Disclosures: Daniel A. Sainburg, DO: No financial relationships or conflicts of interest

Case Description: The patient presented for right elbow pain occasionally radiating down to his 5th digit. Pain was centered proximal to the medial epicondyle and noted to be associated with triceps flexion and the cocking phase of throwing a baseball. A painful clicking/popping sensation was also noted during throwing. The patient had failed conservative treatment including gabapentin, dry needling, iontophoresis and 4 weeks of nighttime splinting. He had not participated fully in baseball activities for over 8 weeks. The patient was referred to us for electrodiagnostic evaluation.

Setting: Electrodiagnostics Laboratory

Patient: A 21-year-old male collegiate baseball player, pitcher Assessment/

Results: Electrodiagnostics were performed in our clinic. Motor nerve conduction studies of the right median and ulnar nerves demonstrated normal distal motor latencies, CMAP amplitudes, and conduction velocities. Sensory nerve conduction studies of the right median and ulnar nerves demonstrated normal peak latencies and SNAP amplitudes. Following electrodiagnositic testing, the ulnar nerve was evaluated under ultrasound. Upon evaluation, fibrous scar tissue compressing the ulnar nerve about 4cm proximal to the medial epicondyle was visualized. The patient underwent hydrodissection with short term relief and ultimately underwent ulnar nerve transposition for a more definitive treatment.

Discussion: Clinical examination and electrodiagnostic studies remain the gold standard for diagnosis of nerve injuries. This case demonstrates an instance in which a patient had a subclinical ulnar neuropathy affecting his participation in sport which was unable to be detected with electrodiagnostics. Following the electrodiagnostic study, ultrasound evaluation was able to reveal the cause of the patient’s symptoms as the ulnar nerve was being compressed by scar tissue proximal to the cubital tunnel. Following the diagnosis, the patient subsequently underwent ulnar nerve transposition with symptomatic relief and was able to return to sport.

Conclusion: Ultrasound can be a useful modality the further evaluate subclinical neuropathies that are not picked up by electrodiagnostics.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/oh-snap-ultrasound-reveals-subclinical-ulnar-neuropathy-undetectable-with-electrodiagnostics-in-pitcher-with-snapping-elbow-pain-a-case-report/