Working Diagnosis:
Olecranon stress reaction, left

Treatment:
Counseling was provided regarding continued use of oral anti-inflammatories for pain control, activity modification, continued appropriate aerobic and strengthening exercises to increase function while minimizing pain. He was advised to stop throwing for 4-6 weeks and continue physical therapy sessions with special attention to the biomechanics of throwing.

Outcome:
At 6-week follow-up, there was significant improvement in pain without further use of analgesic medications. On reexamination, there was no tenderness to palpation, no strength deficits, and no impaired range of motion. The patient was cleared to return to baseball and begin throwing again, as tolerated. He was advised to continue advancing activities, as instructed by his physical therapist, and keep track of pitch counts to prevent further overuse injuries (MLB, 2022).

Author's Comments:
Medial elbow pain is a common problem in throwers, but this was an uncommon presentation. Differentials included ulnar collateral ligament injury, medial epicondylitis, osteochondral defect, olecranon stress reaction, olecranon stress fracture, and cubital tunnel syndrome. The olecranon stress reaction was appropriately identified prior to progression to a stress fracture. This decreased the recovery time and need for further interventions. This indicates the importance of early consideration of advanced imaging, such as MRI, when there is a high clinical index of suspicion (Brucker et al., 2015). In youth athletes, early sport specialization can lead to increased physiological stress with specific, repetitive movements, which can consequently lead to higher rates of overuse injuries (MLB, 2022). Research has shown that limiting the number of pitches per day in youth athletes through pitch counts can be protective against elbow pain and range of motion deficits (Matsuura et al., 2021). The core aspect of management for an olecranon stress fracture is rest and activity modification; however, advanced pathology can require surgical intervention for resolution of pain and return to play (McBride et al., 2020). Appropriately managing overuse injuries in throwers, avoiding aggravating movements when arm pain and fatigue are present, and refraining from early sport specialization are important considerations in youth athletes.

Editor's Comments:
Overuse injuries are common in baseball. Medial elbow pain is a common presentation among throwing athletes (McBride et al. 2020). While a stress reaction is within the differential for medial elbow pain it is not a common cause of these complaints. “Overhead athletes subject their elbows to valgus stresses throughout the throwing cycle.” (Rossy et al. 2016) These valgus stressors can lead to a variety of injuries involving the bones, nerves, musculature, and support structures in the elbow. Each of these structures plays a specific role in the biomechanics of the throwing athlete. (Rossy et al., 2016) Since many of these injuries are related to repetitive overhead activity pitch counts have become an important consideration for these athletes. Pitch counts have been a topic in baseball since the 1980’s and have been adjusted over the years. The MLB has published guidelines for age ranges to help reduce injuries (MLB, 2022). To correctly treat these patients, it is important to understand the presentation of pain with further emphasis on the location, onset, and timing during the throwing cycle. In the case of medial elbow pain, it necessary to start with plain radiographs. Conditions such as a UCL injury can be diagnosed with findings such as avulsion fracture or calcifications in the ligamentous complex. (Rossy et al., 2016) Radiographs can also rule out osteophytes or any signs of arthritis or fractures. If plain radiographs do not show a definitive diagnosis advanced imaging should be pursued. This case is an example of the need to proceed with advanced imaging to definitively diagnosis the cause of medial elbow pain.

References:
Rossy, W. H., & Oh, L. S. (2016a). Pitcher’s elbow: Medial elbow pain in the overhead-throwing athlete. Current Reviews in Musculoskeletal Medicine, 9(2), 207–214. https://doi.org/10.1007/s12178-016-9346-7

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