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# These authors share co-first authorship for this work.
Nicholas O. Gerard III
Correspondence
Corresponding Author: Nicholas O. Gerard III, MS, Tulane Institute of Sports Medicine, 202 Janet Yulman Way, New Orleans, LA 70118, USA. Tel: (504) 988-8476
Proximal to distal, the ulnar nerve can be compressed in Struthers’ arcade, under Osborne’s ligament (cubital tunnel), and at the common aponeurosis between the humeral head of the flexor carpi ulnaris (FCU) and the flexor digitorum superficialis.
The arcade of Struthers, is defined as the musculoaponeurotic structure that goes from the medial intermuscular septa to the medial head of the triceps brachii muscle, at varying distances superior to the medial humeral epicondyle.
Osborne’s ligament connects the olecranon and the medial epicondyle proximally and connects the two heads of the FCU distally covering the cubital tunnel proper and is the most common site for compression of the ulnar nerve.
Cubital tunnel syndrome, or ulnar neuritis at the elbow, can be classified by the 1950 McGowan system of grades 1-3 or by the 1989 Dellon system of mild, moderate, or severe.
Both classification systems provide a basic framework to guide treatment. Treatment options vary widely and include but are not limited to splinting, physical/occupational therapy, subcutaneous injection, hydrodissection, endoscopic decompression, open decompression, and medial epicondylectomy with anterior transposition of the ulnar nerve.
Hydrodissection has been shown to be an effective minimally invasive therapy in treating fascial compression syndromes in the upper and lower extremity.
The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review.
Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option.
Hydrodissection typically involves injecting an anesthetic solution along with corticosteroid, saline, dextrose, or other injectates to physically separate adhesions from neural, vascular, or muscular structures.
The symptoms associated with cubital tunnel syndrome range from transient paresthesia in the fourth and fifth digits to muscle weakness of the dorsal interossei, weakness in adduction of the thumb, and hand contractures.
This poses a particular challenge to the overhead throwing athlete as the kinetic change of a pitch moves from the lower extremities, through the body to the fingertips to the point of release of the ball. Dynamic compressive neuropathies have been defined as neuropathies that have a specific activity-dependent onset and resolution like pitching.
Thus, dynamic compression of the ulnar nerve and subsequent weakening of hand muscles and motor functioning could impose risk for serious injuries to the athlete by stressing the surrounding anatomy.
In this case report, we describe a division I collegiate baseball pitcher who presented with dynamic ulnar neuritis, in which the ulnar nerve was tethered to the subcutaneous fascia over the medial epicondyle. This case highlights the use of ultrasound-guided hydrodissection of a fascial adhesion compressing the ulnar nerve in an overhead throwing athlete.
Case Presentation
The patient is a 19-year-old right-hand dominant male division I collegiate baseball pitcher. He presented for evaluation of right medial elbow pain and dynamic ulnar neuritis, citing no trauma or previous injury. He characterized the pain as “aching and stabbing”, with paresthesia in the fourth and fifth digits with end-range throwing. Prior to presenting to clinic, symptoms were ongoing for one week, with pain worsening after pitching a game. The pain did not improve with rest, stretching, or physical therapy, and was at a level of severity that did not stop him from pitching a game at his expected performance level. The dynamic aspect of his symptoms occurred such that symptoms only presented with certain movements associated with pitching. The athlete did not report nighttime symptoms or difficulty with activities of daily living. He rated the pain as a 5 on a scale of 0 to 10. He denied any weakness in his right upper extremity.
A focused neurologic exam was within normal limits, with equal bilateral handgrip strength, no sensation deficits, and normal deep tendon reflexes. The athlete demonstrated hyperextensible elbows bilaterally and a negative milking maneuver, suggestive of no ulnar collateral ligament (UCL) injury on the effected elbow. He exhibited tenderness to palpation of the right cubital tunnel which reproduced his symptoms inferior and distal to the medial epicondyle. Dynamic pain was reproduced with late cocking. In-office ultrasound evaluation (Butterfly iQ+) revealed a fibrotic adhesion between the ulnar nerve and subcutaneous fascia over the medial epicondyle, in the distal third of the cubital tunnel (Figure 1). No nerve enlargement was appreciated. As the ulnar nerve was tethered by the adhesion, the nerve did not have any instability in the cubital tunnel. The UCL was not dynamically evaluated under ultrasound because the ligament’s integrity was clinically evaluated. The athlete demonstrated a normal neurologic exam, symptoms were reproducible with movement, and an abnormality on ultrasound correlated with the athlete’s clinical picture. It was not felt that nerve conduction study, electromyography, or further imaging was necessary at this time.
