
tumbling) for 12 weeks.
Orthopedic recommendations:  
Agreed with non-weight bearing
status.
Repeat MRI in 12 weeks to identify
healing.
Told to anticipate slow progress and
to avoid weight bearing activities
until full healing documented. Once
full healing has occurred, she may
return to her usual sport
participation.

Outcome:
Follow Up:
At 4 weeks, she confirmed that she
had been compliant with instructions
and was asymptomatic.
At 4 months, a repeat MRI showed
minimal improvement of her
capitellar OCD.
Return to activity was not granted
and is pending.

Author's Comments:
Osteochondral lesion of the capitellum:

Risk factors:
12 – 17 years old
Dominant upper extremity
Repetitive overhead activity in a
weight bearing athlete
Common Sports:
Pitching, competitive gymnastics,
racquet sports, weight lifting
Presentation:
Often insidious dull pain which is
progressive and activity related
Clicking and/or locking is
suggestive of loose body
Flexion contractures of 15°-30° can
lead to loss of range of motion
Etiology:
Idiopathic, localized disorder of
subchondral bone
Repetitive microtrauma leads to
compression of the radiocapitellar
joint
Fractures occur at the weakened
capitellar subcondral bone,
eventually leaving an avascular
fragment

Panner disease may have a similar clinical presentation and X-ray findings. However, this disorder
occurs more commonly in males, ages 4-8 years old. There is generally no history of trauma.
Work-up includes X-ray. Obtain AP, lateral, 45° flex AP, and oblique views. In Panner disease, X-ray reveals fragmentation of the entire ossific nucleus of the capitellum. X-ray may show a capitellar radiolucency, flattening of the articular surface, and/or a loose body.
MRI is the gold standard and should be performed if there is clinical concern and/or X-ray is suggestive. MRI can identify loose bodies and assess articular cartilage.
There are no universal treatment guidelines for Panner disease. Rest and conservative treatment is recommended in those with an open capitellar growth plate and good elbow motion.
Surgery is recommended in those with a closed capitellar growth plate, articular cartilage fragmentation, restricted elbow
motion ≥20°, and those who have failed 6 months of conservative
treatment.
50% of those with Panner disease develop degenerative joint disease. Those with open capitellar physes have a better prognosis. There are no clear guidelines for return to activity.

Editor's Comments:
The differential for elbow pain in adolescent athletes is vast. Although OCD of the capitellum is relatively uncommon compared to some of the other diagnoses, it should not be dismissed in the young athlete with lateral elbow pain. Although the exact cause of capitellar OCD is unknown, it occurs most commonly in athletes with repetitive valgus stress on the elbow, such as baseball pitchers and female gymnasts. If X-ray is negative, MRI can be diagnostic.

References:
Baker, CL III; Baker, CL Jr; Romeo, AA. Osteochondritis dissecans of the capitellum. J Shoulder Elbow Surg 2010: 19: 76-82.

Baker CL III, Romeo AA, Baker CL Jr. Osteochondritis dissecans of the capitellum. Am J Sports Med 2010; 38: 1917-1928. 

Chen, NC. Osteochondritis dissecans of the elbow. Clin Sports Med 2001; 20: 1188-1189.
 
Kijowski R, Smet AA. MRI findings of osteochondritis dissecans of the capitellum with surgical correlation. Am J Rad 2005; 185: 1453-1459. 

Mihara K, Tsutsui H, Nishinaka N, Uamaguchi K. Nonoperative treatment for osteochondritis dissecans of the capitellum. Am J Sports Med 2009; 37: 298-304.

Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique. J Bone Joint Surg Am 2008; 90: 47-62.

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