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Thread: Ulnar nerve translocation surgery

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    I can talk softball all day mmeece's Avatar
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    Default Ulnar nerve translocation surgery

    Has anyone dealt with ulnar nerve translocation surgery for their dd? Alternatively, has anyone been told they may need it and successfully used other treatments and never had the ulnar neuritis return? My dd is dealing with the numbness and occasionally pain from this condition and we are now considering all options. She has previously rested for 6 weeks (the dr did allow her to throw just enough overhand to be able to play but that was VERY minimal due to multiple rainouts). The numbness never went away entirely but the pain did. Within just 2 or 3 throwing sessions the numbness was more pronounced and just this weekend the pain returned to some degree. If you have dealt with this issue at all I would like to know if anyone had success with resting and then never had the ulnar neuritis come back. I don't want to push for surgery but I also don't want her to lose time only to have the issue become a reoccurring problem. She is a sophomore in HS and if the surgery would ever be necessary it seems like now would be the time to do it. I would love any feedback you have on your own dd, students, or team mates. Thanks in advance.

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    I can talk softball all day Bubrox's Avatar
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    DD2 had a teammate that had the ulnar nerve relocation surgery winter of her 8th grade year if I remember right. Her elbow kept hitting her hip when she pitched and causing pain and then numbness and tingling into the fingers. She's now a Sophomore. She was never quite the same when she came back but did pitch well as a Freshman on Varsity. I don't think she is currently playing club. I'm sure this info doesn't help much but hope your DD can continue pitching whatever you decide to do for her.

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    Softball Junkie Tango's Avatar
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    Coached HS baseball 20 years ago and had a player undergo ulnar nerve relocation surgery. He had already signed with a JUCO and didn't recover well from the surgery. He was a middle infielder and was moved to 2nd from SS after the surgery and just couldn't throw well afterwards. Only played one year. I'm not sure he gave it enough time.

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    I can talk softball all day murphdog's Avatar
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    I’m not an athlete but I had a similar surgery done years ago. There are definitely things I’ve learned to lefty since it feels weird sometimes. Given I had no PT or anything after like an athlete would but I’m not sure how much difference that would have made

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    Checking out the clubhouse Orthodoc's Avatar
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    A lot to unpack with this information/ question. Just so you know, I am hand and upper extremity fellowship trained board certified orthopedic surgeon that is a member of the American Society for Surgery of the Hand. I do about 300 ulnar nerve surgeries a year, mostly in situ releases and some ulnar nerve transpositions. I am not going to come on here and recommend anything because everyone’s case is different and there is so much value in doing a physical exam, but I hope that I can help with translate the information and provide some insight.

    First, there are different transposition surgeries that are done. They are subcutaneous, sub muscular, and intramuscular. The vast majority of transpositions are subcutaneous so I am assuming that is what has been proposed to you.

    Let me say that I am a little biased because as a general rule, I gave up ulnar nerve transpositions on pitchers and throwing athletes about 8 years ago in favor of a release of the compressive tissues overlying the ulnar nerve and leaving the nerve in the groove (AKA in situ release), because I have found that the vast majority of the time, the site of ulnar nerve compression in throwing athletes is located at the two heads of the FCU muscle and it is released during both surgeries. I do a transposition of the ulnar nerve only if it is subluxing from the groove after release. I believe that doing a transposition can add some risk to the procedure such as devascularization of the nerve’s intrinsic blood supply, so I want to avoid those possible risks. Having said that, there is nothing wrong with a transposition. When they work, they work well, I just rarely do it. I’ve done this surgery (in situ ulnar nerve release) on 5 High School pitchers, 3 fastpitch and 2 baseball. All 5 athletes were able to get back to their preinjury level. It is important to make sure you have the correct diagnosis because many players come in with medial epicondylitis (golfers elbow) and it irritates the ulnar nerve. This mimics cubital tunnel syndrome (which is a true compression of the ulnar nerve) or it could just be a plain ulnar neuritis without true compression of the nerve. I generally can figure this out on physical exam, but use a nerve conduction study to confirm the diagnosis. They aren’t always 100% and give some false negative readings especially in young people, but if positive will clearly lead you to getting it fixed with surgery (and with excellent results). From time to time, I will have patients that are negative on nerve study and is very difficult to nail down if the problem is cubital tunnel, ulnar neuritis, or medial epicondylitis with ulnar neuritis, and I will do a diagnostic (and possibly therapeutic if it is medial epicondylitis) injection as the next step to help me get to the bottom of it. If you get the injection and get better (even temporarily) then the problem is medial epicondylitis. If you don’t get better, then it is either cubital tunnel (with a negative nerve study) or ulnar neuritis, and surgery may be an option. Note that there are other possible diagnoses (UCL tear with neuritis or thoracic outlet) which can be identified with a good exam, but I’m trying to keep it simple. If you opted for surgery, I would be doing an in situ release, and there is a good chance that will provide relief if it is cubital tunnel. It probably won’t help if it is ulnar neuritis, which rest and rehab would be the best option for (sounds like you’ve already done that). In many cases where you have cubital tunnel vs ulnar neuritis, it is a leap of faith when undergoing the surgery, because you don’t now for sure which it is.