Figure 1Ultrasound image (Butterfly iQ+) shows ulnar nerve (UN) compressed by adhesion of subcutaneous fascia. OL, olecranon.
The athlete agreed to proceed with ultrasound-guided hydrodissection. He was placed in a supine position with his right shoulder abducted to 90 degrees and elbow flexed to 90 degrees. Ultrasound was used to again identify the ulnar nerve, the adhesion between the nerve, and subcutaneous fascia. The ulnar artery was identified, and the ultrasound probe was moved proximally along the elbow to isolate the ulnar nerve. The injection site was sterilized. Power Doppler was used to confirm the absence of vascular structures within the planned needle path. A 25-gauge needle was advanced under ultrasound guidance, with the needle visualized outside the ulnar nerve sheath. A solution of 2cc 1% lidocaine, 7cc normal saline, and 1cc of 6mg/mL betamethasone was injected (Figure 2, Video 1). The needle was removed, and bleeding was controlled (Figure 3). Immediately after the procedure, the patient noted improvement in pain. Strength and sensation testing post-procedure was normal, and the patient was able to reproduce overhead pitching motions in clinic without pain or paresthesia. He no longer experienced pain with late cocking.
Figure 2Ultrasound-guided hydrodissection of subcutaneous fascial adhesion (circle) from the ulnar nerve (UN). Dotted line delineates needle advancement between ulnar nerve and subcutaneous fascial adhesion. OL, olecranon; ME, medial epicondyle.
The day of the procedure the patient rested. Post-procedure day 1 and 2, he did stretch and massage therapy with the team's athletic trainer. He was allowed to practice as tolerated. Post procedure day 4, he pitched a full game at his expected level of performance without pain or reproduction of symptoms. At 7 months post-procedure, the athlete reports the same level of collegiate pitching, and he continues to play without limitations or symptoms of ulnar neuritis.
Discussion discussion
To the best of our knowledge, this is the first case report related to peripheral nerve hydrodissection of the ulnar nerve in an overhead throwing athlete. Hydrodissection offers a less invasive treatment compared to traditional surgical interventions for patients who do not respond to more conservative treatment options.
The use of ultrasound-guided hydrodissection in the treatment of peripheral nerve entrapment syndromes is still an emerging concept. However, there are examples in the literature that support its efficacy. A cadaveric study by Kim et. al successfully separated ulnar nerves from the medial epicondyle and surrounding connective tissue using ultrasound-guided injection.
In another study by Choi et al, 10 patients diagnosed with cubital tunnel syndrome were treated with ultrasound-guided injection with lidocaine and triamcinolone. Patients were assessed pre-injection and at 1- and 4-weeks post-injection. Overall, there were no side effects reported during the period of study, and investigators noted significantly improved motor conduction velocity across the elbow on electrodiagnostic studies 4 weeks post-injection. Patients also experienced decreased pain and measured ulnar nerve cross-sectional area.
There is a myriad of published case reports on successful hydrodissection for peripheral nerve entrapment. Such reports include a case of dorsal scapular nerve entrapment neuropathy treated with hydrodissection using 1% lignocaine, 5% dextrose, and triamcinolone
Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option.
. A systematic review from 2020 concluded that ultrasound-guided hydrodissection is safe and effective in the treatment of nerve entrapment syndromes, including carpal tunnel syndrome and ulnar neuropathy at the elbow, with a variety of injectate showing clinical improvement, including normal saline, platelet-rich plasma (PRP), local anesthetics, corticosteroids, and 5% dextrose in water (D5W).
The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review.
Patients suffering from an ulnar nerve entrapment often present with paresthesia and numbness in the fifth digit and ulnar half of the fourth digit, like the athlete presented. They may also experience grip and hand strength deficits secondary to muscle weakness.
Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option.
The superficial location of the ulnar nerve makes it particularly vulnerable to injury as it is susceptible to mechanical factors such as compression, irritation, trauma, and traction. Literature indicates that throwing athletes, like the patient in this case, are particularly prone to ulnar nerve entrapment and injury given the great rotational moments and force placed on the elbow.
