A 20-year-old collegiate left handed baseball pitcher presented at beginning of academic year to Certified Athletic Trainer (ATC) stating he suffered a coronoid stress fracture during summer league participation. ATC evaluation revealed no edema, full active ROM compared bi-laterally; however, athlete presented with a 10 degree extension lag. Athlete had full strength with no reported neurological or circulatory issues noted. Valgus and Varus Stress tests were (-) with solid endpoints, (+) Valgus Extension Overload test. In consultation with Team Physician, rehabilitation program was initiated. Differential Diagnosis: Lateral Epicondylitis, Osteochondritis Dissecans, Valgus Extension Overload, Olecrannon Stress Fracture, Process Stress Fracture. Treatment: Initial treatment included six weeks of non-activity. During this time, an extensive and detailed rehabilitation focused on ROM and strengthening exercises. Exercises included wrist flexion/extension, pronation/ supination, grip strength, and elbow flexion/extension exercises steadily progressing resistance each week. Shoulder exercises included scapular stabilization, proprioception, and rotator cuff exercises with weekly progression. After six weeks of pain free rehabilitation, he was cleared for the interval throwing program (ITP) and light strength training. After completing ITP, no edema or pain noted. ROM and strength were WNL and was granted full clearance. While scrimmaging one week later, he reported similar pain as initial injury to ATC were examination revealed posterolateral pain with extension. Athlete referred to Team Physician who ordered an MRI which revealed marrow edema, with a coronoid process fracture. Conservative treatment was initiated without success; thus, Team Physician proceeded with surgical intervention. Surgery identified coronoid as an intact structure and three microfractures were drilled into coronoid to initiate a healing process. Following surgery he was immobilized for 10 days, with restriction from active biceps activities for 1 month. He began rehabilitation, restoring ROM and strength. Approximately 3.5 months post-surgery, he was cleared for throwing. Athlete completed ITP and was granted full clearance. He had a successful fall and spring raining, and started second game of the season, but felt pain in his elbow. ATC examination revealed swelling over posterior elbow, pain with ROM, AROM 30-100 degrees, (-) ligamentous stress tests. Athlete referred to Team Physician who ordered MRI revealing marrow edema involving coronoid process. He was withheld from participation for 6 weeks and began another rehabilitation program. After 6 weeks, athlete had full elbow ROM and strength. ATC could not elicit pain with special tests. At this time, he began ITP, reporting minimal soreness. Athlete returned for last game of season pitching successfully. However following game, athlete reported to ATC complaining of similar pain as initial evaluation. Uniqueness: Coronoid fractures are typically associated with posterior elbow joint dislocations with an occurrence rate of approximately 10%. Through an extensive literature search, a coronoid stress fracture is extremely rare and data supporting their occurrence is limited. This case highlights the challenges of a coronoid stress fracture in an elite throwing athlete when applying conventional stress fracture protocols. Athletewould respond well to rehabilitation until his scheduled return to competitive pitching. Conclusions: This case highlights extensive treatment and rehabilitation of an athlete suffering from chronic stress fractures of the coronoid process. This case is extremely unique due to the low incidence of initial and recurring coronoid process stress fractures. This case exhausted both conservative and surgical treatment options with minimal success. The case demonstrates need for ATCs to appreciate complexity of injuries associated with elite throwing athletes and understand that although conventional rehabilitation would be successful with most athletic populations, the demands of the sport ultimately played an essential role in determining final outcome of this case. Athlete was unable to continue sports participation and efforts were focused on maintaining activities of daily living.
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