    Hope that helps you understand a little more about what it could be and how to best approach it.

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    I'm a fan Laphoneman's Avatar
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    If you could figure out what motion twist or impact is causing it would be great information. I would like to know “if you do this it could cause numbness and possibly ulnar surgery “ All dads worry about this exact scenario happening to their dd. We sympathize with your dd struggle. Also good reason to figure out wouldn’t want to have surgery only to end up in same situation due to same motion twist or impact. Any information would be greatly appreciated. I will be praying for her.

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    I can talk softball all day mmeece's Avatar
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    @Orthodoc I am so glad that you saw this post and I appreciate your information so much. She did have a nerve study that indicated mild compression of the ulnar nerve. They then performed an MRI with a dye injection in the elbow that also showed there was inflammation and compression of the nerve. Additionally she has an anatomical variant muscle called anconeus epitrochlearus that is inflamed and/or hypertrophied and can be a cause of compression of the nerve.

    The Dr. has proposed further rest and conservative treatment but also feels the surgery is warranted since the first rest period never fully resolved her symptoms. He prefers the subcutaneous transposition surgery for various reasons. When you mentioned an injection were you referring to a corticosteroid injection? I asked about that but he had a few reasons he preferred not to do one at the time. Thanks again for your information!

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    I can talk softball all day mmeece's Avatar
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    @Laphoneman Thanks for your kind words. It does not appear that any particular motion (other than throwing in general) causes this condition as far as I can tell from my research. It is not an entirely uncommon condition for overhead throwing athletes of all kinds.

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    Softball Junkie STRIKE3's Avatar
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    Quote Originally Posted by mmeece View Post
    @Laphoneman Thanks for your kind words. It does not appear that any particular motion (other than throwing in general) causes this condition as far as I can tell from my research. It is not an entirely uncommon condition for overhead throwing athletes of all kinds.
    I know nothing about it mmeece but I send you all well wishes and hope for the best and quickest recovery!!

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    Checking out the clubhouse Orthodoc's Avatar
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    Quote Originally Posted by mmeece View Post
    @Orthodoc I am so glad that you saw this post and I appreciate your information so much. She did have a nerve study that indicated mild compression of the ulnar nerve. They then performed an MRI with a dye injection in the elbow that also showed there was inflammation and compression of the nerve. Additionally she has an anatomical variant muscle called anconeus epitrochlearus that is inflamed and/or hypertrophied and can be a cause of compression of the nerve.

    The Dr. has proposed further rest and conservative treatment but also feels the surgery is warranted since the first rest period never fully resolved her symptoms. He prefers the subcutaneous transposition surgery for various reasons. When you mentioned an injection were you referring to a corticosteroid injection? I asked about that but he had a few reasons he preferred not to do one at the time. Thanks again for your information!

    All good information. I am not there but based on the additional information that you have given me, I would be most likely be recommending surgery. A confirmatory NCV/EMG for cubital tunnel would be all I would need to see after the history and a matching exam. A steroid injection wouldn’t be considered after seeing a positive nerve study (NCV/EMG) because the diagnosis is confirmed. Again, I would never do an ulnar nerve transposition on a throwing athlete, and based on the most recent literature, I see no reason beyond subluxation of the nerve after release to really ever do transposition because outcomes are statistically the same with fewer complications and less recovery time.

    The anconeous epitrochlearus can also be a dynamic compressor of the ulnar nerve as well. What I mean by that is that the compression on the nerve gets worse when the muscle contracts, which happens a lot in throwing athletes. I don’t envy you or your situation , but it would be a lot more difficult of a call if the nerve study came back completely normal. If it were normal it would very much be a crap shoot on whether the surgery would help. In my experience, when the history, exam, and diagnostic tests match up, the outcomes are typically excellent. I wish you and her the best in whatever direction you choose to pursue.

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