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Stress Fracture of the Ulnar Diaphysis Due to Excessive Training Associated With Axial Loading

*Teppei Suzuki, MD; *Masayoshi Yagi, MD; *Yasunobu Iwasaki, MD; *Kenji Fujita, MD; *Hideto Maruno, MD; #Hiroyuki Fujioka, MD2

*Department of Orthopaedic Surgery, Shin-suma, Hospital, Kobe, Japan
#Department of Orthopaedic Surgery, Kobe University of medicine, Kobe, Japan

Address for Correspondence

Teppei Suzuki, MD; Department of Orthopaedic Surgery, Shin-Suma Hospital,
4-1-6 Isonare-cho Suma-ku
Kobe, 654-0047, Japan.
Phone: 81 (78) 735-0001
Fax: 81(78) 735-0721



J.Orthopaedics 2005;2(1)e4


Stress fractures are common entities in intensively trained athletes and are considered to be a result of repeated application of low-grade stress to the bones. Stress fractures are most common in the weight-bearing bones of the lower extremities and the spine, but are rarely found in the non-weight-bearing bones of the body3,5. In the following case report, we have reported stress fracture of the ulnar diaphysis due to axial loading during excessive training.


Case report

A 17-year-old volleyball player had an eight month history of increasing pain of the ulnar diaphysis. She had started on excessive daily training program eight months before. Her training required her to stand on her hands, with a partner holding her up by her ankles (Fig. 1).

Almost every morning for four months before playing volleyball, she had to walk on her hands and sometimes bounce up. The pain in her left forearm gradually became worse, and she experienced difficulties playing volleyball. Finally after being hit by a volleyball on the ulna, she could not continue to play. Almost all activity with the arm was painful. She was initially diagnosed as having a fresh fracture of the ulnar diaphysis because radiographs revealed a clear fracture line in the midshaft of the ulna in July 2002 (Fig. 2).

As a result she was treated with long arm casting for four weeks. However, after four months of conservative treatment, the pain continued and gradually became worse. She was referred to our clinic four months after the initial diagnosis. On examination, palpation along the left forearm elicited pain, tenderness, and minimal swelling at the middle third of the ulna, however there was minimal pain on pronation and supination of the forearm and flexion and extension of the wrist and the elbow. There was no malalignment in the forearm, no wrist joint effusion, no increased warmth, normal joint motion, and normal health status with no history of systemic administration of steroids or rheumatologic disorders. We reviewed the history of the condition again and discovered that initial pain had actually started four months before the volleyball struck her, when she had started on excessive daily training program. The pain in her left forearm gradually became worse, but she had nevertheless continued this training every day for four months. Additionally, we discovered that when she was struck by the volleyball that exacerbated the pain, it was not with exceptional force but in a manner that might be considered normal during play. Thus review of this history and the plain radiographs showing callus formation of the lower ends of the ulna in November 2002 (Fig. 3) led us to a diagnosis of delayed union of a stress fracture of the ulna diaphysis.

We treated the patient with noninvasive low-intensity ultrasound using SAFHS (Sonic Accelerated Fracture Healing System; Exogen, Inc., Piscataway, NJ) with a 100-volt alternating current and ultrasound signal consisting of a 200-µs burst sine wave of 1.5 MHz repeating at 1.0 kHz. The spatial average, temporal average intensity was 30mW/cm2. The fracture site was exposed to ultrasound for 20 minutes per day. Eight weeks after the start of ultrasound therapy the patient was pain free.

Radiographs showed almost complete resolution of the fracture and clinical healing occurred over an eight week period in January 2003 (Fig. 4). The patient progressed to full workout activities including competitive volleyball games twelve weeks later.


Stress fractures of the ulnar diaphysis have been described in baseball10 and soft ball pitchers18, tennis players1,16, body builder11, bowlers7 and golfer15. The etiology of these fractures has been described as either a traction injury of the hand flexors and extensors11, or related to torsional forces associated with excessive pronation and supination1,18. In this case, the patient had to walk on her hands leading her wrist to be extended and her forearm pronated and sometimes bounce up with the wrist ulna deviated, and this excessive training is very common among all the sports players in Japanese field training. This type of training required the patient’s forearm to be loaded not with torsional, or tractional force, but with excessive weight-bearing force. This mechanism of axial loading has previously been reported in a case of cyclic weight bearing associated with crutch use9. During axial loading, the radius carries most of the load (82%) and the ulna carries a smaller load (18%), but the load along the ulna increases when the wrist is a position of flexion, ulna deviation, and forearm pronation4. Therefore we hypothesize that the cause of the fracture was due to axial loading during excessive muscle training. Low-intensity ultrasound has been reported to be useful in promoting fracture healing in both clinical and basic studies8,14,17. In this case, the stress fracture of the ulna diaphysis had been conservatively treated for four months, with a final diagnosis of delayed union. Therefore standard procedures such as resting of the affected limb were non-effective in this case. The athlete’s rapid return to full sporting activity may be attributed to the acceleration of healing due to low-intensity ultrasound therapy13. It has been estimated that between five and ten percent of all sports-related injuries involve stress fractures11 and a good proportion of these result in delay or non-union. For example, Hulkko and Orava estimated delay or non-union in ten percent of stress fractures in Finland12. The reason for these poor result are two fold: delayed diagnosis due to late consultation of expert physicians, and/or too short a rest from hard physical activity. Furthermore in many cases, the diagnosis is difficult and repeated clinical, radiological examinations are necessary. Emphasis should therefore be placed on the earliest possible diagnosis and provision of effective primary treatment. The mechanism of stress in present case is only speculative, but it suggests the possibility of stress fractures of the ulna diaphysis in individuals participating in excessive training regimens such as that outlined in this paper.



1. Bollen SR Robinson DG Crichton KJ et al: Stress fractures of the ulna in tennis players using a double-handed backhand stroke Am J Sports Med 21: 751-752, 1993
2. Brand JC Jr  Brindle T  Nyland J  et al: Does pulsed low intensity ultrasound allow early return to normal activities when treating stress fractures? A review of one tarsal navicular and eight tibial stress fractures Iowa Orthop J 19: 26-30, 1999
3. Brooks AA: Stress fractures of the upper extremity. Clin Sports Med Jul 20(3):613-620, 2001
4. Clark R J  Sizer PS Jr  Slavterbeck: Stress fracture of the ulna in a male competitive polo player Am J Sports Med 30(1): 130-132, 2002
5. Courtenay BG, Bowers DM: Stress fractures: clinical features and investigation. Med J Aust Aug 6;153(3): 155-156, 1990
6. Ekenstam FW  Palmar AK  Glisson RR: The load on the radius and ulna in different positions of the wrist and forearm A cadaver study  Acta Orthop Scand 55:363-365, 1984
7. Escher SA: Ulnar diaphyseal stress fracture in a bowler Am J Sports Med 25(3):412-413 1997
8. Fujioka H, Tsunoda M, Noda M, et al.: Treatment of ununited fracture of the hookof the hamate by low-intensity pulsed ultrasound. A case report. J Hang Surg   Am


 This is a peer reviewed paper 

Please cite as :

Teppei Suzuki, Stress Fracture of the Ulnar Diaphysis due to Excessive Training Associated with Axial Loading

J.Orthopaedics 2005;2(1)e4





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