Case 55
History and Physical Examination
A 43-year-old, right-hand–dominant manual laborer presents with a 6-month history of recurrent lateral elbow pain and catching. He denies frank locking of the elbow. However, repetitive activities such as hammering cause pain and swelling. He denies any numbness, weakness, or loss of elbow motion.
Elbow range of motion demonstrates a 15-degree extension lag and full flexion. Stability testing demonstrates no increased opening to valgus stress and a negative posterolateral rotatory instability test. He is neurovascularly intact, but has tenderness in the area of the posterolateral gutter. He also appears to have a mild effusion in this area. He has no tenderness over the lateral epicondyle and no pain to resisted wrist extension.
Differential Diagnosis
1. Loose body in the elbow
2. Posterolateral rotatory instability
3. Symptomatic synovial plica
4. Olecranon bursitis
5. Lateral epicondylitis
Radiologic Findings
Anteroposterior (AP) and lateral radiographs of the elbow demonstrate no abnormalities.
Diagnosis
Symptomatic Posterolateral Synovial Plica. Although a loose body could potentially account for the patient’s symptoms, tenderness and thickening in the area of the posterolateral gutter are very suggestive of a symptomaticposterolateral plica. Patients with symptomatic plicas often present with symptoms suggestive of a loose body. They can sometimes have decreased range of motion suggestive of amechanical block, but no loose body is ever localized by palpation or radiographically. They may or may not have an effusion, but pain is always present in the area of the posterolateral gutter.
Treatment of the symptomatic lesions centers on nonoperative techniques including nonsteroidal antiinflammatory medications, limitation of activities, and occasional local corticosteroid injections. These interventions will sometimes reduce or even eliminate the symptoms. Failure of nonoperative measures to improve the pain, catching, and swelling in the posterolateral gutter is an indication for surgery.
PEARLS
• The arthroscope is an excellent tool that is minimally invasive and allows for complete release and even resection of a thickened synovial plica in the posterolateral gutter of the elbow. Its use is recommended for those surgeons adequately skilled in elbow arthroscopy.
• Digital pressure in the postero-lateral gutter maintained through a passive range of motion of the patient’s elbow will often reproduce the pain and popping experienced by the patient as the plica band is trapped under the thumb of the examiner. Very few patients will experience pain with this maneuver unless they have a symptomatic plica in this region.
