Working Diagnosis:
Supracondylar Stress Fracture

Treatment:
The patient was instructed to avoid all activity with the right upper extremity including weight lifting, throwing, and swimming for 6 weeks. The patient was re-assessed after that time period and initiated a physical therapy program with a slow return to swim protocol over the next 6 weeks.

Outcome:
After 6-weeks of rest, the patient had no tenderness on examination. He was started on an upper extremity low-impact, non-aquatic physical therapy program in addition to arms-free swimming to recondition the lower extremities and core. By week 10, he was pain free with physical therapy and initiated a progressive return to swim program. The program started with 50% effort of 200 meter free style swim every other day for 4 weeks. He progressed after the second week to 250 meters, followed by 300 meters at week 3, and 350 meters by week 4. By week 14, he had successfully completed two monitored 550 meter swims and initiated speed work in 50-100 meter increments. Swimming techniques were limited to free style, back stroke, and breast-stroke with progression to butterfly as tolerated. After 7 months post-presentation, the patient returned to competitive sports without restriction.

Author's Comments:
It is unknown what the main cause of the injury was. Theories include overuse from swimming or weightlifting, altered mechanics from scapular winging, sequelae of COVID-19 and lack of proper return-to-sport progression. Overuse injuries of the supracondylar region in swimmers is rare and not well documented in the literature. He was weightlifting inconsistently without supervision or monitoring, which could increase injury risk. Additionally, the patient had scapular winging which can contribute to mechanical flaws and predispose to injury, especially in the setting of fatigue. It is unknown if the layoff from COVID-19 infection played a role in the acute worsening of his stress reaction given the time off and lack of appropriate return-to-sport protocol. There is not a well-defined return-to-sport protocol for this injury pattern. In this case, a combination of post-surgical fixation and overhead throwing injury protocols were used to take a conservative approach. Bony edema in a stage 4a Fredrickson stress fracture can last around 12 weeks. Our goal was to target a 12-week minimum for return-to-sport. The patient did experience a minor set-back 3 months after returning to sport with a brief flare-up of symptoms. He was shut down for 2 weeks with resolution of symptoms and has had no further issues.

Editor's Comments:
Stress fractures are common injuries in endurance and high-impact athletes that typically resolve with conservative measures, including rest, physical therapy, and a graded return-to-play protocol. This particular case demonstrates that the basic tenets of treatment for stress injuries can be applied to rarer locations of injury. Furthermore, the sport is also uncommon for such injury. Typically stress fractures f the elbow are seen in throwing sports or gymnastics.

References:
1. Reed DN, Frix JT. Scapular Stress Fracture of the Inferior Angle in an adolescent swimmer. {published online ahead of print, 2022 SP 12}. Orthoedics. 2022; 1-4. doin:10.3928/01477447-20220907-01.
2. Low S, Kern M, Atanda A. First-rib stress fracture in two adolescent swimmers:a case report. J Sports sci. 2016;34)13):1266-1270. doi:10.1080/02640414.2015.1108452.
3. Shinozaki T, Kondo A, Takagishi L. Olecranon stress fracture in a young tower-diver swimmer. orthopedist. 2006:29(8):693-694. doi:10.3928/01477447-2006801-11.
4. Trazla M, Stanula A, Krezalek P, Ostrowski A, Kaca M, Glab G., Butterfly sprint swimming technique, analysis of somatic and spatial-temporal coordination variables. J hum kinetic. 2017:60:51-62. published 2017 Dec 28. don:10.1515/hukin-2017-0089.
5. Iauer J, Rocard AH, Vilas-Bosas JP. Upper limb joint forces and moments during underwater cyclical movement. J Biomech. 2016; 49(14):3344-3361. doi10.1016/j.jbiomech.2016.08.027.
6. Knechte B, Jastrzebski Z, Hill L, Nikolaidis PT. Vitamin D and stress fractures in sports. Prevention and therapeutic measures- A narrative review. Medicina (Kaunas). 2021;57(3);223. Published 2021 Mar 1. doin:10.3390/medicina5703223.
7. McBride, Andrew P., et al. "Stress reactions and fractures around the elbow in athletes." Journal of Science and Medicine in Sport 24.5 (2021): 425-429.

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