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“Little league elbow” refers to medial elbow pain in a young overhead throwing athlete and is typically due to medial epicondyle apophysitis.


Baseball is the sport most commonly associated with medial epicondyle apophysitis. During the overhead throwing motion, significant valgus stress occurs at the humeroulnar joint and the flexor-pronator musculature. Repeated stress on the medial elbow structures can lead to widening of the apophysis, flexor apophysitis or avulsion fracture.

Epidemiology including risk factors and primary prevention

“Little league elbow” is most commonly seen in 9- to 14-year-old adolescents participating in throwing activities, particularly baseball pitchers. The incidence of youth elbow injuries has increased which has been correlated with an increase in overall sport participation and trend toward sport specialization.1,2

Although acute, macro traumatic injuries, such as fractures, dislocations, and avulsions occur in sports, overuse injuries such as apophysitis are more common.1 Research shows that age, height, playing for multiple teams, pitch velocity and arm fatigue are risk factors of injury. 2-5 Historically, early use of a curve ball has been considered a risk factor for little league elbow; however, many recent studies have not supported this concept.2,3,5-7 Biomechanical studies show that the fastball creates the greatest stress on the elbow, and breaking pitches may actually be protective against the development of elbow injuries due to the decreased arm velocity used when throwing these pitches.3,8

In light of the increasing number of injuries, and current state of research, multiple youth baseball leagues have adopted pitch count limits and mandated rest days. A program “Pitch Smart”, formulated by the USA Baseball Medical and Safety Advisory Committee and Major League Baseball (MLB), recommends pitch counts for individual games and weeks, as well as rest recommendations based on age group.9 USA Baseball Guidelines from 2018 and Little League Baseball Regulations from 2023, each recommend pitch counts for individual games and weeks with relation to days of rest. Furthermore, pitchers have been recommended to monitor their overall workload (amount of overhead throwing), which includes playing other positions on the field as well as warm up pitches. The American Sports Medicine Institute recommends that a pitcher should not also be a catcher for his team, as this significantly increases throwing volume.2,10


The distal humerus is composed of multiple ossification centers that arise during childhood and subsequently fuse. The medial epicondylar apophysis is the attachment site of the flexor-pronator musculature, and is the primary dynamic restraint to valgus stress during the throwing motion in skeletally immature throwers.13 Typically, the medial epicondylar apophysis is the last ossific nucleus to close and does so as late as 15 to 16 years of age.11 Prior to ossification, the medial epicondyle is the “weak link” in resisting elbow valgus stress, and is approximately five times weaker than the ulnar-collateral ligament.12 In the skeletally mature athlete the ulnar collateral ligament is the primary restraint to valgus stress.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • Acute: Acute medial elbow pain with or without a history of prior injury may signify an avulsion fracture of the medial epicondyle. A “pop” sensation may occur at the time of an avulsion injury. In older athletes, with closed growth plates, an acute ulnar collateral ligament rupture is more likely.
  • Insidious: Most patients will present with an insidious onset of medial elbow pain and/or complaints about performance and endurance. These individuals should be carefully evaluated for medial epicondyle apophysitis following the principles outlined below and should refrain from participation.
  • Chronic: If the injury is not treated, apophysitis may progress to a full avulsion fracture and/or nonunion of the ossific nucleus. Chronic elbow pain may develop, including recurrent intermittent symptoms with activity, pain at rest, and damage to other articular structures in the elbow.

Specific secondary or associated conditions and complications

Ulnar neuritis can coexist and is a poor prognostic indicator. Shoulder pain in the young or adolescent athlete may also be present but is beyond the scope of this discussion. However, weakness in the shoulder and a breakdown in the kinetic chain can often put more stress on the distal segments, most notably the throwing elbow. A flexion contracture of the affected elbow is not uncommon and can be present in throwing athletes who do not have elbow pain. Compression through valgus extension overload of the lateral structures, including the radial head and capitellum, may occur with repetitive medial elbow distraction forces. This can lead to osteophyte formation and posterior impingement.

Essentials of Assessment


Typically, little league elbow involves youth athletes who engage in repetitive overhead motions between 6-15 years of age. Patients typically present with medial elbow pain, a decrease in throwing velocity, and/or decrease in throwing distance. A detailed participation history includes playing position, training schedule, number of leagues/teams, type of overhead motion, as well as an estimate of number of innings and pitches per week.12 Prior injuries, dexterity, other sports participation, and past medical history are important. Nighttime pain is uncommon and should be specifically evaluated.

Differential diagnosis

Differential diagnosis of a young athlete with elbow pain should include medial epicondyle apophysitis, avulsion fracture, ulnar collateral ligament pathology, ulnar neuropathy, or local muscular injury. Any type of apophyseal maturation issues such as delayed growth or accelerated growth should be considered as well. On the radial aspect, osteochondrosis (Panner’s disease) or osteochondritis dissecans should be considered. Finally, olecranon apophysitis and posteromedial impingement should also be ruled out.

