Little League Elbow

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Search Strategy

Databases:  Cinhal, Medline, Pubmed

Keywords: Little, league, elbow, pitchers, medial

Search Timeline: 11/2/11-- 11/28/11

Definition/Description

Little league elbow is a term used to describe lesions in the medial aspect of the elbow in preadolescent and adolescent baseball pitchers. [1] Most commonly seen in children under the age of 10. The phenomenon is correlated to chronic forces of valgus overload produced during the early and late cocking phases of throwing. This valgus force places tension on the medial structures (medial epicondyle, medial epicondylar apophysis, medial collateral ligament) and compression of the lateral structures (radial head, capitellum). Little league elbow encompasses delayed or accelerated growth of the medial epicondyle, medial epicondlyar fragmentation and medial epicondylitis. The type of injury pattern depends on the stage of the developing elbow.

Epidemiology/Etiology

Over the past 20-30 years there has been an increase sport related injuries; 30 million school aged children participate in sports in the US. Across all ages, the peak incidence of emergency department visits for sport-related injures occurs at ages 5-14 years and tapers gradually with age.[2]  Each year over 2 million children participate in little league. In 1976, baseball leagues based in Houston, TX and Eugene, OR reported symptomatic elbow pain in 17-20% of all little league throwers. A more recent study found a 26% frequency of elbow pain in 9-12 year old baseball players. [3]

Characteristics/Clinical Presentation

Little League Elbow refers to elbow pain and encompasses different anatomical and clinical presentations. The term “Little League Elbow” is meant to include prevention and includes the physician, coach, trainer, parents, and officials. Proper throwing mechanics and adherence to pitch counts should be emphasized at a young age.[1]


Most Common Presentation

Medial sided injuries

Related to valgus overload in early and late cocking phases of throwing

Presentation depends on age

      • Younger Children: apophysitis
      • Older Children: epicondylar avulsion fracture
      • Not common to see ligamentous or flexor/pronator injuries in children

Signs/Symptoms

      • Medial sided elbow pain
      • Decreased throwing speed or distance
      • Point tenderness
      • Effusion
      • Flexion contracture (noted up to 15 degrees)
      • Widening and/or fragmentation of apophysis on radiographs


Other Presentations

Lateral sided injuries

Late cocking and early acceleration phases of throwing produces compressive forces

Deceleration during follow-through produces shear forces on the radiohumeral joint

Examples: Panner's disease, OCD of the capitellum or radial head

Signs/Symtoms of Panner's disease

      • Self-limiting
      • Dull, activity-related pain in lateral elbwo
      • Minimal effusion
      • Flexion contracture
      • Fragmentation of capitellar epiphysis on radiograph

Signs/Symtoms of OCD

      • Insidious onset
      • Dull, activity-related pain in lateral elbow
      • Poorly localized pain
      • May develop into locking, decreased ROM, flexion contracture >15 degrees


Posterior injuries

Acceleration and deceleration phases of throwing produces shearing forces

Uncommon in child athletes; more common in older children/adolescents

Injuries may include: olecranon apophysitis, posteriormedial impingement, avulsion fractures

Signs/Symptoms

      • Widening of apophysis on radiograph
      • Pain in extension
      • Localized tenderness in posterior elbow


(Use by permission from Barbara J. Hiller of MMMI)

Differential Diagnosis

Emphasis for differential diagnosis should be based on anatomy, radiographs, history/MOI, age, location of pain, and other factors such as position(s) played, number of throws per week and pitch types. [1][4]


Medial

Medial epicondyle

  • apophysitis
  • avulsion fracture
  • fragmentation
  • growth disturbance
  1. delayed ossification
  2. accelerated growth

Ulnar collateral ligament
Common flexor origin
Ulnar nerve neuritis
Radiculopathy of C8, T1


Lateral

Capitellum

  • osteochondrosis (Panner’s disease)—rare; usually age 8-11 y/o
  • osteochondritis dissecans (OCD)—more common in 10-14 y/o
  • traumatic osteochondral fracture

Radial head

  • OCD
  • deformation

Lateral extension overload
Extension origin


Posterior

Olecranon

  • apophysitis/osteochondrosis
  • avulsion fracture/lack of apophyseal fusion
  • posteromedial impingement/osteophytes


Anterior

Flexion contracture/capsular contracture

Outcome Measures

Visual Analog Scale for Pain Assessment

NPRS (Numeric Pain Rating Scale)

DASH Outcome Measure

Website with free PDF documents

Examination

During childhood, medial elbow pain is usually secondary to micro-injury at the apophysis or ossification center of the medial epicondyle. In contrast, valgus overload during adolescence more commonly produces complete or partial avulsion fractures of the medial epicondyle. Once the medial epicondyle fuses during young adulthood, injuries to the musculotendinous and/or ligamentous complex predominate.[1][5]

