Reinforcement Learning May Demystify the Limited Human Motor Learning Efficacy Due to Visual-Proprioceptive Mismatch.

Vision and proprioception have fundamental sensory mismatches in delivering locational information, and such mismatches are critical factors limiting the efficacy of motor learning. However, it is still not clear how and to what extent this mismatch limits motor learning outcomes. To further the understanding of the effect of sensory mismatch on motor learning outcomes, a reinforcement learning algorithm and the simplified biomechanical elbow joint model were employed to mimic the motor learning process in a computational environment. By applying a reinforcement learning algorithm to the motor learning of elbow joint flexion task, simulation results successfully explained how visual-proprioceptive mismatch limits motor learning outcomes in terms of motor control accuracy and task completion speed. The larger the perceived angular offset between the two sensory modalities, the lower the motor control accuracy. Also, the more similar the peak reward amplitude of the two sensory modalities, the lower the motor control accuracy. In addition, simulation results suggest that insufficient exploration rate limits task completion speed, and excessive exploration rate limits motor control accuracy. Such a speed-accuracy trade-off shows that a moderate exploration rate could serve as another important factor in motor learning.

Evaluation of generic EMG-Torque models across two Upper-Limb joints.

Advanced single-use dynamic EMG-torque models require burdensome subject-specific calibration contractions and have historically been assumed to produce lower error than generic models (i.e., models that are identical across subjects and muscles). To investigate this assumption, we studied generic one degree of freedom (DoF) models derived from the ensemble median of subject-specific models, evaluated across subject, DoF and joint. We used elbow (N = 64) and hand-wrist (N = 9) datasets. Subject-specific elbow models performed statistically better [5.79 ± 1.89 %MVT (maximum voluntary torque) error] than generic elbow models (6.21 ± 1.85 %MVT error). However, there were no statistical differences between subject-specific vs. generic models within each hand-wrist DoF. Next, we evaluated generic models across joints. The best hand-wrist generic model had errors of 6.29 ± 1.85 %MVT when applied to the elbow. The elbow generic model had errors of 7.04 ± 2.29 %MVT when applied to the hand-wrist. The generic elbow model was statistically better in both joints, compared to the generic hand-wrist model. Finally, we tested Butterworth filter models (a simpler generic model), finding no statistical differences between optimum Butterworth and subject-specific models. Overall, generic models simplified EMG-torque training without substantive performance degradation and provided the possibility of transfer learning between joints.

A low carrying angle is measured in elite tennis players just before ball impact during the forehand, suggesting a dynamic varus instant accommodation moving towards full extension.

PURPOSE: The goal of this study was to use image analysis recordings to measure the carrying angle of elite male tennis players during the forehand stroke, with the hypothesis that elite tennis players overstress their elbow in valgus over the physiological degree in the frontal plane just before ball contact on forehand groundstrokes. METHODS: The carrying angle of male tennis players ranked in the top 25 positions in the ATP ranking was measured on selected video frames with the elbow as close as possible to full extension just before the ball-racket contact in forehands. These frames were extracted from 306 videos professionally recorded for training purposes by a high-profile video analyst. All measures were conducted by three independent observers. RESULTS: Sixteen frames were finally included. The mean carrying angle was 11.5° ± 4.7°. The intraclass correlation coefficient value was 0.703, showing good reliability of the measurement technique. The measured carrying angle was lower than what has been observed in historical cohorts using comparable measurement methodology, suggesting a possible instant varus accommodation mechanism before hitting the ball. CONCLUSIONS: The observed decrease in the carrying angle is a consequence of an increase in elbow flexion position dictated by the transition from a closed to open, semi-open stances. As the elbow flexes during the preparation phase, it is less constrained by the olecranon and its fossa, increasing the strain on the medial collateral ligament and capsule structures. Moving towards full extension before the ball-racket contact, the elbow is dynamically stabilised by a contraction of the flexor muscles. These observations could provide a new explanation for medial elbow injuries among elite tennis players and drive specific rehabilitation protocols. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level IV.