Recent data from Major League Baseball indicates that 16% of reported injuries relate to an elbow pathology, with over 40% of the elbow pathologies involving the medial elbow.
The physician performing a hydrodissection of the ulnar nerve should have experience in using ultrasound as a dynamic imaging modality and should be aware of relevant anatomy findings of the elbow on ultrasound. While the ulnar nerve is not usually accompanied by vasculature at the proximal elbow, the ulnar artery is found next to the ulnar nerve more distally. Identifying the ulnar artery on initial scanning of the elbow and forearm, in addition to using Doppler on ultrasound, can prevent injury to the artery and excessive bleeding or hematoma formation. In the case of this athlete’s adhesion, located at the distal third of the cubital tunnel, there is little risk for detrimental effects on the stabilizing ligaments of the elbow such as the UCL. Additional potential complications of ulnar nerve hydrodissection include infection, lidocaine or bupivacaine toxicity, fat atrophy, skin discoloration, and post-injection flare.
The clinician should be aware of these complications and how to manage them should they occur.
Conclusion conclusion
This report details the case of a division I collegiate-level right-handed pitcher who experienced ulnar neuritis at the elbow, one of the most common neuropathies seen in overhead throwing athletes. This case suggests that ultrasound-guided hydrodissection can offer many positive benefits, including symptom resolution for ulnar neuritis, quick return to sport for overhead athletes, and a relatively low procedural cost. More large-scale studies should be performed to compare the risks, benefits, and efficacy of ulnar nerve hydrodissection against more traditional interventions like surgery. We also suggest further comparison studies to evaluate varying injectate contents in a more standardized fashion.
The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review.
Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option.
Institutional review board approval was not required for this case report.
Disclaimers:
Funding: No funding was disclosed by the authors.
Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Tulane University School of Medicine, New Orleans, LA, USA
Correspondence
Corresponding Author: Nicholas O. Gerard III, MS, Tulane Institute of Sports Medicine, 202 Janet Yulman Way, New Orleans, LA 70118, USA. Tel: (504) 988-8476
Tulane University School of Medicine, New Orleans, LA, USA
Correspondence
Corresponding Author: Nicholas O. Gerard III, MS, Tulane Institute of Sports Medicine, 202 Janet Yulman Way, New Orleans, LA 70118, USA. Tel: (504) 988-8476
Ultrasound-guided hydrodissection of subcutaneous fascial adhesion (circle) from the ulnar nerve (UN). Dotted line delineates needle advancement between ulnar nerve and subcutaneous fascial adhesion. OL, olecranon; ME, medial epicondyle.
Cubital tunnel syndrome, or ulnar neuritis at the elbow, can be classified by the 1950 McGowan system of grades 1-3 or by the 1989 Dellon system of mild, moderate, or severe.8x8Dellon, A.L. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg Am. 1989;
14: 688–700 Abstract | Full Text PDF | PubMed | Scopus (310) | Google ScholarSee all References,15x15Mc, G.A. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br. 1950;
32-b: 293–301 Crossref | PubMed | Google ScholarSee all References Both classification systems provide a basic framework to guide treatment. Treatment options vary widely and include but are not limited to splinting, physical/occupational therapy, subcutaneous injection, hydrodissection, endoscopic decompression, open decompression, and medial epicondylectomy with anterior transposition of the ulnar nerve.1x1Adkinson, J.M., Zhong, L., Aliu, O., and Chung, K.C. Surgical Treatment of Cubital Tunnel Syndrome: Trends and the Influence of Patient and Surgeon Characteristics. J Hand Surg Am. 2015;
40: 1824–1831https://doi.org/10.1016/j.jhsa.2015.05.009 Abstract | Full Text | Full Text PDF | PubMed | Scopus (26) | Google ScholarSee all References Authors suggest surgery should be reserved for grade 2 or moderate and more serious cases.9x9Doughty, C.T. and Bowley, M.P. Entrapment Neuropathies of the Upper Extremity. Med Clin North Am. 2019;
103: 357–370https://doi.org/10.1016/j.mcna.2018.10.012 Abstract | Full Text | Full Text PDF | PubMed | Scopus (25) | Google ScholarSee all References,19x19Staples, J.R. and Calfee, R. Cubital Tunnel Syndrome: Current Concepts. J Am Acad Orthop Surg. 2017;