  • Pain is the most common presenting complaint and the chronicity or duration of pain must be assessed. An acute onset of symptoms is more suggestive of an avulsion type injury, whereas longstanding pain may signal a chronic, overuse type phenomenon. Location of pain will lead the evaluating therapist through the appropriate differential diagnosis.
  • Physical exam begins with the observation of both elbows, assessing for overall alignment and carrying angle of the upper extremities. The presence of swelling, atrophy, or hypertrophy should be identified.
  • Range of motion should be tested and documented, comparing flexion, extension, pronation and supination to the contralateral, non-painful elbow.
  • Palpation of all bony protuberances, including the medial epicondyle, the radiocapitellar joint and the posterior olecranon apophysis, may reveal tenderness and true pathology.
  • Ligamentous stability is also evaluated, ideally testing the lateral ligamentous structures with a varus stress applied to an internally rotated, pronated arm, and medial structures via a valgus stress applied to an externally rotated, supinated arm with the elbow flexed ~25°. Moving valgus stress test should be provocative in these patients.

General evaluation of the neck, ipsilateral shoulder and wrist is also important, as well as a complete neurological assessment, specifically the ulnar nerve.

Imaging

Following a complete history and physical exam, routine radiographic evaluation in the form of anterioposterior, lateral and oblique views is indicated. As stated previously, contralateral elbow films are invaluable in differentiating true pathology from normal or slightly variable development. Stress radiographs may aid in the evaluation of underlying instability. Magnetic resonance imaging (MRI) is often indicated to evaluate the displacement of fractures, delineate the extent of OCD or identify the presence of loose bodies within the joint. MRI can also be diagnostic for medial collateral ligament avulsions or isolated disruptions. Rarely, ultrasound or a three-phase bone scan can be helpful to identify certain overuse injuries.[1]

  Medical Management

Anytime a young throwing athlete presents with medial elbow pain, it should result in a high suspicion of Little League Elbow.  Early recognition and intervention are extremely important and can lead to better treatment outcomes and decrease the risk of permanent damage or persistent functional disability.[1]  Because these types of injuries are most commonly age dependent, the medical management will ultimately depend on the underlying cause of the symptoms.[1]


Conservative Management:  Universally referred to as the first and most preferred treatment approach.  Treatment commonly consists of complete rest from throwing activities for a minimum of 4-6 wks, ice, non-steroidal anti-inflammatory medication (NSAIDs), elbow extension brace if a flexion contracture is present, immobilization if symptoms are severe and referral for Physical Therapy.[4][6][7]


Surgical Intervention:  It is rare that a young athlete should need surgery for Little League Elbow, and there continues to be controversy on whether surgical intervention is actually more beneficial than conservative management. 

Surgery is usually only recommended when the following are present:[7]
• Loose cartilaginous bodies
• Avulsion fractures
• Osteochondritis dissecans
• As a last resort when conservative treatment has not improved symptoms 

Most researchers agree that medial epicondylar displaced fractures >5mm will require some type of surgical fixation.[6]  Some advocate for operative treatment with displacement fractures >2mm, and others indicate surgical fixation if any instability is present, regardless of displacement, for fear that the athlete may not be able to return to full activities if conservative management results in only a fibrous union formation.[6]


Retrospective Studies:  In a 2001 retrospective review of 42 patients, Farsetti et al. concluded that conservative management of medial epicondyle fractures displaced >5mm had similar long-term results to those treated surgically after approximately 34 years post-op.[8]
In a 2009 retrospective study of 139 cases, Louahem et al. found surgical results to be excellent in 130 cases and good in 9 cases with union of the fracture and reports of the elbow being stable and pain-free after approximately 3.9 years.[9]

Physical Therapy Management


Throughout Recovery[10]

  • Core strengthening: transverse abdominis, multifidus
  • Scapular control: T’s, Y’s, angel wings, wall slides
  • Rotator cuff: IR/ER in adduction and progress to 90 ° abduction


Medial Epicondyle Apophysitis

Rest[1][11]

  • 4-6 weeks: patient should stop performing activities that stresses the medial elbow. Active rest consisting of decrease level, duration, and amount of throwing recommended for patients with early symptoms and minimal pain. Immobilization recommended only in cases of severe pain symptoms.
  • NSAIDs, RICE

Early mobilization[12]

  • ROM: active wrist and elbow extension and flexion, forearm supination and pronation. Progress to gentle pain free PROM when AROM no longer painful.
  • Mobilization with movement, nerve mobilizations, grade 3 and 4 mobilizations at elbow and wrist joints

Progressive strengthening[1][11]

  • Elbow and wrist flexion and extension eccentric exercises: low load, high repetitions to promote localized circulation and correct fiber orientation during tissue healing
  • Resisted elbow flexion and extension, resisted wrist flexion and extension with theraband or cuff weights
  • Throwing-specific exercises[12]. Progress to throwing protocol once exercises are pain free.