Understanding Shoulder and Elbow Injuries in the Windmill Softball Pitcher.

Although pitching-related injuries in the overhead athlete have been studied extensively, injuries associated with windmill pitching are not as clearly elucidated. Windmill pitching produces high forces and torques in the upper extremity, and studies have shown it creates similar shoulder and elbow joint loads to those reported in baseball pitchers. Studies have shown that the windmill pitching motion generates high levels of biceps activation with an eccentric load, placing the biceps at increased risk for overuse injuries. Although the American Orthopaedic Society for Sports Medicine published prevention guidelines including recommendations for maximum pitch counts in softball, these recommendations have not been adopted by most United States softball governing bodies. The repetitive windmill motion in conjunction with high pitch count demands in competitive softball creates notable challenges for the sports medicine physician. As with overhead throwing athletes, identifying and preventing overuse is crucial in preventing injuries in the windmill pitcher, and prevention and rehabilitation should focus on optimizing mechanics and kinematics, core, hip, and lower body strength, and recognition of muscle fatigue. With more than two million fastpitch softball participants in the United States, it is essential to better understand the etiology, evaluation, and prevention of injuries in the windmill pitching athlete.

Location of the posterior interosseous nerve in relation to common lateral approaches to the elbow.

PURPOSE: The risk of posterior interosseous nerve (PIN) injury during surgical approaches to the lateral elbow varies depending on the chosen approach, level of dissection, and rotational position of the forearm. Previous studies evaluated the trajectory of the PIN in specific surgical applications to reduce iatrogenic nerve injuries. The goal of this study is to examine the location of the PIN using common lateral approaches with varying forearm rotation. METHODS: The Kaplan, extensor digitorum communis (EDC) split, and Kocher approaches were performed on 18 cadaveric upper extremity specimens. Measurements were recorded with a digital caliper from the radiocapitellar (RC) joint and the lateral epicondyle to the point where the PIN crosses the approach in full supination, neutral, and full pronation with the elbow at 90°. The ratio of the nerve's location in relation to the entire length of the radius was also evaluated to account for different-sized specimens. RESULTS: The PIN was not encountered in the Kocher interval. For Kaplan and EDC split, with the forearm in full supination, the mean distance from the lateral epicondyle to the PIN was 52.0 ± 6.1 mm and 59.1 ± 5.5 mm, respectively, and the mean distance from the RC joint to the PIN was 34.7 ± 5.5 mm and 39.3 ± 4.7 mm, respectively; with the forearm in full pronation, the mean distance from the lateral epicondyle to the PIN was 63.3 ± 9.7 mm and 71.4 ± 8.3 mm, respectively, and the mean distance from the RC joint to the PIN was 44.2 ± 7.7 mm and 51.1 ± 8.7 mm, respectively. CONCLUSIONS: The PIN is closer to the lateral epicondyle and RC joint in the Kaplan than EDC split approach and is not encountered during the Kocher approach. The PIN was not encountered within 26 mm from the RC joint and 39 mm from the lateral epicondyle in any approach and forearm position and is generally safe from iatrogenic injury within these distances.

An assessment of co-contraction in reinnervated muscle.

Aim: To investigate co-contraction in reinnervated elbow flexor muscles following a nerve transfer. Materials & methods: 12 brachial plexus injury patients who received a nerve transfer to reanimate elbow flexion were included in this study. Surface electromyography (EMG) recordings were used to quantify co-contraction during sustained and repeated isometric contractions of reinnervated and contralateral uninjured elbow flexor muscles. Reuslts: For the first time, this study reveals reinnervated muscles demonstrated a trend toward higher co-contraction ratios when compared with uninjured muscle and this is correlated with an earlier onset of muscle fatigability. Conclusion: Measurements of co-contraction should be considered within muscular function assessments to help drive improvements in motor recovery therapies.

