What Is an Olecranon Stress Fracture?
Olecranon stress fractures are rare injuries. They are primarily found in throwing athletes, particularly baseball pitchers. These injuries can often be misdiagnosed and are poorly understood due to their rarity. It is important to see healthcare providers that deal with throwing athletes frequently and have an understanding of this condition. I want to provide a brief breakdown of the anatomy, cause, diagnosis, and treatment of an olecranon stress fracture.
First, you need to know what the olecranon is. It refers to the tip of your elbow. The olecranon is part of your ulna, which is the larger bone in your forearm. Primarily, the elbow moves in flexion and extension, but some supination and pronation is important. During extension, the olecranon comes into contact with the olecranon fossa, which is part of your humerus. The fossa provides a space for the olecranon to sit without contacting the humerus and creating damage. You can see the movement of the olecranon in the video below:
Notice how extending my elbow causes it to almost disappear into the humerus? This is because the olecranon fossa is ensuring that there is smooth movement.
Overuse or abnormal forces can cause the olecranon to create abnormal contact with the humerus. Chronic force from these contacts can cause a stress reaction and eventually a stress fracture to occur at the site. There can be many reasons for the contact to occur, but it is important to understand the process that is occurring between the bones.
What Causes an Olecranon Stress Fracture?
As I mentioned before, throwing athletes are particularly susceptible to olecranon stress fractures. This is mostly due to the repetitive nature of throwing along with the extreme velocity. In the above video, I am slowly moving my arm. Imagine violently swinging my arm to simulate throwing a baseball. If I did that hundreds of times, I may create damage to the olecranon and other bones.
There can be many reasons why a pitcher might suffer more stress in the backside of the elbow, but the primary reason is the growth plates. I have discussed growth plates before (including Osgood-Schlatter Disease, Little League Elbow, Sever's Disease, and Little League Shoulder). They are the areas of bone that allow lengthening as we get taller. Growth plates have less density to accommodate the new bone formation and they are more susceptible to injury. Growth plate injuries typically peak between 12-14 years as that is when growth spurts are greatest. Throwing too many pitches with decreased rest time at this age can lead to a stress fracture.
Rest is crucial to allow for bone remodeling. A hypothesis behind the cause of stress fractures is that there is not enough time for bones to remodel and heal between damaging incidents. If you throw too many pitches, but you allow your bones time to heal then you may avoid a stress fracture. However, if you throw too many pitches and do not allow the damage to heal before throwing again, you are setting yourself up to be injured. Rest and recovery are crucial, even at younger ages.
It is important to consider the elbow complex as a whole. A study by Ahmad, et al. showed that decreased strength of the UCL in the elbow leads to altered contact at the olecranon. If your UCL is not providing the support to your inner elbow, then your olecranon will make abnormal contact and more damage at the humerus. This concept was demonstrated by Furushima, et al. who examined 200 baseball players who suffered an olecranon stress fracture. They found that 71-95% of those athletes had a UCL injury or medial epicondyle avulsion fracture. UCL injuries are happening at younger ages now, and it is important to recognize that any damage to the ligament can have consequences elsewhere in the elbow.
How Do I Know If I Have an Olecranon Stress Fracture?
One of the easiest ways to diagnose the cause of pain is to find the location. An olecranon stress fracture typically results in pain at the medial olecranon, pictured below:
Full elbow extension is usually the most painful position for an olecranon stress fracture. Because of this, many people will avoid this position. It is common for baseball pitchers to lose full elbow extension due to the repetitive trauma of throwing, but pain in extension should be evaluated further. Pitchers will also notice pain while releasing the ball due to the force into elbow extension. UCL injuries typically cause pain at full layback where the most stress is on the ligament. This is a simple way to evaluate which tissue is injured.
Due to the pain with ball release, many pitchers will experience poor control and decreased velocity. If you are hesitant to finish your pitches due to pain, you will often miss your target significantly. The pain and symptoms will usually get worse with prolonged pitching as the area becomes more inflamed. Early signs of an olecranon stress fracture can be worsening pain or performance throughout the game.