Ulnar Collateral Ligament[12]

Rest

  • Active rest without replication of the demanding activities stressing the medial elbow. Throwing motions should be avoided for 2-6 weeks post-injury.

Immediate motion

  • 0-2 weeks: non-painful ROM (20-90). Elbow and wrist AAROM/PROM. Exercises include isometrics and shoulder stabilization without IR/ER. Ice and compression

Intermediate phase

  • 3-6 weeks: ROM to 135 degrees. Exercises include wrist curls, wrist extension, pronation/supination, biceps curl, triceps extension, shoulder ER/IR and adduction. Ice and compression.

Advances phase

  • Weeks 7-12: Full ROM. Resisted elbow and wrist extension and flexion, forearm supination and pronation, throwing-specific exercises. Progress to throwing protocol when exercises are pain free.


Return to Throwing:

Axe protocol

Prevention:

  • Throwing mechanics[13][14]
  • Thrower's Ten program
  • Pitch count by age[15]
  • Education regarding early identification and treatment of symptoms

Key Research

Klingele K, Kocher M. Little league elbow: valgus overload injury in the paediatric athlete. Sports Medicine [serial online]. December 2002;32(15):1005-1015. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 19, 2011

Clinical Bottom Line

Little league elbow is the name used to describe a group of elbow problems related to the stress of throwing in young athletes. Throwing can cause medial symptoms as well as lateral and posterior symptoms. The medial symptoms are related to the repetitive valgus distraction forces on the medial elbow. Microtrauma from overuse or improper throwing mechanics can cause injury. The predominant risk factors for elbow injuries that require surgery in young baseball players during high school and college are regularly pitching with arm fatigue, competitively pitching for more than eight months a year, and averaging more than 80 pitches per appearance.[16]  There continues to be controversy on whether surgical intervention actually has better long-term benefits over conservative management and when surgical intervention is necessary.  Universally, the BEST treatment is prevention through patient education and/or early diagnosis with proper treatment.

Recent Related Research (from Pubmed)

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References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Klingele K, Kocher M. Little league elbow: valgus overload injury in the paediatric athlete. Sports Medicine [serial online]. December 2002;32(15):1005-1015. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 19, 2011
  2. Hang D, Chao C, Hang Y. A clinical and roentgenographic study of little league elbow. American Journal Of Sports Medicine [serial online]. 2004 Jan-Feb 2004;32(1):79-84. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 19, 2011
  3. Adirim T, Cheng T. Overview of injuries in the young athlete. Sports Medicine [serial online]. 2003;33(1):75-81. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 21, 2011.
  4. 4.0 4.1 Benjamin HJ & Briner WW. Little League Elbow. Clin J Sport Med. 2005; 15:37-40.
  5. Wells M, Bell G. Concerns on little league elbow. Journal Of Athletic Training [serial online]. September 1995;30(3):249-253. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 26, 2011.
  6. 6.0 6.1 6.2 Crowther M. Elbow pain in pediatrics. Current Reviews In Musculoskeletal Medicine [serial online]. June 2009;2(2):83-87. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 27, 2011.
  7. 7.0 7.1 Cassas K, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries. American Family Physician [serial online]. March 15, 2006;73(6):1014-1022. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 27, 2011.
  8. Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. The Journal Of Bone And Joint Surgery. American Volume [serial online]. September 2001;83-A(9):1299-1305. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 27, 2011.
  9. Louahem D, Bourelle S, Cottalorda J, et al. Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A report of 139 cases. Archives Of Orthopaedic And Trauma Surgery [serial online]. May 2010;130(5):649-655. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 27, 2011.
  10. Axe MJ, L Snyder-Mackler, JG Konin, and MJ Strube. Development of a distance-based interval throwing program for Little League-aged athletes. Am J Sports Med. 1996; 24: 594-602
  11. 11.0 11.1 Elder KE. Little league elbow. Team Physician: Athletic training and sports health care. 2010; 2(3): 100-03.
  12. 12.0 12.1 12.2 Wilk KE, Reinold MM, Andrews JR. Rehabilitation of the thrower’s elbow. Clinics in sports medicine. 2004; 23(4): 765-801.
  13. Huang YH et al. A comparison of throwing kinematics between youth baseball players ith and without a history of medial elbow pain. Chinese journal of physiology. 2010; 53(3): 160-166.
  14. Kocher SM, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports med 2000; 30(2): 117-136.
  15. Protecting young pitching arms: Little league pitch count regulations. http://www.momsteam.com/sports/baseball/safety/2011-little-league-baseball-pitch-count-limits-and-mandatory-rest-periods. Accesses Nov 22, 2011.
  16. Chorley J. Elbow injuries in the young athlete. Up To Date. May 2010 p.1-34