Identifying a Upper-Limb Phase-Dependent Variable under Perturbations for Powered Prosthesis Arm Control.

This paper investigates upper-limb kinematic reaching responses during a mechanical perturbation to understand interjoint arm coordination used towards powered prosthesis control development. Common prosthesis arm controllers use electromyography sensors with data-driven models to decode muscle activation signals in controlling prosthesis joint movements. However, these control approaches produce non-natural, discrete movements with no guarantee the controller can react to unexpected disturbances during continuous task motion. Determining a continuous phase-dependent variable for measuring a human's progression during reaching can derive a time-invariant kinematic function to control the prosthesis joint in a natural, continuous manner. A perturbation experimental study was conducted across three participants in evaluating the shoulder and elbow joint kinematics to examine the existence of a phase shift during reaching. Experimental results demonstrated the effects of arm proximal-distal interjoint coordination that validated the proposed mechanical phase variable of the shoulder used in parameterizing elbow joint kinematic for reaching. This could allow for a continuous phase-based control strategy that can handle disturbances to achieve arm reaching in prosthesis control.

Spatial mapping of posture-dependent resistance to passive displacement of the hypertonic arm post-stroke.

BACKGROUND: Muscles in the post-stroke arm commonly demonstrate abnormal reflexes that result in increased position- and velocity-dependent resistance to movement. We sought to develop a reliable way to quantify mechanical consequences of abnormal neuromuscular mechanisms throughout the reachable workspace in the hemiparetic arm post-stroke. METHODS: Survivors of hemiparetic stroke (HS) and neurologically intact (NI) control subjects were instructed to relax as a robotic device repositioned the hand of their hemiparetic arm between several testing locations that sampled the arm's passive range of motion. During transitions, the robot induced motions at either the shoulder or elbow joint at three speeds: very slow (6°/s), medium (30°/s), and fast (90°/s). The robot held the hand at the testing location for at least 20 s after each transition. We recorded and analyzed hand force and electromyographic activations from selected muscles spanning the shoulder and elbow joints during and after transitions. RESULTS: Hand forces and electromyographic activations were invariantly small at all speeds and all sample times in NI control subjects but varied systematically by transport speed during and shortly after movement in the HS subjects. Velocity-dependent resistance to stretch diminished within 2 s after movement ceased in the hemiparetic arms. Hand forces and EMGs changed very little from 2 s after the movement ended onward, exhibiting dependence on limb posture but no systematic dependence on movement speed or direction. Although each HS subject displayed a unique field of hand forces and EMG responses across the workspace after movement ceased, the magnitude of steady-state hand forces was generally greater near the outer boundaries of the workspace than in the center of the workspace for the HS group but not the NI group. CONCLUSIONS: In the HS group, electromyographic activations exhibited abnormalities consistent with stroke-related decreases in the stretch reflex thresholds. These observations were consistent across repeated testing days. We expect that the approach described here will enable future studies to elucidate stroke's impact on the interaction between the neural mechanisms mediating control of upper extremity posture and movement during goal-directed actions such as reaching and pointing with the arm and hand.

EMG-Informed Neuromusculoskeletal Modelling Estimates Muscle Forces and Joint Moments During Electrical Stimulation.

This study implemented an electromyogram (EMG)-informed neuromusculoskeletal (NMS) model evaluating the volitional contributions to muscle forces and joint moments during functional electrical stimulation (FES). The NMS model was calibrated using motion and EMG (biceps brachii and triceps brachii) data recorded from able-bodied participants (n=3) performing weighted elbow flexion and extension cycling movements while equipped with an EMG-controlled closed-loop FES system. Models were executed using three computational approaches (i) EMG-driven, (ii) EMG-hybrid and (iii) EMG-assisted to estimate muscle forces and joint moments. Both EMG-hybrid and EMG-assisted modes were able estimate the elbow moment (root mean squared error and coefficient of determination), but the EMG-hybrid method also enabled quantifying the volitional contributions to muscle forces and elbow moments during FES. The proposed modelling method allows for assessing volitional contributions of patients to muscle force during FES rehabilitation, and could be used as biomarkers of recovery, biofeedback, and for real-time control of combined FES and robotic systems.

