PMC9528722_01
Elbow MRI with intra-articular contrast demonstrating bone marrow edema of the medial epicondyle (red circle).
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A 15-year-old right-handed male high school catcher presented to physical therapy with an approximate six-month history of medial elbow pain of gradual onset, having had an MRI with contrast (Figure 1).
Standing alignment posterior view.. Reproduction of subject's initial posture demonstrating scapular asymmetry and increased humeral external rotation.
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The increased observed right scapular internal rotation suggested external humeral rotation was especially prevalent (Figure 2).
Initial painful varus stress test (left) vs. painless varus stress test (right) with a red line to denote position of the humeral epicondyles.. Note original test position was performed in a position simulating hitting, although modified above for clarity to the reader.
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Manually internally rotating the humerus and then reapplying valgus force to the elbow made the motion pain free (Figure 3).
Novel kinesiology taping technique to promote humeral internal rotation.. Stretch was applied distal-to-proximal across the proximal antebrachium and medial epicondyle to the scapula.
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Kinesiology tape was applied in a novel method, originating at the right medial antebrachial and elbow regions, and then spiraling proximally across the humerus to the right scapular region (Figure 4).
Prone shoulder internal rotation exercise to promote subscapularis use while inducing a stretch to the posterior shoulder.
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Prone (Figure 5) and supine (Figure 6) humeral rotation exercise in 90  of abduction was prescribed.
Supine shoulder internal rotation exercise to promote increased posterior shoulder flexibility (left).. Incorrect performance (right) with compensatory anterior migration or extension of the humerus.
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Prone (Figure 5) and supine (Figure 6) humeral rotation exercise in 90  of abduction was prescribed. Supine shoulder internal rotation with a dumbbell was also prescribed to eccentrically activate the humeral external rotators (Figure 6).
Humeral internal rotator strengthening with cues to prevent compensatory scapular internal rotation.
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The subject stood with a heavy band anchored to the side, while he horizontally adducted the humerus and pronated the forearm against resistance (Figure 7).
Forearm supination neuromuscular reeducation exercise to teach dissociation from humeral external rotation.
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As the subject advanced, neuromuscular reeducation during gripping was added to train the subject to allow for forearm supination without compensatory external rotation of the humerus (Figure 8).
Bench press neuromuscular reeducation activity modified to promote a posterior shoulder stretch while strengthening the pectoralis major (left). Incorrect performance (right) with scapular internal rotation.
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For example, bench pressing was modified with cueing to adduct the scapula and avoid scapular protraction during the concentric phase of the press (Figure 9).
Hitting Drill for swing phase to ball contact to prevent positioning of the elbow anterior to the knob of the bat, therefore reducing potential varus force.
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During the first drill, a 10 lbs. dumbbell was utilized while the subject moved the weight through the 1st half of the swing with an isometric hold at what would be the contact point of the swing (Figure 10).
Hitting drill for retraining follow-through phase.. Note the right humerus remains in significant relative internal rotation compared to the magnitude of forearm supination.
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The second drill was completed with a PVC pipe, maintaining the same position as the first drill with the isometric hold, then carrying out the remainder of the swing (Figure 11).