25: e215–e224https://doi.org/10.5435/jaaos-d-15-00261 Crossref | PubMed | Scopus (0) | Google ScholarSee all References Hydrodissection has been shown to be an effective minimally invasive therapy in treating fascial compression syndromes in the upper and lower extremity.2x2Buntragulpoontawee, M., Chang, K.V., Vitoonpong, T., Pornjaksawan, S., Kitisak, K., Saokaew, S. et al. The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review. Front Pharmacol. 2020;
11: 621150https://doi.org/10.3389/fphar.2020.621150 Crossref | PubMed | Scopus (11) | Google ScholarSee all References,7x7Courseault, J., Kessler, E., Moran, A., and Labbe, A. Fascial Hydrodissection for Chronic Hamstring Injury. Curr Sports Med Rep. 2019;
18: 416–420https://doi.org/10.1249/jsr.0000000000000650 Crossref | PubMed | Google ScholarSee all References,20x20Stoddard, J.M., Taylor, C.R., and OʼConnor, F.G. Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option. Curr Sports Med Rep. 2019;
18: 382–386https://doi.org/10.1249/jsr.0000000000000649 Crossref | PubMed | Google ScholarSee all References Hydrodissection typically involves injecting an anesthetic solution along with corticosteroid, saline, dextrose, or other injectates to physically separate adhesions from neural, vascular, or muscular structures.4x4Cass, S.P. Ultrasound-Guided Nerve Hydrodissection: What is it? A Review of the Literature. Curr Sports Med Rep. 2016;
15: 20–22https://doi.org/10.1249/jsr.0000000000000226 Crossref | PubMed | Google ScholarSee all References
The symptoms associated with cubital tunnel syndrome range from transient paresthesia in the fourth and fifth digits to muscle weakness of the dorsal interossei, weakness in adduction of the thumb, and hand contractures.16x16Palmer, B.A. and Hughes, T.B. Cubital tunnel syndrome. J Hand Surg Am. 2010;
35: 153–163https://doi.org/10.1016/j.jhsa.2009.11.004 Abstract | Full Text | Full Text PDF | PubMed | Scopus (145) | Google ScholarSee all References This poses a particular challenge to the overhead throwing athlete as the kinetic change of a pitch moves from the lower extremities, through the body to the fingertips to the point of release of the ball. Dynamic compressive neuropathies have been defined as neuropathies that have a specific activity-dependent onset and resolution like pitching.21x21von Bergen, T.N. and Lourie, G.M. Etiology, Diagnosis, and Treatment of Dynamic Nerve Compression Syndromes of the Elbow Among High-Level Pitchers: A Review of 7 Cases. Orthop J Sports Med. 2018;
6: 2325967118807131https://doi.org/10.1177/2325967118807131 Crossref | PubMed | Scopus (6) | Google ScholarSee all References Thus, dynamic compression of the ulnar nerve and subsequent weakening of hand muscles and motor functioning could impose risk for serious injuries to the athlete by stressing the surrounding anatomy.21x21von Bergen, T.N. and Lourie, G.M. Etiology, Diagnosis, and Treatment of Dynamic Nerve Compression Syndromes of the Elbow Among High-Level Pitchers: A Review of 7 Cases. Orthop J Sports Med. 2018;
6: 2325967118807131https://doi.org/10.1177/2325967118807131 Crossref | PubMed | Scopus (6) | Google ScholarSee all References
In this case report, we describe a division I collegiate baseball pitcher who presented with dynamic ulnar neuritis, in which the ulnar nerve was tethered to the subcutaneous fascia over the medial epicondyle. This case highlights the use of ultrasound-guided hydrodissection of a fascial adhesion compressing the ulnar nerve in an overhead throwing athlete.
Case Presentation
The patient is a 19-year-old right-hand dominant male division I collegiate baseball pitcher. He presented for evaluation of right medial elbow pain and dynamic ulnar neuritis, citing no trauma or previous injury. He characterized the pain as “aching and stabbing”, with paresthesia in the fourth and fifth digits with end-range throwing. Prior to presenting to clinic, symptoms were ongoing for one week, with pain worsening after pitching a game. The pain did not improve with rest, stretching, or physical therapy, and was at a level of severity that did not stop him from pitching a game at his expected performance level. The dynamic aspect of his symptoms occurred such that symptoms only presented with certain movements associated with pitching. The athlete did not report nighttime symptoms or difficulty with activities of daily living. He rated the pain as a 5 on a scale of 0 to 10. He denied any weakness in his right upper extremity.
