“Little League elbow” traditionally refers to medial epicondyle apophysitis in a young overhead throwing athlete. The term is also used by the public to describe any elbow pain in this population.
During the overhead throwing motion, significant valgus stress occurs at the humeroulnar joint. This stress creates a distraction force on the medial elbow structures that resist the valgus force. Repeated motion causing the accumulation of trauma can lead to a flexor apophysitis or avulsion fracture.
Epidemiology including risk factors and primary prevention
The incidence of youth elbow injuries have increased with increases in overall sport participation, and the increase in year-round single sport play.1Although acute, macro traumatic injuries, such as fractures, dislocations, and avulsions are common, overuse injuries such as aphophysitis are seen more frequently.1 Research shows that increased pitching time, measured by both innings and pitches, is the greatest risk factor of injury.2-4 Early use of a curve ball has long been held as a risk factor; however, many recent studies have not supported this concept.4-7 As a matter of fact, biomechanics studies demonstrated less varus torque with curveballs than with fastballs in high school pitchers. 8 Instead, an indirect correlation may be made between throwing breaking balls, and the fatigue thereof, causing a loss in proper pitching form and mechanics. Thereby predisposing the patient to injury. In light of the increasing number of injures and current state of research, multiple youth baseball leagues have adopted pitch count limits and mandated rest days. USA Baseball Guidelines from 2006 and Little League Baseball Regulations from 2010, each recommend pitch counts for individual games and weeks. Furthermore, pitchers have been recommended to monitor their overall amount of overhead throwing, which includes playing other positions on the field. The American Sports Medicine Institute recommends that a pitcher should not also be a catcher for his team, as this significantly increases the number of throws.9
The distal humerus is composed of multiple ossification centers that arise during childhood and subsequently fuse with the humeral shaft. The medial epicondylar ossific nucleus is most commonly the last to close and does so as late as 15 to 16 years of age. Prior to ossification, the medial epicondyle is the “weak link” in resisting elbow valgus stress as the attachment site of the flexor-pronator musculature. This muscle unit is the primary dynamic restrain to valgus stress during the throwing motion.10 In the skeletally mature athlete the ulnar collateral ligament is the primary restraint to valgus stress. Avulsion fractures and stress to the entire flexor-pronator bundle are more common in these athletes.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
- New onset/acute: Acute medial elbow pain with or without a history of prior injury may signify an avulsion fracture of the medial epicondyle. In older athletes, with closed growth plates, an acute ulnar collateral ligament rupture is more likely.
- Subacute: Most patients will present with an insidious onset of medial elbow pain and/or complaints about performance. These individuals should be carefully evaluated for medial epicondyle apophysitis following the principles outlined below and should refrain from participation.
- Chronic/stable: If the injury is not detected, or if the injured child is not treated, the apophysitis may progress to a full avulsion fracture. Chronic elbow pain may develop, including recurrent intermittent symptoms with activity, pain at rest, and damage to other articular structures in the elbow.
- Pre-terminal: Injury severity and concomitant articular damage may determine the need for surgical repair and return to play, discussed below.
Specific secondary or associated conditions and complications
Ulnar neuritis can coexist; it 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. A flexion contracture of the affected elbow is not uncommon and is often present in throwing athletes who do not have elbow pain. Compression through valgus extension overload, of lateral structures, including the radial head and capitellum, may occur in association with medial elbow distraction injuries.
2. ESSENTIALS OF ASSESSMENT
Typically the young athlete presents with medial elbow pain, decreased velocity and decreased throwing distance. A detailed participation history includes position, training schedule, number of leagues/teams, as well as an estimate of number of innings and pitches per week. Prior injuries, dexterity, other sports participation, and past medical history are important. Nighttime pain is uncommon and should be specifically evaluated.
Differential diagnosis of a young athlete with elbow pain should include medial epicondyle apophysitis, avulsion fracture, ulnar collateral ligament pathology, or ulnar neuropathy. Any type of apophyseal maturation issues: such as delayed growth or accelerated growth should be taken into account as well. On the radial aspect, osteochondrosis (Panner’s disease), osteochondritis dissecans, or trauma to the extensor origin are not uncommon. Finally, olecranon apophysitis and posterio-medial impingement should also be ruled out.
A full examination is performed assessing range of motion, strength, flexibility, and neurologic evaluation that includes ulnar nerve and C8/T1 assessment. Inspection 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 swelling and local pain with or without elbow flexion contracture. 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 or evaluate stability. 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, scapulo-thoracic rhythm, and core strength should also be evaluated.
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 a resumption of throwing. 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 are not required unless other systemic or infectious conditions are suspected in which case evaluation my include a CBC, ESR, CRP.
AP, lateral and oblique elbow radiographs are commonly obtained. Comparison views can be helpful in the skeletally immature athlete. 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 requires surgical referral. Magnetic resonance imaging can provide a higher level of detail but will not likely alter the treatment plan in the majority of cases.
Supplemental assessment tools
Ultrasonography can 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, which may be an impediment to periods of active rest. 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.11 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 the sport, even for a short period of time, can be difficult and requires attention. The young player should be encouraged to continue taking part in team training activities. Coaching staff, parental, and peer pressure should be assessed.
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.
3. 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
- Potential curative interventions.
For the majority of individuals who can be treated conservatively, an initial period of 4-6 weeks of rest from all throwing activities is initiated. Significantly displaced avulsion fractures require surgical referral.
- Symptom relief
Ice and anti-inflammatory medications can be utilized for pain relief. 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.
- Rehabilitation strategies intended to stabilize or optimize function or to prepare for further interventions at later disease stages
During the active rest period, an active exercise program should be encouraged and should focus on conditioning as well as lower limb and core strengthening. Joint range of motion should be maintained.
