Insidious Ulnar Sided Forearm Pain in Softball Pitcher and Bowler

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Clin J Sport Med

Abstract

History: A 16-year-old right hand dominant female softball pitcher and bowler presented as new patient for evaluation of right ulnar sided forearm pain. She says her pain began insidiously with softball pitching about 1 month prior to the visit. About 8 months prior she had similar pain during bowling season that had resolved. The patient was pitching in a tournament and noticed moderate pain in the ulnar forearm after pitching. The location of pain was at the ulnar side forearm about 8-10 cm distal to the medial elbow joint line. She says she was able to continue pitching during that weekend, but the pain had persisted over the prior 4 weeks. She had taken a 2 week break from softball prior to the visit which had helped her with pain symptoms. She denies any numbness, tingling or weakness in her hand. She denied fatigue, irregular menstruation, weight loss, depression or anxiety. Physical Exam: General: alert, oriented, conversant. Right elbow/Forearm: Skin intact, no lesions or abnormalities. No significant swelling noted. Tenderness to palpation over midproximal ulnar diaphysis at medial border. Wrist/elbow range of motion: Normal and symmetrical. Sensation intact to light touch in median, radial and ulnar nerve distributions in the hand. Motor units intact in AIN, PIN and ulnar nerve distributions in the hand. No pain with resisted wrist extension. Mild pain with resisted wrist flexion. No pain with resisted supination. Mild pain with resisted pronation. Grip strength: symmetric bilaterally. Negative varus and valgus stress testing of the elbow. Negative Milking maneuver. Differential Diagnosis: 1. Proximal forearm flexor/pronator tendinopathy 2. Ulnar diaphysial stress injury 3. Medial epicondylitis/avulsion 4. Pronator syndrome 5. Medial antebrachial cutaneous nerve pathology Test Results: XR right forearm: Questionable periosteal reaction of the mid-shaft ulnar diaphysis noted in clinic prompting workup with advanced imaging. MRI of right forearm without contrast: T2 weighted images show high signal of the mid-shaft ulna involving the cortex, bone marrow and periosteum. T1 weighted images in the same region demonstrated hypointense signal consistent with marrow replacement. No clear fracture line was seen. This is consistent with a bone stress injury to the ulna. Final Diagnosis: Bone stress injury of the mid-shaft ulna without evidence of fracture. Discussion: Ulnar diaphyseal stress injuries are rare and often misdiagnosed as flexor tendinitis initially. There is a paucity of literature on the topic, but ulnar stress injuries have been reported in active athletes that perform significant pronation/ supination and rotational motions. In softball, the windmill pitch motion causes the revolving force of the radius to exert high forces on the ulna which is relatively immobile. The middle third of the ulna has the smallest diameter and thinnest cortex of the bone making the most likely location. Notably, there are no pitch count regulations in softball. Clinicians should consider ulnar stress injuries in throwing athletes with forearm pain. Outcome: We treated our patient with a course of strict rest including no pitching, weightlifting, repetitive forearm pronation/supination. At 4 weeks she continued to have mild tenderness to palpation of the ulna which was resolved at the 7- week follow-up visit. The patient was then transitioned to physical therapy to begin gradual return to throw program. Follow-Up: Our patient has been cleared to start a gradual return to throw program with the goal to return to previous form over the next several months. We strongly encouraged her to continue to address general strength and throwing biomechanics in order to prevent future occurrence and injury. She was screened for signs of relative energy deficiency in sport (RED-S) and had no worrisome components.

Volume

35

Issue

3

First Page

e10

Last Page

e11

Find It @ Sladen

Share

COinS