Pitcher's pain-usual presentation of unusual diagnosis
Swartz A, and Owczarek L. Pitcher's pain-usual presentation of unusual diagnosis. Clin J Sport Med 2019; 29(2):e12.
Clin J Sport Med
History: Fifteen year-old right hand dominant female who is a high-level competitive softball pitcher, presented with right forearm pain for greater than 1 month. Pain was located at the anterior/medial aspect of the right forearm and was described as a sharp, burning pain that radiated to her fourth and fifth digits. She also complained of numbness in this same distribution. Pain was worse with any type of wrist movement, especially wrist flexion and palpation of a pinpoint area of her forearm. Up to initial evaluation, the only treatments performed were icing and Aleve use. She denied trauma to the arm or any previous similar symptoms. She does pitch/practice year round and did obtain a new pitching coach just prior to the development of symptoms, but she denied any significant change in pitching practice regimen. Physical Exam: No erythema, warmth, open wound or ecchymosis of the forearm. Point tenderness to palpitation with palpable swelling 5 cm proximal from wrist along the ulna. No other areas of tenderness. Full active and passive range of motion at elbow, wrist and MTP/PIP/DIP joints. Pain was elicited with resisted wrist extension and supination. Varus and valgus stress at elbow was negative. Sensation intact. 5/5 strength with elbow/wrist flexion and extension. Radial pulse 21. Differential Diagnosis: Neurogenic Thoracic Outlet Syndrome Wrist extensor strain Ulnar stress fracture Lateral epicondylitis Cubital tunnel syndrome Test Results: Two view X-ray of the right forearm demonstrated a smooth periosteal reaction along the ulnar and volar aspects of the mid to distal ulnar diaphysis. No fracture lucency was visualized and no cortical irregularity was appreciated. MRI of the right forearm without contrast revealed a smooth periosteal reaction with cortical thickening and extensive bone marrow edema in the ulnar diaphysis compatible with a grade 4A stress fracture with intracortical signal but no discrete cortical fracture line. Final Diagnosis: Right grade 4a ulnar diaphysis stress fracture. Discussion: Stress fractures are a partial or complete fracture through the bone due to the repeated application of stress that is lower than that required to fracture the bone in a single loading situation. Lower extremity stress fractures are more common. When upper extremity stress fractures are described and more specifically pertaining to ulnar stress fractures in softball players, a more common location is the ulnar olecranon. This case is unique in that the stress fracture occurred in the diaphysis and only a handful of case reports discuss such injuries. In line with similar case reports, our patient obtained a full recovery with complete rest, physical therapy and gradual return to play. Outcome: Initially, she was placed into a wrist brace, ordered complete rest of the right arm and advised to ice the area and continue Aleve. After re-evaluation 1 month later, she was weaned from the wrist brace for a total of 6 weeks of immobilization. After this, physical therapy was initiated with a return to pitching program. Two months later, she was symptom free and able to participate in games. Follow-up: Final X-rays demonstrated near complete healing of the ulnar midshaft stress fracture. After the 6 week period, she progressed from total rest to overhand throwing only then eventually advanced to throwing with strict pitch count limits, pitching only once per week and was then able to perform her regular routine. Two months later, the patient played in her first game without symptoms.