An Underappreciated Challenge in Sports Medicine
– Written by Milos Bojovic and Elisabet Hagert, Qatar
INTRODUCTION
In elite sports, where muscle strains, tendinopathies, and ligament tears dominate the conversation, bone stress injuries (BSI) in the upper limb often hide in plain sight. They whisper, rather than scream. And unless you're listening carefully, you might miss them altogether. Unlike their well-known counterparts in the lower limb, such as tibial stress fractures in runners or navicular injuries in basketball players, upper limb BSI remain underrecognized and frequently misdiagnosed1-4. This diagnostic blind spot is surprising, especially considering the repetitive, high-load demands placed on the upper extremities in throwing sports, gymnastics, weightlifting, and racket sports5-8.
The reality is clear: no bone is safe from harm. From the distal clavicle in a volleyball player to the olecranon in a javelin thrower, or the scaphoid in a gymnast, stress injuries can, and do, affect almost every bone of the upper limb9-15 (Figure 1), and without heightened clinical suspicion, they are often mistaken for soft-tissue overload, joint inflammation, or even psychological factors13,16.
This review aims to shine a light on the often-overlooked panorama of upper limb bone stress injuries. Through the lens of clinical experience and emerging evidence, we will explore how to better recognize, diagnose, and manage these complex conditions before they evolve from subtle discomfort to structural failure.
PATHOPHYSIOLOGY AND RISK FACTORS OF UPPER LIMB BSI
BSI occur due to the inability of bone tissue to adequately adapt to repetitive mechanical loads, leading to microdamage accumulation that outpaces the natural bone remodeling and repair processes3,17. In the initial stages, repetitive loading leads to bone stress reactions characterized by bone marrow edema and periosteal reactions, detectable primarily through advanced imaging techniques such as MRI18-20. If repetitive loading continues without appropriate modification, these early stress reactions progress into stress fractures with clear fracture lines and cortical disruption21.
The pathophysiological mechanism behind these injuries involves an imbalance between osteoblastic and osteoclastic activity3,4. Normally, repetitive mechanical loading stimulates osteoblast activity, enhancing bone formation and increasing bone density. However, excessive repetitive loading without adequate recovery induces osteoclast dominance, resulting in microdamage accumulation, bone resorption, and subsequent weakening of bone structure22-25. Specifically, in young athletes, the imbalance between bone formation and resorption can be exacerbated due to high-intensity training combined with nutritional deficiencies, particularly of calcium and vitamin D, which are critical for bone mineralization and overall skeletal health26.
Certain anatomical regions within the upper limb are especially prone to stress injuries due to specific biomechanical forces27. For example, humeral shaft stress injuries in overhead athletes, such as baseball pitchers or tennis players, typically result from repetitive torsional and bending forces during throwing motions15,16,28,29. Similarly, stress fractures of the ulna frequently arise in athletes involved in sports requiring repetitive forearm pronation and supination, such as fast-pitch softball pitchers and kendo practitioners, where these repetitive stresses exceed the bone’s adaptive capacity30-33.
Pediatric and adolescent athletes represent a subgroup at particularly high risk due to open growth plates and rapidly changing bone physiology34,35. Repetitive stress in these populations can lead to injuries such as “Little League shoulder”, characterized by proximal humeral physeal widening due to repetitive throwing, or gymnast’s wrist, defined by distal radial physeal stress reactions from repeated axial loading and hyperextension8,14,36.
Several intrinsic and extrinsic risk factors contribute to the development of BSI4,8,37. Intrinsic factors include anatomical and biomechanical variations, muscle imbalance, hormonal influences, and nutritional status. Athletes, particularly female athletes, exhibiting the Relative Energy Deficiency in Sport (RED-S) syndrome, caused by prolonged deficit in energy intake vs output, are at elevated risk due to hormonal imbalances and impaired bone density regulation3,38. Extrinsic factors encompass training errors such as rapid increases in training volume or intensity, inadequate recovery periods, inappropriate equipment, and improper technique5,7,10.
Recognition of these risk factors, along with an understanding of pathophysiology, is essential for clinicians managing athletes with upper limb complaints, enabling timely diagnosis and effective preventive strategies. Interventions aimed at correcting training regimens, addressing nutritional deficiencies, and improving biomechanical techniques are crucial components in mitigating the risk of BSI in athletes.