Resisted elbow extension is an excellent way to evaluate for an olecranon stress fracture. The triceps is primarily responsible for elbow extension and it inserts into the olecranon. Tensing the triceps can cause pulling and pain at the insertion site. Simply resist the movement to extend your arm as shown below:
Another painful movement is supination and pronation. We often forget that the elbow is the focal point of these movements, and they can create stress for an injured elbow. While they are often not as painful as extension, they are important to evaluate. Supination and pronation are shown in the following video:
Early diagnosis of a stress fracture is crucial for better management. A study by Ohta-Fukushima, et al. showed that athletes who had their stress fracture diagnosed within 3 weeks of the injury returned to their sport in an average of 10.4 weeks compared to 18.4 weeks for those who waited. X-rays can be helpful to diagnose the stress fracture, but they may be unable to view the injury if it is too small. An MRI may be necessary to look for swelling in the area and provide more information.
Is Surgery Necessary for an Olecranon Stress Fracture?
Surgery may be necessary if you are diagnosed with an olecranon stress fracture, but it depends on your presentation. Surgeons may try to avoid surgery due to the growth plates in the area. Damage to the growth plates can cause them to close early and limit your bone growth in the affected area. Many people wait over 6 months before surgery to try and benefit from rest and physical therapy according to a study by Fujioka, et al. Their study highlighted several patients who waited 6 months for surgery and were able to return to their sport by 6 months after the surgery. Delaying surgery may be an option to try and progress with physical therapy.
A fracture may sound like it needs to be fixed surgically right away, but stress fractures are much different than a typical fracture. Relative rest and physical therapy should be the primary treatment option. Looking at factors including workload and overall strength and mobility can determine if there were other areas that led to the injury.
Manual therapy can be useful along with soft tissue mobilization of the triceps. As I mentioned before, the triceps insert into the olecranon and can worsen symptoms. Simply using a lacrosse ball as pictured below can decrease tension in the triceps muscle.
What Kind of Exercises Can Help with a Olecranon Stress Fracture?
Olecranon stress fractures can be due to poor deceleration throughout the body while pitching. It is important to consider other muscles that help slow down momentum after ball release. While you are in pain or avoiding stressing the elbow, you can still improve your lower body strength. I like hip thrusts because they focus on the posterior muscles on the back of your leg that decelerate your momentum while pitching. Hip thrusts do not require you to hold the barbell like you do for squats or deadlifts, making them a good starting exercise if you are in pain. The video below shows the basic form for hip thrusts with a barbell.
Another important muscle group for deceleration is the rotator cuff. These muscles are primarily on the back side of your shoulder and help keep the humerus centered and limit stress. Many baseball players have weaknesses in these muscles due to repetitive stress from throwing. You can start training the rotator cuff with band exercises. I particularly like J Bands because you are able to exercise without gripping the band and stressing your elbow:
Once you have less symptoms, rowing exercises are a great way to introduce gripping while strengthening the rotator cuff and scapular muscles.
As your symptoms continue to decrease you can address the muscles of the elbow. The biceps are responsible for decelerating the elbow during the pitching motion. Simple biceps curls with a focus on eccentric strengthening as you lower the weight can provide significant benefits.
Finally, it is important to strengthen the triceps muscle itself. Strengthening can begin with less load and in an easier position for the muscle to work with gravity. Triceps extension with a band can be an easy starting point that will not provide an aggressive stretch on the muscle.
If you are a pitcher, you want to begin stressing the elbow and shoulder in overhead movements. Overhead triceps extensions put the triceps in a longer position which allows for more loading to mimic the throwing motion.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about olecranon stress fractures and their symptoms and treatment. If you have interest in other elbow injuries, check out our elbow page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you want to subscribe so that you don’t miss any other posts, click the sign in button on the top right of this page. Once you have created an account, click the drop-down menu in the top right next to your name and go to your settings page. Click the subscribe button next to “Blog Subscription” and you won’t miss any future posts! If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at danny@eclipsewellnessnova.com or follow me on Instagram or Twitter @drdannydpt.
If you prefer your information in video format, check out our Youtube video about olecranon stress fractures here!