Etiology, Diagnosis, and Treatment of Dynamic Nerve Compression Syndromes of the Elbow Among High-Level Pitchers: A Review of 7 Cases

Abstract

Background: Dynamic compressive neuropathies around the elbow are a rare entity described by a relatively small body of literature, mostly consisting of single-case reports. No standardized diagnostic protocols have been described to date. To the authors' knowledge, this study represents the largest case series of dynamic compressive neuropathies in the upper extremity.

Purpose: To identify various etiologies of dynamic compressive neuropathies around the elbow, devise a systematic diagnostic protocol, and review treatment options.

Study design: Case series; Level of evidence, 4.

Methods: A retrospective review was conducted of patients who presented to a single practice between 2013 and 2017 and were diagnosed with a dynamic compressive neuropathy around the elbow.

Results: A total of 7 patients were identified, with a mean follow-up of 2 years. All patients were high-level pitchers. One patient was a minor league pitcher; 4 patients were National Collegiate Athletic Association athletes; and 2 patients were high school athletes. All patients underwent a systematic diagnostic workup. The diagnosis was established with dynamic nerve conduction testing. Three etiologies for dynamic nerve compression around the elbow were identified: 1 case of lateral antebrachial cutaneous nerve compression by the biceps tendon, 3 cases of ulnar nerve compression by an anconeus epitrochlearis muscle, and 3 cases of posterior interosseous nerve compression at the arcade of Frohse with hypertrophic extensor carpi radialis brevis and extensor digitorum communis muscles. Two patients were treated conservatively, while 5 patients required surgery. All patients were able to return to pitching.

Conclusion: Dynamic compressive neuropathies around the elbow are rare entities that present unique diagnostic challenges to the treating clinician. In this cohort, all patients were young throwing athletes. Physical examination of the patient frequently lacks typical findings of chronic nerve entrapment syndromes. Dynamic nerve conduction studies establish the diagnosis, and treatment often requires surgical decompression to achieve complete resolution of symptoms.

Keywords: athlete; baseball; dynamic nerve compression; dynamic nerve entrapment; elbow; elbow surgery; nerve decompression; neurolysis; pitcher; return to play.

Figure 1.

Proposed diagnostic protocol. dNCS, dynamic nerve conduction study; MRI, magnetic resonance imaging.

Figure 2.

The dissection scissors point to the lateral antebrachial cutaneous (LABC) nerve exiting underneath the biceps brachialis tendon in supination. Entrapment is exacerbated by pronation, as demonstrated in Video Supplement 1.