DIAGNOSTIC CHALLENGES IN UPPER LIMB BSI
Diagnosing BSI of the upper limb poses significant clinical challenges due to their often subtle and non-specific presentation. Symptoms frequently begin insidiously, characterized by mild, diffuse pain exacerbated by activity and initially relieved by rest, leading clinicians to underestimate the severity or misinterpret these injuries as benign soft tissue disorders8,38. This subtlety contributes to delayed diagnosis and prolonged periods without adequate treatment, potentially resulting in complications such as malunion, delayed healing, or chronic pain16,28,33.
Physical examination findings are usually nonspecific, often limited to local tenderness and minimal swelling, with normal or near-normal range of motion and strength, which further complicates clinical diagnosis4. Specific provocative tests, such as the “humeral squeeze test,” can aid localization, but their specificity and sensitivity remain limited due to overlap with symptoms of adjacent soft-tissue pathology29.
Radiographs, typically the first-line imaging modality, frequently fail to detect early-stage BSI due to their low sensitivity in identifying subtle bone changes such as marrow edema and periosteal reactions39,40. Consequently, clinicians may prematurely dismiss BSI based on negative X-ray findings, prolonging patient discomfort and delaying proper management9,41.
Advanced imaging modalities, particularly Magnetic Resonance Imaging (MRI), significantly enhance diagnostic accuracy by clearly visualizing early-stage stress reactions and subtle fracture lines through detection of marrow edema, periosteal reaction, and early cortical disruption ward3,17,18,20. Bone scintigraphy and Single Photon Emission Computed Tomography (SPECT) may also provide valuable diagnostic information, especially in ambiguous cases or where MRI availability is limited, though they lack the anatomical resolution provided by MRI42 and are frequently less readily available resources.
Diagnostic challenges also extend to anatomical regions less commonly associated with BSI, such as the scapula, hamate, and scaphoid bones, where clinical awareness remains limited10,11,13. Clinicians may not initially consider these diagnoses due to their rarity and atypical presentations, which underscores the importance of maintaining a high index of suspicion based on patient history and repetitive mechanical loads12,43. Furthermore, clinical suspicion must be high in pediatric and adolescent athletes, as stress injuries may be present differently in these populations34,35. Accurate diagnosis hinges upon a high index of clinical suspicion, detailed patient history, appropriate selection of advanced imaging techniques, and multidisciplinary collaboration to promptly recognize and manage these potentially debilitating injuries2,36.
REGIONAL ANATOMY-BASED REVIEW OF UPPER LIMB BSI
Scapula and Clavicle
Scapular stress fractures, although relatively uncommon, primarily occur in athletes involved in sports requiring significant repetitive overhead activities and axial loading, such as gymnastics and weightlifting9–11. These fractures typically involve the body, spine, or acromion of the scapula27. Clinical presentation usually includes vague posterior shoulder pain exacerbated by overhead movements and localized tenderness over the scapular region. Diagnosis often necessitates advanced imaging, particularly MRI or CT scans, due to the subtlety of radiographic findings. Treatment generally involves rest, activity modification, and targeted physiotherapy for muscle strengthening and biomechanical correction5,41.
Distal clavicular stress fractures commonly affect athletes in sports involving repetitive compressive loading or traction on the shoulder girdle, including throwers and rowers. Clinical signs include localized distal clavicular pain and tenderness, particularly with cross-body adduction of the shoulder44,45. Radiographs may initially appear normal, necessitating MRI or CT imaging for definitive diagnosis. Conservative management including rest and activity modification usually results in successful outcomes3.
Humerus
Stress injuries of the humerus often involve the proximal, middle, and distal thirds of the bone, depending on the repetitive mechanical forces applied16,28. A notable injury, known as “Thrower’s fracture”, is a spiral stress fracture commonly seen in baseball pitchers due to repetitive torsional stress29. Ulnar neuropathy can sometimes masquerade as a humeral stress fracture, complicating clinical diagnosis15. Symptoms typically include mid-arm pain aggravated by throwing activities, often accompanied by neural symptoms such as tingling or numbness. MRI remains the diagnostic modality of choice39 (Figure 2). Conservative management with rest followed by structured rehabilitation and gradual return to throwing programs is the standard treatment protocol3,40.
Figure 2: diffuse bone edema in the distal humeral diaphysis and mild periosteal reaction overlying the anteromedial margin of the distal humerus consistent with BSI
Ulna and Radius
Ulna stress fractures are prevalent among gymnasts and weightlifters, frequently involving the shaft due to repetitive axial loading combined with hyperextension30–32. Clinical presentation includes dorsal forearm pain exacerbated by activity, specifically resisted wrist extension or forearm rotation. MRI and bone scintigraphy are critical in diagnosing these subtle fractures early46 (Figure 3). Conservative management, including immobilization and activity modification, typically leads to successful healing3.