Comparison of Lower Arm Weight and Passive Elbow Joint Impedance Compensation Strategies in Non-Disabled Participants.

People with severe muscle weakness in the upper extremity are in need of an arm support to enhance arm function and improve their quality of life. In addition to weight support, compensation of passive joint impedance (pJimp) seems necessary. Existing devices do not compensate for pJimp yet, and the best way to compensate for it is still unknown. The aim of this study is to 1) identify pJimp of the elbow, and 2) compare four different compensation strategies of weight and combined weight and pJimp in an active elbow support system. The passive elbow joint moments, including gravitational and pJimp contributions, were measured in 12 non-disabled participants. The four compensation strategies (scaled-model, measured, hybrid, and fitted-model) were compared using a position-tracking task in the near vertical plane. All four strategies showed a significant reduction (20-47%) in the anti-gravity elbow flexor activity measured by surface electromyography. The pJimp turned out to contribute to a large extent to the passive elbow joint moments (range took up 60%) in non-disabled participants. This underlines the relevance of compensating for pJimp in arm support systems. The parameters of the scaled-model and hybrid strategy seem to overestimate the gravitational component. Therefore, the measured and fitted-model strategies are expected to be most promising to test in people with severe muscle weakness combined with elevated pJimp.

Model-Based Upper-Limb Gravity Compensation Strategies for Active Dynamic Arm Supports.

NeuroMuscular Disorders (NMDs) may induce difficulties to perform daily life activities in autonomy. For people with NMDs affecting the upper-limb mobility, Dynamic Arm Supports (DASs) turn out to be relevant assistive devices. In particular, active DASs benefit from an external power source to support severely impaired people. However, commercially available active devices are controlled with push buttons, which add cognitive load and discomfort. To alleviate this issue, we propose a new force-based assistive control framework. In this preliminary work, we focus on the computation of a feedforward force to compensate upper-limb gravity. Four strategies based on a biomechanical model of the upper limb, tuned using anthropometric measurements, are proposed and evaluated. The first one is based on the potential energy of the upper-limb, the second one makes a compromise between the shoulder and elbow torques, the third one minimizes the sum of the squared user joint torques and the last one uses a probabilistic approach to minimize the expected torque norm in the presence of model uncertainties. These strategies have been evaluated quantitatively through an experiment including nine participants with an active DAS prototype. The activity of six muscles was measured and used to compute the Mean Effort Index (MEI) which represents the global effort required to maintain the pose. A statistical analysis shows that the four strategies significantly lower the MEI (p-value < 0.001).

Detecting age-related changes in skeletal muscle mechanics using ultrasound shear wave elastography.

Aging leads to a decline in muscle mass and force-generating capacity. Ultrasound shear wave elastography (SWE) is a non-invasive method to capture age-related muscular adaptation. This study assessed biceps brachii muscle (BB) mechanics, hypothesizing that shear elastic modulus reflects (i) passive muscle force increase imposed by length change, (ii) activation-dependent mechanical changes, and (iii) differences between older and younger individuals. Fourteen healthy volunteers aged 60-80 participated. Shear elastic modulus, surface electromyography, and elbow torque were measured at five elbow positions in passive and active states. Data collected from young adults aged 20-40 were compared. The BB passive shear elastic modulus increased from flexion to extension, with the older group exhibiting up to 52.58% higher values. Maximum elbow flexion torque decreased in extended positions, with the older group 23.67% weaker. Significant effects of elbow angle, activity level, and age on total and active shear elastic modulus were found during submaximal contractions. The older group had 20.25% lower active shear elastic modulus at 25% maximum voluntary contraction. SWE effectively quantified passive and activation-dependent BB mechanics, detecting age-related alterations at rest and during low-level activities. These findings suggest shear elastic modulus as a promising biomarker for identifying altered muscle mechanics in aging.

