Conservative Management of Ulnar Collateral Ligament Injury in a Throwing Elbow Complicated by Ulnar and Median Neuropathy: A Case Report

Abstract

Ulnar collateral ligament (UCL) injury is a common cause of medial elbow pain in baseball pitchers. Concomitant ulnar nerve involvement is common, whereas median nerve dysfunction may further impair dynamic stability via reduced flexor digitorum superficialis (FDS). However, reports on the conservative management of both nerves with neuromuscular re-education remain limited. A 17-year-old high school baseball pitcher presented with medial elbow pain, weakness in ulnar nerve-innervated muscles, and sensory disturbance after he pitched. Magnetic resonance imaging (MRI) and ultrasonography revealed UCL injury with valgus laxity. Examination showed tenderness over the cubital tunnel (ulnar nerve) and along the median-nerve course with neurological deficits (sensory loss, weakness) of the right elbow. Initial physiotherapy consisted of ultrasound-guided mobilization of the cubital tunnel and median nerve branches, combined with nerve-gliding techniques and real-time ultrasonography feedback for targeted activation of the FDS and flexor carpi ulnaris. Although early treatment improved pain and reduced spasms, symptoms recurred during throwing progression. Subsequent ultrasound-guided hydrodissection (hydrorelease) of the cubital tunnel and median nerve branch near the FDS, followed by continued neuromuscular re-education, resulted in complete pain relief, restoration of muscle strength, and improved elbow stability. Ultrasonography confirmed reduced valgus widening during FDS contraction. The athlete successfully returned to competitive pitching two months post-injury and remained symptom-free at four months. This patient highlights that ultrasound-guided physiotherapy, including manual release, hydrodissection, and functional re-education targeting both the ulnar and median nerves, can restore dynamic stabilization of the elbow and facilitate an early return to play in patients with UCL injuries with concomitant neuropathy.

Keywords: baseball pitcher; hydrodissection (hydrorelease); median nerve; nerve mobilization; return to play; ulnar collateral ligament; ulnar nerve; ultrasonography.