- Secondary prevention and disease management strategies.
USA Baseball Medical and Safety Advisory Committee has published recommended limits for youth pitch counts. 10
- Symptom relief
As above, ice and anti-inflammatory medications are the mainstays of symptom relief during the period of rest.
- Rehabilitation strategies intended to optimize function
Following the rest period, pain-free range of motion should be established; exercises for strengthening can then be initiated. A throwing program is started after 1-2 weeks of strengthening and 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.
- Secondary prevention and disease management strategies
Throughout the treatment course the patient and his or her family is counseled on prevention strategies such as time off from sport, or early sport specialization, inning and pitch count limits, and the pros and cons of throwing breaking pitches.
- Palliative strategies
Analgesic and anti-inflammatory medication may be taken if needed following a painful acute episode, but generally are not indicated for chronic use or to “pre-load” before overhead activities.
- Symptom relief
A return of pain is not expected and, if it does, should prompt a thorough review of the treatment to that point and a biomechanical evaluation of throwing. Further rest and rehabilitation may be necessary at that point.
- Rehabilitation strategies intended to optimize function
Pre-terminal or end of life care
Coordination of care
Treating elbow pain in a young athlete requires input from multiple healthcare providers, including physician and 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. A rheumatology evaluation could be helpful when chronic or recurrent elbow pain is present with swelling, particularly when other joints are involved.
Patient & family education
The patient and family must be counseled on resting for the prescribed amount of time and subsequently adhering 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 study by the American Sports Medicine Institute demonstrated that proper pitching technique does not change as the player ages and advances in career. However, at higher levels of play, increased force is inevitable.12 This emphasizes the importance of learning proper technique at the younger age, while the forces upon the elbow joint are less. Education about rest during a portion of the year my also be important.
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.13, 14
MEASUREMENT OF PATIENT OUTCOMES
The primary outcome is a full return to participation at the prior level of competition, without further elbow pain. By referring to published outcome measures the clinician can better understand how his or her patients with similar characteristics will heal.
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. The best pearl to impart on physicians is that early recognition of the condition, immediate cessation of pitching, gradual return to throwing with an increasing amount to regain arm strength, and attention to good pitching mechanics can all assist in ensuring optimum recovery, return to play at the highest level, and prevention of re-injury.15-17
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Strategies such as periodization may be implemented; this could include avoiding any overhead throwing sports for three months out of the year.
For many reasons, elbow surgery such as Tommy John surgery is on the rise in young athletes, primarily those of high school age. The combined factors of 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.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
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 breaking pitches, concomitant play at other positions having increased throwing frequency (eg, catcher), and training strategies.
- Klingele, KE, Kocher, MS. Little league elbow-Valgus overload injury in the pediatric athlete. Sports Medicine. 2002;32(15):1005-1015.
- Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30(4):463-468.
- Fleisig GS, Weber A, Hassell N, Andrews JR. Prevention of elbow injuries in youth baseball pitchers. Curr Sports Med Rep. 2009;8(5):250.
- Olsen SJ, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34(6):905-912.
- Fleisig GS, Kingsley, DS, Loftice JW, Dinnen KP, Ranganthan R, Dun, S, et al. Kinetic comparison among the fastball, curveball, change-up, and slider in collegiate baseball pitchers. Am J Sports Med. 2006;34:423.
- Little League Baseball-The learning curve. http://www.littleleague.org/Assets/forms_pubs/media/UNCStudy.pdf Accessed April 5, 2012 [Ref list]
- Fleisig, GS, Andrews JR. Prevention of elbow injuries in youth baseball players. Sports Health. 2012 Sep; 4(5): 419–424.
- Nissen CW, Westwell M, Ounpuu S, Patel M, Solomito M, Tate J. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers. Am J Sports Med. 2009 Aug; 37(8):1492-8.
- Position Statement for Youth Baseball Pitchers, American Sports Medicine Institute. www.amsi.org. April 2013.
- Park MC, Ahmad CS. Dynamic contributions of the flexorpronator mass to elbow valgus stability. J Bone Joint Surg Am. 2004;86:2268-2274.
- Kaplan KM, ElAttrache NS, Jobe FW, Morrey BF, Kaufman KR, Hurd WJ. Baseball pitchers who reside in warm- and cold-weather climates comparison of shoulder range of motion, strength, and playing time in uninjured high school. Am J Sports Med. 2011;39:320-328
- Fleisig GS, Barrentine SW, Zheng N, Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. Journal of Biomechanics 32(12):1371-1375, 1999.
- Institute for Work and Health (IWH), American Academy of Orthopaedic Surgeons (AAOS). Disabilities of the arm, shoulder and hand (DASH). http://www.dash.iwh.on.ca. Accessed May 11, 2011.
- Patient Reported Outcomes Measurement Information System (PROMIS). Dynamic tools to measure health outcomes from the patient perspective. National Institutes of Health. http://www.nihpromis.org/. Accessed May 11, 2011.
- Cain EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes. Am J Sports Med. 2003;31(4):621.
- Benjamin HJ, Briner Jr WW. Little League elbow. Clin J Sports Med. 2005;15(1):37.
- Kibler, BW, Sciascia, MS, Kinetic chain contributions to elbow function and dysfunction in sports. Clin Sports Med. 2004;23:545-442.
Original Version of the Topic:
Michael K. Mallow, MD. Elbow Pain in Little League Pitcher’s Elbow. Publication Date: 2011/11/10.
Michael K. Mallow, MD
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H. Kelly Pfeiffer, DO
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