Elasticity of the Forearm Flexor-Pronator Muscles as a Risk Factor for Medial Elbow Injuries in Young Baseball Players: A Prospective Cohort Study of 314 Players.

BACKGROUND: Young baseball players with medial elbow injuries are known to have high forearm flexor-pronator muscle elasticity; however, the causal relationship between forearm muscle elasticity and the occurrence of medial elbow injuries remains unclear. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether the forearm flexor-pronator muscle elasticity is a risk factor for medial elbow injury in young baseball players. It was hypothesized that high flexor carpi ulnaris (FCU) elasticity would be a risk factor for medial elbow injuries. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Young baseball players (aged 9-12 years) with no history of elbow injuries underwent examination during which the strain ratios (SRs) of the pronator teres, flexor digitorum superficialis, and FCU muscles were measured using ultrasound strain elastography as an index of elasticity. Additionally, the participants completed a questionnaire assessing age, height, weight, months of experience as a baseball player, position in baseball, number of training days per week, number of throws per day, and elbow pain during throwing; then the range of motion of the shoulder and hip internal/external rotation were measured. One year after the baseline measurements, the occurrence of new medial elbow injuries was evaluated. Multivariate logistic regression analysis was subsequently conducted to determine risk factors for medial elbow injuries. Cutoff points for significant SR values obtained from the multivariate logistic regression analysis were calculated using the receiver operating characteristic curve. RESULTS: Of the 314 players, 76 (24.2%) were diagnosed with medial elbow injury. Multivariate logistic regression analysis showed that a 0.1 increase in the SR of the FCU muscle (odds ratio [OR], 1.211; 95% CI, 1.116-1.314) and number of throws per day (OR, 1.012; 95% CI, 1.001-1.022) were significantly associated with medial elbow injuries. Receiver operating characteristic curve analyses revealed that the optimal cutoff for the SR of the FCU muscle was 0.920 (area under the curve, 0.694; sensitivity, 75.0%; specificity, 56.7%). CONCLUSION: Increased FCU elasticity is a risk factor for medial elbow injury. Evaluation of the FCU elasticity may be useful in identifying young baseball players at high risk of medial elbow injuries and may facilitate prevention of medial elbow injury. As shown by the results of multivariate logistic regression analysis, FCU elasticity itself may be useful in identifying young baseball players at high risk of elbow injuries. However, we believe that other factors, such as the number of pitches per day, need to be considered to improve its accuracy.

Effect of Forearm Postures and Elbow Joint Angles on Elbow Flexion Torque and Mechanomyography in Neuromuscular Electrical Stimulation of the Biceps Brachii.

Neuromuscular electrical stimulation plays a pivotal role in rehabilitating muscle function among individuals with neurological impairment. However, there remains uncertainty regarding whether the muscle's response to electrical excitation is affected by forearm posture, joint angle, or a combination of both factors. This study aimed to investigate the effects of forearm postures and elbow joint angles on the muscle torque and MMG signals. Measurements of the torque around the elbow and MMG of the biceps brachii (BB) muscle were conducted in 36 healthy subjects (age, 22.24 ± 2.94 years; height, 172 ± 0.5 cm; and weight, 67.01 ± 7.22 kg) using an in-house elbow flexion testbed and neuromuscular electrical stimulation (NMES) of the BB muscle. The BB muscle was stimulated while the forearm was positioned in the neutral, pronation, or supination positions. The elbow was flexed at angles of 10°, 30°, 60°, and 90°. The study analyzed the impact of the forearm posture(s) and elbow joint angle(s) on the root-mean-square value of the torque (TQRMS). Subsequently, various MMG parameters, such as the root-mean-square value (MMGRMS), the mean power frequency (MMGMPF), and the median frequency (MMGMDF), were analyzed along the longitudinal, lateral, and transverse axes of the BB muscle fibers. The test-retest interclass correlation coefficient (ICC21) for the torque and MMG ranged from 0.522 to 0.828. Repeated-measure ANOVAs showed that the forearm posture and elbow flexion angle significantly influenced the TQRMS (p < 0.05). Similarly, the MMGRMS, MMGMPF, and MMGMDF showed significant differences among all the postures and angles (p < 0.05). However, the combined main effect of the forearm posture and elbow joint angle was insignificant along the longitudinal axis (p > 0.05). The study also found that the MMGRMS and TQRMS increased with increases in the joint angle from 10° to 60° and decreased at greater angles. However, during this investigation, the MMGMPF and MMGMDF exhibited a consistent decrease in response to increases in the joint angle for the lateral and transverse axes of the BB muscle. These findings suggest that the muscle contraction evoked by NMES may be influenced by the interplay between actin and myosin filaments, which are responsible for muscle contraction and are, in turn, influenced by the muscle length. Because restoring the function of limbs is a common goal in rehabilitation services, the use of MMG in the development of methods that may enable the real-time tracking of exact muscle dimensional changes and activation levels is imperative.

