922 - Medical Epicondyle Stress Fracture in a Swimmer

17-year-old male swimmer with medial epicondyle stress fracture.

Case Description:

A 17-year-old swimmer presents with one week of left medial elbow pain. He was seen four months prior for a left rotator cuff tear, which has since resolved. He reports no trauma and describes it as a 2/10 dull ache, worsening to 5/10 with bending. He denies numbness, tingling, or weakness, and has no history of elbow injuries. Examination reveals mild tenderness to palpation along the posterior aspect of the medial epicondyle. Range of motion and motor strength are normal. He has a negative valgus stress test and negative passive lateral and medial epicondylitis tests. X-rays demonstrate a medial epicondylar stress fracture. He is prescribed 5000U of vitamin D and 200mg of calcium daily and advised to rest the elbow from activity, including swimming, for 6 weeks. He is referred for left elbow shockwave consult and follow-up in four weeks. Follow-up imaging was not performed, but patient reported improved symptoms.

Discussions:

Stress fractures in the upper extremities are primarily seen with athletes involved in overhead activities and result from highly repetitive loading and overuse. This patient's story is unique, as this injury is commonly seen in baseball pitchers but is rarely observed in swimmers. This patient may have been predisposed to this injury due to his prior rotator cuff tear, causing him to overcompensate during competitive swimming with improper elbow biomechanics.

Conclusions:

This case illustrates the importance of keeping broad differentials when treating athletes. Although a patient's sport can increase our suspicion of certain pathologies, it is important not to rule out a process due to the rarity of the injury in their sport. There must be consideration given to identifying risk factors for presentations of different injuries. Additionally, this case demonstrates how unresolved prior injuries can predispose patients to developing subsequent injuries.