57 year old patient presented with distinct medial-sided elbow pain. There was no identifiable acute traumatic event or other clear precipitating cause. Symptoms had been present for 3 months and were associated with flexor loading.
Ultrasound examination of the medial elbow demonstrates a small partial tear at the origin of the common flexor tendon at the medial epicondyle.
The defect measures approximately 3 × 3 × 2 mm and is confined to a limited portion of the tendon origin.
Colour Doppler examination demonstrates no relevant neovascularisation at the site of the tear.
Given its location, the partial tendon tear provides a plausible structural correlate for the patient's medial elbow pain. As there was no distinct traumatic event, the lesion may represent repetitive mechanical overload and microtrauma of the flexor-pronator origin, potentially occurring within the spectrum of medial epicondylar tendinopathy.
1. Final diagnosis
Small partial tear of the common flexor tendon origin at the medial epicondyle, measuring approximately 3 × 3 × 2 mm, without relevant Doppler neovascularisation.
2. Differential diagnosis
In the absence of a clear traumatic event, repetitive loading and microtrauma of the flexor-pronator tendon origin should be considered as a possible underlying mechanism, including medial epicondylar tendinopathy. In patients with persistent or atypical medial elbow pain, other potential pain generators include ulnar nerve pathology and injury of the ulnar collateral ligament.
3. Teaching points
Small partial tears of the common flexor tendon origin can be a source of focal medial elbow pain even without a distinct traumatic event. Ultrasound allows assessment of the tendon defect, associated tendinopathic change and Doppler vascularity. A complete medial elbow examination should also consider the ulnar nerve and ulnar collateral ligament when symptoms are persistent or not fully explained by the tendon findings.
4. Injury/disease information
Given the small size of the partial tear, initial management is generally conservative, with temporary reduction of provocative loading such as forceful gripping, resisted wrist flexion and resisted pronation, followed by progressive restoration of flexor-pronator loading capacity. Rehabilitation may include pain-guided loading and progressive isometric and isotonic strengthening before gradual return to work- or sport-specific activities.
If symptoms persist despite an adequate conservative rehabilitation programme, clinical reassessment and additional evaluation of structures such as the ulnar nerve and ulnar collateral ligament may be appropriate. If an invasive treatment is considered, ultrasound guidance is preferable to a blind landmark-based procedure to allow accurate peritendinous placement and to avoid intratendinous injection into the tear. Based on the proposed treatment strategy in this case, PRP would be preferred over corticosteroid injection.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
More Cases from Marc Schmitz
