Review Question - QID 218171

A 33-year-old civil engineer presents with 3 months of worsening medial elbow pain. She recently started playing in a recreational bowling league with her colleagues. She endorses pain with resisted wrist flexion and pronation on examination, has a Tinel's sign over the cubital tunnel, and endorses increasing paresthesias about the ulnar two digits of the hand with flexion-compression testing at the elbow. She undergoes six months of conservative treatment, including counter-force bracing, kinesiology taping, and extracorporeal shockwave therapy, which have not helped her symptoms. An EMG/NCS demonstrates moderate to severe ulnar neuropathy at the elbow. A radiograph of her elbow is shown in Figure A. When patients with this condition are treated surgically, which of the following factors has been linked to inferior clinical outcomes?