Load sharing between synergistic muscles characterized by a ligand-binding approach and elastography.

The skeletal muscle contraction is determined by cross-bridge formation between the myosin heads and the actin active sites. When the muscle contracts, it shortens, increasing its longitudinal shear elastic modulus ([Formula: see text]). Structurally, skeletal muscle can be considered analogous to the molecular receptors that form receptor-ligand complexes and exhibit specific ligand-binding dynamics. In this context, this work aims to apply elastography and the ligand-binding framework to approach the possible intrinsic mechanisms behind muscle synergism. Based on the short-range stiffness principle and the acoustic-elasticity theory, we define the coefficient [Formula: see text], which is directly related to the fraction saturation of molecular receptors and links the relative longitudinal deformation of the muscle to its [Formula: see text]. We show that such a coefficient can be obtained directly from [Formula: see text] estimates, thus calculating it for the biceps brachii, brachioradialis, and brachialis muscles during isometric elbow flexion torque (τ) ramps. The resulting [Formula: see text] curves were analyzed by conventional characterization methods of receptor-ligand systems to study the dynamical behavior of each muscle. The results showed that, depending on muscle, [Formula: see text] exhibits typical ligand-binding dynamics during joint torque production. Therefore, the above indicates that these different behaviors describe the longitudinal shortening pattern of each muscle during load sharing. As a plausible interpretation, we suggested that this could be related to the binding kinetics of the cross-bridges during their synergistic action as torque increases. Likewise, it shows that elastography could be useful to assess contractile processes at different scales related to the change in the mechanical properties of skeletal muscle.

Individuals with hemiparetic stroke abnormally perceive their elbow torques when abducting their paretic shoulder.

OBJECTIVE: Individuals with hemiparetic stroke exhibit an abnormal coupling between shoulder abduction and elbow flexion, or flexion synergy, due to an increased reliance on cortico-bulbospinal pathways. While this motor impairment is well documented, its impact on how movements are perceived remains unexplored. This study investigates whether individuals with hemiparetic stroke accurately perceive torques at their paretic elbow while abducting at their shoulder. METHODS: Ten individuals with hemiparetic stroke participated. We recorded the extent of their abnormal joint coupling as the torque at their elbow, with respect to the maximum voluntary torque in elbow flexion, when abducting at their shoulder. Next, we estimated the perception of their elbow torque by reporting their errors on our torque-matching task. RESULTS: When abducting at the shoulder, the participants with stroke generated a greater non-volitional torque at their paretic elbow (13.2 ± 8.7%) than their non-paretic elbow (1.2 ± 11.2%) (p = 0.003). Regarding the perception of our torque-matching task, participants overestimated their torques to a lesser extent at their paretic elbow (1.8 ± 6.6%) than at their non-paretic elbow (6.2 ± 5.4%) (p = 0.004). CONCLUSIONS: Torque perception at the paretic elbow differed from the non-paretic elbow when abducting at the shoulder. SIGNIFICANCE: This work advances our understanding of the i) somatosensory deficits occurring post hemiparetic stroke and ii) neural basis of torque perception.