Radial stress fractures, particularly involving the distal metaphysis, frequently affect tennis players and rowers due to repetitive pronation-supination and axial loading5. Clinical findings include tenderness over the distal radius and pain aggravated by wrist movements. MRI is essential for early diagnosis due to subtle radiographic findings19,20,41.
Stress injuries of the radial head, although rare, can occur in athletes subjected to repetitive forearm rotation. Diagnosis is challenging and often relies heavily on advanced imaging modalities like MRI and SPECT scans19.
Bones of the Wrist and Hand
Scaphoid stress fractures are notably seen in gymnasts and acrobatic dancers due to repetitive axial loading in wrist hyperextension12. Clinical presentation includes pain in the anatomical snuffbox and decreased grip strength. MRI or CT imaging is crucial for early diagnosis and management typically involves immobilization, with surgical intervention considered in delayed or complicated cases6,21.
Stress fractures of the capitate and lunate bones, although uncommon, are observed in sports involving repetitive compressive and shear forces like gymnastics or CrossFit. Clinical features include deep wrist pain exacerbated by load-bearing activities7,47. MRI provides definitive diagnostic clarity, and conservative management generally yields good outcomes3.
Hook of hamate fractures are important to consider in athletes using a bat, racket or club, i.e. baseball, tennis, ice hockey, golf, where the end of the bat/club can cause repetitive micro-trauma to the hook of the hamate in the ulnovolar aspect of the hand, finally leading to stress fractures48. These fractures are frequently not visible on XR and require MRI/CT for definitive diagnosis. The hook of hamate fracture is important to identify early as the location of the fracture can predispose for compression of the deep motor branch of the ulnar nerve as well as attrition ruptures of the flexor tendons to the little- and ring fingers.
Metacarpal stress fractures typically affect athletes involved in boxing, rowing, or weightlifting. Pain localizes dorsally, worsening with gripping or punching8. Diagnosis often requires MRI due to subtle radiographic changes, and treatment typically involves rest and immobilization.
Phalangeal stress injuries, though rare, have been reported in athletes and musicians, such as climbers, throwers, and keyboard players49,50. Diagnosis is clinical, supported by imaging, with conservative management being highly effective3.
MANAGEMENT STRATEGIES FOR UPPER LIMB BSI
Conservative Management
Conservative treatment remains the cornerstone for managing upper limb BSIs, with primary interventions including load modification, immobilization, and targeted physical therapy. Initial management involves immediate cessation or substantial reduction of the activity causing stress to the bone, allowing the remodeling processes to repair existing microdamage and prevent progression to overt fractures. Immobilization using splints, braces, or casts is frequently recommended, particularly in cases involving distinct stress fractures, to facilitate bone healing by minimizing mechanical loading8,36.
Following immobilization, structured physical therapy programs emphasizing gradual load progression, muscle strengthening, and correction of biomechanical deficits are critical for successful recovery and preventing recurrence. Rehabilitation programs typically incorporate neuromuscular control exercises and gradually increase the intensity and specificity of physical activities to return athletes safely to full competition3.
Surgical Intervention
Although most upper limb BSI respond well to conservative management, surgical intervention becomes necessary under specific conditions51. Indications for surgery include displaced or non-union fractures, fractures demonstrating inadequate healing despite conservative treatment, or injuries associated with significant structural compromise or persistent functional impairment52. Surgical options generally involve internal fixation, often using screws or plates, aiming to provide mechanical stability, promote anatomical alignment, and accelerate healing processes, thereby facilitating earlier return to activity6,8,36.
MONITORING RECOVERY
Effective monitoring of recovery involves clinical, functional, and radiological assessments53. Clinically, the resolution of symptoms such as pain and tenderness remain an essential indicator of healing progression. Functionally, objective measures of strength, range of motion, and sport-specific performance criteria guide rehabilitation and return-to-play decisions37. Radiological monitoring, primarily through serial MRI, is invaluable for objectively assessing bone healing by tracking the reduction of marrow edema and cortical restoration20,54.
A structured multidisciplinary approach encompassing clinical judgment, physical therapy assessments, and radiological evaluations ensures a comprehensive and safe return-to-activity strategy, minimizing the risk of reinjury and optimizing athletic performance post-recovery55.