A focused neurologic exam was within normal limits, with equal bilateral handgrip strength, no sensation deficits, and normal deep tendon reflexes. The athlete demonstrated hyperextensible elbows bilaterally and a negative milking maneuver, suggestive of no ulnar collateral ligament (UCL) injury on the effected elbow. He exhibited tenderness to palpation of the right cubital tunnel which reproduced his symptoms inferior and distal to the medial epicondyle. Dynamic pain was reproduced with late cocking. In-office ultrasound evaluation (Butterfly iQ+) revealed a fibrotic adhesion between the ulnar nerve and subcutaneous fascia over the medial epicondyle, in the distal third of the cubital tunnel (Figure 1Figure 1). No nerve enlargement was appreciated. As the ulnar nerve was tethered by the adhesion, the nerve did not have any instability in the cubital tunnel. The UCL was not dynamically evaluated under ultrasound because the ligament’s integrity was clinically evaluated. The athlete demonstrated a normal neurologic exam, symptoms were reproducible with movement, and an abnormality on ultrasound correlated with the athlete’s clinical picture. It was not felt that nerve conduction study, electromyography, or further imaging was necessary at this time.
Figure 1
Ultrasound image (Butterfly iQ+) shows ulnar nerve (UN) compressed by adhesion of subcutaneous fascia. OL, olecranon.
The athlete agreed to proceed with ultrasound-guided hydrodissection. He was placed in a supine position with his right shoulder abducted to 90 degrees and elbow flexed to 90 degrees. Ultrasound was used to again identify the ulnar nerve, the adhesion between the nerve, and subcutaneous fascia. The ulnar artery was identified, and the ultrasound probe was moved proximally along the elbow to isolate the ulnar nerve. The injection site was sterilized. Power Doppler was used to confirm the absence of vascular structures within the planned needle path. A 25-gauge needle was advanced under ultrasound guidance, with the needle visualized outside the ulnar nerve sheath. A solution of 2cc 1% lidocaine, 7cc normal saline, and 1cc of 6mg/mL betamethasone was injected (Figure 2Figure 2, Video 1Video 1). The needle was removed, and bleeding was controlled (Figure 3Figure 3). Immediately after the procedure, the patient noted improvement in pain. Strength and sensation testing post-procedure was normal, and the patient was able to reproduce overhead pitching motions in clinic without pain or paresthesia. He no longer experienced pain with late cocking.
Figure 2
Ultrasound-guided hydrodissection of subcutaneous fascial adhesion (circle) from the ulnar nerve (UN). Dotted line delineates needle advancement between ulnar nerve and subcutaneous fascial adhesion. OL, olecranon; ME, medial epicondyle.
The day of the procedure the patient rested. Post-procedure day 1 and 2, he did stretch and massage therapy with the team's athletic trainer. He was allowed to practice as tolerated. Post procedure day 4, he pitched a full game at his expected level of performance without pain or reproduction of symptoms. At 7 months post-procedure, the athlete reports the same level of collegiate pitching, and he continues to play without limitations or symptoms of ulnar neuritis.