Physical examination

A full examination is performed assessing range of motion, strength, flexibility, and neurologic evaluation that includes ulnar nerve and C8/T1 assessment. Inspection of both elbows is performed to assess for asymmetry or deformity such as increased valgus carrying angle or muscle atrophy. Patients with medial epicondyle apophysitis often present with medial elbow pain with or without swelling or elbow flexion contracture. Range of motion should be tested comparing flexion, extension, pronation, and supination in both elbows. Special tests include the moving valgus stress test and milking maneuver both of which attempt to reproduce pain by creating a valgus stress at the elbow. Further evaluation of the ipsilateral neck, shoulder and wrist are recommended. Attention should be given to the lateral aspect of the elbow, as concomitant shear forces or compression injury along the radiocapitellar joint can occur as well. Shoulder function, scapulothoracic rhythm, and lumbar and hip strength and range of motion (particularly of the leading hip) should also be evaluated.12

Functional assessment

A full assessment of the throwing motion and kinetic chain should be undertaken either at the onset of treatment or after a period of rest and prior to resumption of throwing activities. This can be performed by the treating physician or another healthcare professional with knowledge of pitching mechanics. Pain in the medial elbow is generally appreciated during the cocking and acceleration phases of throwing.

Laboratory studies

Laboratory studies are not required unless other systemic or infectious conditions are suspected in which case evaluation may include a CBC, ESR, CRP.


AP, lateral, and oblique elbow radiographs are commonly obtained. Contralateral comparison views should be obtained in the skeletally immature athlete in order to determine whether there is medial apophysis widening in the involved elbow. Stress views can be obtained to provide evidence of instability but are less commonly obtained in this age group. While most apophyseal injuries can be treated conservatively, a displaced avulsion fracture >3-5 mm requires surgical referral. Magnetic resonance imaging is indicated to further evaluate displacement of fractures, diagnose medial collateral ligament avulsions, and detect widening of the apophyseal physis.14 Despite the higher level of detail, the use of magnetic resonance imaging is not likely to alter the treatment plan in the majority of little league elbow cases. Additionally, magnetic resonance imaging has also been shown to reveal post-season changes in the medial elbow in the absence of symptomatology.15

Supplemental assessment tools

Ultrasonography has good predictive value in identifying medial epicondyle apophysitis and may be useful in the clinical setting to provide early detection and intervention.16 However, not enough studies have investigated the significance of negative US findings in a symptomatic patient and further radiographic evaluation is warranted.12 US can also be of use in individuals in whom ulnar collateral ligament (UCL) injury is suspected. An isolated UCL injury is uncommon in the skeletally immature population for anatomic reasons discussed above. Dynamic musculoskeletal ultrasound may also be used to evaluate the medial epicondyle under valgus stress.

Early predictions of outcomes

Poorer prognosis is suspected in children with displaced avulsion injuries or those with concomitant ligamentous or neurologic lesions. Another potential consequence of little league elbow if ignored and not treated is osteochondritis dissecans, which is caused by compression on the lateral structures of the elbow through repetitive actions like pitching, resulting in poor blood flow and areas of bone death.


In warmer climates, it is more common to have year-round baseball participation. A study by Kaplan, et al. compared little league players living in warm vs cold climates. Those in warmer climates engaged in an average of 9-months of pitching activities per year, as opposed to those in cold climates, who averaged 6-months per year. Although the elbow was not examined in the study, there were significant differences in shoulder strength and range of motion.17 Further studies are needed to compare the elbow of players from different climates.

Social role and social support system

As with any athletically minded individual, one must be cognizant of the patient’s and family’s goals and future aspirations. Time loss from sport, even for a short period of time, can be difficult. The young player should be encouraged to continue taking part in team training activities. Coaching staff and parents should be educated on the condition and the typical recovery.

Professional issues

Returning to overhead sport while still symptomatic may worsen the injury. Often the sports physiatrist must manage the expectations of coaches, parents, or players themselves who wish to return the injured athlete to the sport too soon. Sending a minor back to the sport before full healing can result in more serious injury, such as avulsion fracture or osteochondritis dissecans. Physiatrists must also screen for concomitant neurologic or vascular injuries, which could be potential pitfalls.

Rehabilitation Management and Treatments

Available or current treatment guidelines

No specific guidelines are available. The core elements of treatment are outlined below.

At different disease stages

New onset/acute includes

  • The majority of individuals can be treated conservatively without bracing for a period of 4-6 weeks but may last up to 2-3 months. Rest from all throwing activities is maintained for 4-6 weeks. After completion, if pain free, physical therapy and a throwing program are initiated with the caveat that if any pain resurfaces further rest is warranted and may take up to 3 months. Significantly displaced avulsion fractures require surgical referral.12
  • Symptom relief
    can include ice and anti-inflammatory medications for pain relief in apophysitis. If pain is significant, immobilization can be accomplished with a long-arm posterior splint or a hinged orthosis, but the duration of immobilization should be brief. Bracing, however, is typically only used for avulsions that don’t require surgery.
  • If pain-free during the rest period, an active exercise program should be encouraged with a focus on shoulder and elbow strengthening as well as lower limb and core strengthening. Joint range of motion should be maintained. 2 In cases of apophysitis, a gradual return to throwing can typically be started after 6 weeks of rest with set limits to throws/pitches using a structured throwing program.12

Subacute includes

  • Injuries require at least 4-6 weeks of rest but may need up to 3 months.
  • Symptom relief
    Includes ice and anti-inflammatory medications are the mainstays of symptom relief during the period of rest.
  • Following the rest period, pain-free range of motion should be established; exercises for strengthening can then be initiated. After 4 to 6 weeks of rest and 1 to 2 weeks of strengthening, a structured return to throwing program may be started with set limits to throws/pitches. 12 The athlete is allowed to return to full sport participation at about week 12. The return to play protocol and time frame must be tailored to the athlete being mindful of position, skill, severity of injury, and recent progress.