RETURN TO PLAY CONSIDERATIONS FOR UPPER LIMB BSI
Criteria for Return to Play
Determining an athlete's readiness to return to play following an upper limb BSI involves a multidimensional evaluation incorporating clinical, radiological, and functional criteria. Complete resolution of pain, both at rest and during sport-specific activities, is the primary clinical indicator of healing3. Persistent pain typically suggests ongoing stress reactions or incomplete fracture healing, necessitating further rest or intervention.
Radiological evidence of fracture healing is critical and often monitored through advanced imaging modalities such as CT and/or MRI. Key indicators of radiological healing include the absence of bone marrow edema, resolution of periosteal reactions, and evidence of cortical continuity and remodeling20,39. Additionally, functional criteria involving objective assessments of strength, range of motion, and specific sport performance tests ensure athletes meet the physical demands of their sport without risk of reinjury.
Phases of Reintegration into Sports Activities
Return-to-play protocols typically follow a structured, phased approach to ensure safe and progressive reintegration into sports activities56. Initially, athletes undertake basic rehabilitation exercises focusing on restoring joint range of motion and muscular strength. Gradual loading activities are introduced as tolerated, progressively increasing in intensity and specificity toward the athlete's sport.
The subsequent phase involves modified sports participation, starting with controlled, low-impact activities such as throwing or hitting at reduced intensity and volume57,58. As tolerance improves, athletes progress through intermediate stages that incrementally reintroduce higher intensity and sport-specific skills under supervision. A structured throwing or hitting program, for instance, involves progressive increments in throwing distance, intensity, and frequency, closely monitoring for recurrence of symptoms59.
The final phase involves unrestricted sports participation, provided the athlete remains symptom-free during progressive challenges. Successful completion of functional tests and full recovery demonstrated by clinical and imaging assessments are prerequisites for full competitive return (Table 2).
PREVENTION OF RECURRENCE
Preventing recurrence of upper limb BSI involves identifying and addressing risk factors such as training errors, biomechanical abnormalities, and technique flaws. Correction of sport-specific technique through biomechanical analysis and coaching interventions significantly reduces repetitive stress on vulnerable anatomical sites(1,60).
Structured training programming, emphasizing adequate recovery periods, gradual increments in training volume and intensity, and appropriate periodization, is critical in preventing recurrence. Nutritional optimization, including adequate calcium and vitamin D intake, further supports bone health and resilience against repetitive stress injuries26.
A multidisciplinary approach, including medical practitioners, physiotherapists, coaches, and nutritionists, enhances prevention strategies by ensuring comprehensive management tailored to the individual athlete’s needs, thereby minimizing the likelihood of future BSI.
CONCLUSION
BSI of the upper limb, while less common compared to lower limb stress injuries, represent a true clinical challenge due to their subtle and varied presentations, demanding a high degree of clinical suspicion and awareness among healthcare professionals. Key messages from this review emphasize the importance of early recognition, appropriate diagnostic imaging, and comprehensive management strategies tailored to the individual athlete’s needs to facilitate optimal recovery and safe return to sport.
Education of athletes, coaches, and medical professionals about the risk factors, clinical presentations, and diagnostic challenges associated with upper limb BSI is paramount. Enhancing clinical suspicion through focused education can significantly reduce diagnostic delays and prevent complications arising from undiagnosed or inadequately treated injuries.
Future research is essential to advance understanding and management of upper limb BSI. Improved injury classification systems based on anatomical location, specific biomechanical demands, and detailed imaging findings will enable more precise diagnosis, targeted treatments, and structured rehabilitation programs. Additionally, investigating novel biological therapies and preventive strategies will contribute to improved outcomes and reduced injury recurrence rates in athletes.
In summary, ongoing education, heightened clinical awareness, and dedicated research efforts hold significant promise in enhancing the detection, management, and prevention of upper limb BSI, ultimately contributing to better health outcomes and sustained athletic performance.
Milos Bojovic MD
PM&R Specialist / Sports Medicine Physician
Aspetar Orthopaedic and Sports Medicine Hospital
Doha, Qatar
Elisabet Hagert M.D. Ph.D.
Associate Professor
Consultant Hand & Orthopedic Surgeon
Aspetar Orthopedic and Sports Medicine Hospital
Doha,Qatar
Karolinska Institutet, Dept of Clinical Science and Research
Stockholm, Sweden
Contact: milos.bojovic@aspetar.com
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