Discussion discussion
To the best of our knowledge, this is the first case report related to peripheral nerve hydrodissection of the ulnar nerve in an overhead throwing athlete. Hydrodissection offers a less invasive treatment compared to traditional surgical interventions for patients who do not respond to more conservative treatment options.4x4Cass, S.P. Ultrasound-Guided Nerve Hydrodissection: What is it? A Review of the Literature. Curr Sports Med Rep. 2016;
15: 20–22https://doi.org/10.1249/jsr.0000000000000226 Crossref | PubMed | Google ScholarSee all References4
The use of ultrasound-guided hydrodissection in the treatment of peripheral nerve entrapment syndromes is still an emerging concept. However, there are examples in the literature that support its efficacy. A cadaveric study by Kim et. al successfully separated ulnar nerves from the medial epicondyle and surrounding connective tissue using ultrasound-guided injection.14x14Kim, J.M., Oh, H.M., and Kim, M.W. Real-time visualization of ultrasonography guided cubital tunnel injection: a cadaveric study. Ann Rehabil Med. 2012;
36: 496–500https://doi.org/10.5535/arm.2012.36.4.496 Crossref | PubMed | Scopus (10) | Google ScholarSee all References14 In another study by Choi et al, 10 patients diagnosed with cubital tunnel syndrome were treated with ultrasound-guided injection with lidocaine and triamcinolone. Patients were assessed pre-injection and at 1- and 4-weeks post-injection. Overall, there were no side effects reported during the period of study, and investigators noted significantly improved motor conduction velocity across the elbow on electrodiagnostic studies 4 weeks post-injection. Patients also experienced decreased pain and measured ulnar nerve cross-sectional area.5x5Choi, C.K., Lee, H.S., Kwon, J.Y., and Lee, W.J. Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study. Ann Rehabil Med. 2015;
39: 176–182https://doi.org/10.5535/arm.2015.39.2.176 Crossref | PubMed | Scopus (15) | Google ScholarSee all References5
There is a myriad of published case reports on successful hydrodissection for peripheral nerve entrapment. Such reports include a case of dorsal scapular nerve entrapment neuropathy treated with hydrodissection using 1% lignocaine, 5% dextrose, and triamcinolone18x18Sharma, G.K. and Botchu, R. Dorsal scapular nerve entrapment neuropathy managed by ultrasound-guided hydrodissection - a case report. J Ultrason. 2021;
21: 74–76https://doi.org/10.15557/JoU.2021.0012 Crossref | PubMed | Scopus (2) | Google ScholarSee all References18, and a case of ulnar nerve entrapment in a teenage swimmer treated with hydrodissection using 5% dextrose20x20Stoddard, J.M., Taylor, C.R., and OʼConnor, F.G. Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option. Curr Sports Med Rep. 2019;
18: 382–386https://doi.org/10.1249/jsr.0000000000000649 Crossref | PubMed | Google ScholarSee all References20. A systematic review from 2020 concluded that ultrasound-guided hydrodissection is safe and effective in the treatment of nerve entrapment syndromes, including carpal tunnel syndrome and ulnar neuropathy at the elbow, with a variety of injectate showing clinical improvement, including normal saline, platelet-rich plasma (PRP), local anesthetics, corticosteroids, and 5% dextrose in water (D5W).2x2Buntragulpoontawee, M., Chang, K.V., Vitoonpong, T., Pornjaksawan, S., Kitisak, K., Saokaew, S. et al. The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review. Front Pharmacol. 2020;
11: 621150https://doi.org/10.3389/fphar.2020.621150 Crossref | PubMed | Scopus (11) | Google ScholarSee all References2
Patients suffering from an ulnar nerve entrapment often present with paresthesia and numbness in the fifth digit and ulnar half of the fourth digit, like the athlete presented. They may also experience grip and hand strength deficits secondary to muscle weakness.20x20Stoddard, J.M., Taylor, C.R., and OʼConnor, F.G. Ulnar Nerve Entrapment at the Cubital Tunnel Successfully Treated with Ultrasound-Guided Peripheral Nerve Hydrodissection: A Case Report and Further Evidence for a Developing Treatment Option. Curr Sports Med Rep. 2019;
18: 382–386https://doi.org/10.1249/jsr.0000000000000649 Crossref | PubMed | Google ScholarSee all References20 The superficial location of the ulnar nerve makes it particularly vulnerable to injury as it is susceptible to mechanical factors such as compression, irritation, trauma, and traction. Literature indicates that throwing athletes, like the patient in this case, are particularly prone to ulnar nerve entrapment and injury given the great rotational moments and force placed on the elbow.10x10Dowdle, S.B. and Chalmers, P.N. Management of the Ulnar Nerve in Throwing Athletes. Curr Rev Musculoskelet Med. 2020;
13: 449–456https://doi.org/10.1007/s12178-020-09639-7 Crossref | PubMed | Scopus (5) | Google ScholarSee all References10 Recent data from Major League Baseball indicates that 16% of reported injuries relate to an elbow pathology, with over 40% of the elbow pathologies involving the medial elbow.6x6Ciccotti, M.G., Pollack, K.M., Ciccotti, M.C., D'Angelo, J., Ahmad, C.S., Altchek, D. et al. Elbow Injuries in Professional Baseball: Epidemiological Findings From the Major League Baseball Injury Surveillance System. Am J Sports Med. 2017;
45: 2319–2328https://doi.org/10.1177/0363546517706964 Crossref | PubMed | Scopus (59) | Google ScholarSee all References6
The physician performing a hydrodissection of the ulnar nerve should have experience in using ultrasound as a dynamic imaging modality and should be aware of relevant anatomy findings of the elbow on ultrasound. While the ulnar nerve is not usually accompanied by vasculature at the proximal elbow, the ulnar artery is found next to the ulnar nerve more distally. Identifying the ulnar artery on initial scanning of the elbow and forearm, in addition to using Doppler on ultrasound, can prevent injury to the artery and excessive bleeding or hematoma formation. In the case of this athlete’s adhesion, located at the distal third of the cubital tunnel, there is little risk for detrimental effects on the stabilizing ligaments of the elbow such as the UCL. Additional potential complications of ulnar nerve hydrodissection include infection, lidocaine or bupivacaine toxicity, fat atrophy, skin discoloration, and post-injection flare.7x7Courseault, J., Kessler, E., Moran, A., and Labbe, A. Fascial Hydrodissection for Chronic Hamstring Injury. Curr Sports Med Rep. 2019;
18: 416–420https://doi.org/10.1249/jsr.0000000000000650 Crossref | PubMed | Google ScholarSee all References7 The clinician should be aware of these complications and how to manage them should they occur.