Magnitude and variability of individual elbow load in repetitive baseball pitching.

In baseball pitchers the elbow is exposed to high and repetitive loads (i.e. external valgus torque), caused by pitching a high number of balls in a practice session or game. This can result in overuse injuries like the ulnar collateral ligament (UCL) injury. To understand injury mechanisms, the effect of repetitive pitching on the elbow load magnitude and variability was investigated. In addition, we explored whether repetitive pitching affects elbow muscle activation during pitching. Fifteen pitchers threw each 60 to 110 balls. The external valgus torque and electromyography of three elbow muscles were quantified during each pitch. Linear mixed model analyses were performed to investigate the effect of repetitive pitching. On a group level, the linear mixed models showed no significant associations of repetitive pitching with valgus torque magnitude and variability and elbow muscle activity. Significant differences exist between pitchers in their individual trajectories in elbow valgus torque and muscle activity with repetitive pitching. This shows the importance of individuality in relation to repetitive pitching. In order to achieve effective elbow injury prevention in baseball pitching, individual characteristics of changes in elbow load and muscle activity in relation to the development of UCL injuries should be investigated.

Ulnar nerve neuropathy caused by pathologic ossification: a case report.

PURPOSE: Cubital tunnel syndrome is a well-described entity with many reported etiologies and anatomical compression sites. Accessory ossicles of either traumatic or congenital origin might occur around the elbow joint. Only one case reporting such ossicles compressing the ulnar nerve exists in previous literature. We aim to present this entity with a detailed description of the patient history and treatment. CASE REPORT: We report a case of 30-year-old female presenting with classical signs of cubital tunnel syndrome-positive Wartenberg's and Froment's signs, hypoesthesia in the fourth and fifth finger with decreased finger duction strength but without gross hypotrophy of interosseous and hypothenar muscles. Tinel's sign was positive over the ulnar sulcus and an accessory ossicle was found on the elbow radiograph within the ulnar sulcus. The first signs of calcification in this patient were reported 6 years prior in a follow-up after the dislocation of her elbow joint following a bike accident. The EMG confirmed ulnar nerve neuropathy in the elbow area. The ossicle was extirpated, the ulnar nerve was decompressed in the ulnar sulcus in a standard manner and the symptoms quickly resolved. The patient has been regularly visiting our outpatient clinic for the next 12 years without any complaints considering her elbow and the ulnar nerve. CONCLUSION: This is a rare case of cubital tunnel syndrome caused by an accessory ossicle of traumatic origin. Simple bone extirpation with ulnar nerve release followed by anterior subcutaneous transposition is the recommended method of treatment. No report of congenital accessory bones causing ulnar nerve compression in the elbow exists in the literature.

Proprioceptive Acuity Assessment in Multiple Directions Across Multiple Joints in the Upper Limb.

Proprioception is essential for precise movement as it helps the body transmit important data about its surroundings to the central nervous system for maintaining body posture and position. This study aimed to investigate the effect of direction and joint angle on upper limb proprioception. Thirty individuals (all males) completed a position reproduction activity in 13 directions and three joint angles. It was discovered that upper limb proprioception is dependent on joint angle, direction, and range of motion. The position reproduction error was found to be dependent on the direction, which had a significantly lower accuracy in the direction with a larger range of motion. In addition, upper limb repositioning errors increased at greater limb elevation angles. Our findings also showed that the joint angle did not significantly affect the absolute error of elbow flexion. With an increase in the elbow flexion, the increase of the gravitational moment of the upper arm and hand coupled with the increase of the muscle arm of the biceps brachii possibly causes slight changes in muscle length perceived by spindles or muscular force perceived by Golgi tendon organs.