Chronic includes

  • Secondary prevention and disease management strategies
    Throughout the treatment course the patient and their family is counseled on prevention strategies such as time off from sport, early sport specialization, inning and pitch count limits, weighted ball velocity training programs, and the pros and cons of specific pitches.
  • Treatment strategies
    Treatment is similar to subacute recommendations including rest for 4 to 6 weeks followed by therapy and a return to throwing program when pain free.
  • Symptom relief
    Little league elbow is a chronic overuse problem resulting in acute symptoms. After the rest period, a return of pain is not expected and, if it does, should prompt a thorough review of the treatment, other diagnoses, and a biomechanical evaluation of throwing.

Pre-terminal or end of life care

Symptom relief

Coordination of care

Treating elbow pain in a young athlete requires input from a physician, physical therapist, as well as coordination with parents and coaches. For patients who require surgical intervention, an interdisciplinary approach may be undertaken, planning for postoperative rehabilitation and addressing any concomitant injuries.

Patient & family education

The patient and family must be counseled to rest for the prescribed amount of time and subsequently to adhere to the return to play treatment plan. Correction of predisposing factors, such as overtraining, must be discussed.

Pitching mechanics and physical conditioning are essential to a healthy elbow. A recent study evaluating pitching biomechanics over a 7-year span noted kinematic changes to be most prevalent from the ages of 9 to 13 years and found that forces and torque through the shoulder and elbow increased with age, especially after 13 years of age.18 This emphasizes the importance of learning proper technique at the younger age, while overall power and forces upon the elbow joint are less.

Lastly, education about rest/low intent throwing during a portion of the year and avoidance of single-sport specialization is also very important. A study in 2019 revealed that 70-80% of parents believed that single-sport specialization would yield higher likelihood of their child making a college baseball team; however, only 47% of parents believed that single-sport specialization could lead to injury.19 A study of Little League World Series (LLWS) pitchers who were noted to exceed pitch counts at the LLWS indicated a greater risk of UCL reconstruction as Major League pitchers compared to those who did not exceed pitch counts during the LLWS.2

Emerging/unique interventions

Impairment-Based Measurement

Shoulder- or arm-specific functional tools are available using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, or the NIH PROMIS Pediatric Upper Extremity questions.20,21

Measurement of Patient Outcomes

The primary outcome is a full return to participation at the prior level of competition, without further elbow pain.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Unfortunately, few clinical studies are available that suggest one type of rehabilitation treatment or throwing program is better than another. Early recognition of the condition, immediate cessation of pitching/overhead throwing, gradual return to throwing, arm strength, and attention to good pitching mechanics can all assist in ensuring optimum recovery and prevention of re-injury.2,12

Cutting Edge/Emerging and Unique Concepts And Practice

Strategies such as periodization may be implemented; this could include avoiding any overhead throwing sports versus continued low intensity throwing for three months out of the year. It is thought that protective adaptation occurs with low intensity throwing, which is lost with complete discontinuation of throwing. It is important that if throwing continues emphasis is placed on proper throwing mechanics and low intensity performance.

Emerging/unique interventions

For many reasons, elbow surgery such as UCL reconstruction/primary repair (Tommy John surgery) is on the rise in young athletes, primarily those of high school age. The combined factors of increased velocity/weighted ball velocity training programs, year-round play in warmer climates, lack of recognition of the symptoms, and pressure to perform, even in young adolescents, results in focus on a single sport and has led to increased numbers of injuries.

Gaps in the Evidence-Based Knowledge

Prevention is the cornerstone in treatment of elbow pain in the little league athlete. While good evidence exists to support limiting the number of pitches thrown during a season, other areas require further study. These potential areas of study are the effects of velocity and weighted ball training programs, overall throwing workload (not just pitches in game scenarios), breaking pitches, concomitant play at other positions leading to increased throwing volume (e.g., catcher), and training strategies.


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Original Version of the Topic

Michael K. Mallow, MD. Elbow Pain in Little League Pitcher’s Elbow. 11/10/2011.

Previous Version(s) of the Topic

Michael K. Mallow, MD, H. Kelly Pfeiffer, DO. Elbow Pain in Little League Pitcher’s Elbow. 5/5/2016.

Michael K. Mallow, MD, H. Kelly O’Donnell, DO. Elbow Pain in Little League Pitcher’s Elbow. 10/20/2020

Author Disclosure

Robert Bowers, DO
Nothing to Disclose

Patrick Krochmal, MD
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Walter Sussman, DO
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