Conclusion conclusion
This report details the case of a division I collegiate-level right-handed pitcher who experienced ulnar neuritis at the elbow, one of the most common neuropathies seen in overhead throwing athletes. This case suggests that ultrasound-guided hydrodissection can offer many positive benefits, including symptom resolution for ulnar neuritis, quick return to sport for overhead athletes, and a relatively low procedural cost. More large-scale studies should be performed to compare the risks, benefits, and efficacy of ulnar nerve hydrodissection against more traditional interventions like surgery. We also suggest further comparison studies to evaluate varying injectate contents in a more standardized fashion.
1Adkinson, J.M., Zhong, L., Aliu, O., and Chung, K.C. Surgical Treatment of Cubital Tunnel Syndrome: Trends and the Influence of Patient and Surgeon Characteristics. J Hand Surg Am. 2015;
40: 1824–1831https://doi.org/10.1016/j.jhsa.2015.05.009
2Buntragulpoontawee, M., Chang, K.V., Vitoonpong, T., Pornjaksawan, S., Kitisak, K., Saokaew, S. et al. The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review. Front Pharmacol. 2020;
11: 621150https://doi.org/10.3389/fphar.2020.621150
3Caetano, E.B., Sabongi Neto, J.J., Vieira, L.A., and Caetano, M.F. The arcade of Struthers: an anatomical study and clinical implications. Rev Bras Ortop. 2017;
52: 331–336https://doi.org/10.1016/j.rboe.2016.07.006
5Choi, C.K., Lee, H.S., Kwon, J.Y., and Lee, W.J. Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study. Ann Rehabil Med. 2015;
39: 176–182https://doi.org/10.5535/arm.2015.39.2.176
6Ciccotti, M.G., Pollack, K.M., Ciccotti, M.C., D'Angelo, J., Ahmad, C.S., Altchek, D. et al. Elbow Injuries in Professional Baseball: Epidemiological Findings From the Major League Baseball Injury Surveillance System. Am J Sports Med. 2017;
45: 2319–2328https://doi.org/10.1177/0363546517706964
7Courseault, J., Kessler, E., Moran, A., and Labbe, A. Fascial Hydrodissection for Chronic Hamstring Injury. Curr Sports Med Rep. 2019;
18: 416–420https://doi.org/10.1249/jsr.0000000000000650
10Dowdle, S.B. and Chalmers, P.N. Management of the Ulnar Nerve in Throwing Athletes. Curr Rev Musculoskelet Med. 2020;
13: 449–456https://doi.org/10.1007/s12178-020-09639-7
12Granger, A., Sardi, J.P., Iwanaga, J., Wilson, T.J., Yang, L., Loukas, M. et al. Osborne's Ligament: A Review of its History, Anatomy, and Surgical Importance. Cureus. 2017;
9: e1080https://doi.org/10.7759/cureus.1080
14Kim, J.M., Oh, H.M., and Kim, M.W. Real-time visualization of ultrasonography guided cubital tunnel injection: a cadaveric study. Ann Rehabil Med. 2012;
36: 496–500https://doi.org/10.5535/arm.2012.36.4.496
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Institutional review board approval was not required for this case report.
Disclaimers:
Funding: No funding was disclosed by the authors.
Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Patient consent: Obtained
#These authors share co-first authorship for this work.
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