Chronic Forearm Pain in a Musician

Case Diagnosis: Bilateral Anconeus Exertional Compartment Syndrome.

Case Description or Program Description: 24-year-old male presenting with two years of bilateral elbow pain when playing guitar or typing. Occupational therapy, rest, bracing, and anti-inflammatories provided no relief. Elbow x-rays and ultrasound were normal, and right elbow MRI demonstrated low-grade injury to the anconeus. Upper extremity EMG was normal. The patient denied numbness, tingling, weakness, or prior injury. The patient was referred to PM&R to evaluate for possible exertional compartment syndrome of the anconeus.

Setting: Academic Clinic

Assessment/Results: Upper extremities were neurovascularly intact on exam. Pain localized to the anconeus bilaterally, and prominent anconeus musculature was noted on the right. Pre-exercise compartment pressure values were obtained. The patient then played guitar and typed to reproduce symptoms at a 7/10 pain level. Post-exercise values were obtained after one minute. Results demonstrated elevated pre- and post-exercise values in bilateral anconeus muscles, consistent with a diagnosis of compartment syndrome. The patient subsequently underwent right anconeus fasciotomy with Orthopedics. He reported near immediate relief in his symptoms postoperatively, and plans to undergo fasciotomy on the left side.

Discussion (relevance): Chronic exertional compartment syndrome is seen commonly in the lower limbs, but rarely in upper extremities. Anconeus compartment syndrome has been reported in gymnasts, swimmers, and weightlifters. It can be associated with posterolateral rotatory instability of the elbow, where laxity in the lateral collateral ligaments allow the radius and ulna to rotate externally in relation to the distal humerus. Treatments include anconeus fasciotomy and reconstruction to address ligamentous instability if present.

Conclusions: This patient’s workup was consistent with exertional compartment syndrome of the anconeus without evidence of instability, and the patient had excellent relief after fasciotomy. While anconeus compartment syndrome has been documented in athletes, reports of this diagnosis in musicians are scarce. Physiatrists should consider this rare diagnosis not only in athletes but also among performing artists.