Little League elbow is the result of repetitive stress to the growth plate on the inside of the elbow. The greatest stress occurs during the acceleration phase of throwing a baseball. Growing bones are easily injured because the growth plate is much weaker than the ligaments and muscles that attach to it. Kids with Little League elbow must take a break from all throwing for about 6 weeks. For pain and swelling, they can: Put ice or a cold pack on the elbow every 1–2 hours for 20 minutes at a time. This injury most often affects pitchers ages 9-14, though baseball players in other positions, as well as other overhead athletes such as volleyball players and football quarterbacks, may also be susceptible to little league elbow.
Other Names
- Little League Elbow
- Medial Epicondyle Apophysitis
- Medial Epicondyle Stress Fracture
Pathophysiology
- By definition occurs in skeletally immature pediatric patients
- In these patients, avulsion or physical injuries more common than ligamentous or tendon injuries
- As growth plates fuse, these athletes develop other causes of medial elbow pain
- The injury pattern depends on the developmental stage of the elbow
- Occurs as a result of overuse or repetitive valgus stress placed upon the elbow
- Causes a tension force to overload the medial structures
- Produces tension along the medial elbow, shearing at the posterior elbow, and compression along the lateral elbow[4]
Causes
- Sports
- Overhead athletes
- Throwing athletes
- Seen during cocking, acceleration phases of pitching
- Overuse can be classified into 4 stages:
- Pain in the affected area after physical activity
- Pain during activity without restricting performance
- Pain during the activity that restricts performance
- Chronic unremitting pain even at rest
- Factors that contribute to overuse
- Pitching mechanics
- Pitch volume (>80 per game)
- Pitch type (especially fastball)
- Pitch duration (> 8 months per year)
- Pitching when fatigued
- Physical conditioning
Associated Conditions
- Can occur if the disease progresses
- Ulnar Collateral Ligament Injury
- Medial Epicondylitis
Pathoanatomy
- Osseous structures
- Medial Epicondyle including medial epicondyle apophysis, of distal Humerus
- Proximal Ulna
- Humeroulnar Joint
- Static stabilizers
- Ulnar Collateral Ligament
- Dynamic stabilizers
- Common Flexor Tendon
Differential Diagnosis
- Fractures
- Adult
- Radial Head Fracture
- Olecranon Fracture
- Capitellum Fracture
- Coronoid Fracture
- Terrible Triad of Elbow
- Pediatric
- Nursemaids Elbow
- Supracondylar Fracture
- Lateral Condyle Fracture (Peds)
- Medial Condyle Fracture (Peds)
- Olecranon Fracture (Peds)
- Radial Head Fracture (Peds)
- Medial Epicondyle Fracture (Peds)
- Salter Harris Fracture
- Adult
- Dislocations & Instability
- Elbow Dislocation
- Proximal Radioulnar Joint Instability
- Tendinopathies
- Lateral Epicondylitis
- Medial Epicondylitis
- Distal Biceps Tendon Injury
- Triceps Tendon Injury
- Bursopathies
- Olecranon Bursitis
- Ligament Injuries
- Lateral Collateral Ligament Injury (Elbow)
- Ulnar Collateral Ligament Injury
- Neuropathies
- Cubital Tunnel Syndrome
- Radial Tunnel Syndrome
- Arthropathies
- Elbow Arthritis
- Other
- Valgus Extension Overload
- Posteromedial Rotatory Instability
- Posterolateral Rotatory Instability
- Osteochondral Defect
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Diagnosis
- History
- Typically in 9-12-year-old males
- Almost universally insidious in nature with no acute trauma
- Important to clarify sport, position, frequency, etc
- Will complain of pain in throwing arm and loss of speed, accuracy, and/or distance
- Pain is at the medial elbow
- Sometimes stiffness, swelling, limited elbow extension, mechanical symptoms
- Physical: Physical Exam Elbow
- Tenderness to medial elbow
- Swelling and effusion can be present
- Special Tests
- Elbow Valgus Stress Test: Should be painful, instability suggests more significant injury
Radiographs
- Standard Radiographs Elbow
- Diagnosis is primarily clinical
- Often normal early on in disease process
- Findings
- Apophysitis: physeal widening, sclerosis, cortical irregularity
- Epiphysiolysis: fragmentation or avulsion of the medial epicondyle
MRI
- Findings
- Edema across the medial epicondyle physis
- If suspected UCL injury will be best viewed
- Increased T1 and T2 uptake in UCL can be physiologic
Ultrasound
- Findings unknown (needs to be updated
Treatment
Nonoperative
- Indications
- First-line therapy in virtually all cases
- Relative rest
- Discontinue offending activity, typically throwing until pain and tenderness resolve
- Usually about 4-6 weeks
- Physical Therapy
- Begin when pain-free
- Strengthen dynamic stabilizers of core, shoulder
- Eventually throwing program as the athlete approaches RTP
- Medications including
- NSAIDS
- Acetaminophen
- Activity modification
- Pitchers may require biomechanical correction
- Prevention
- Follow pitch count guidelines
- Education of athlete, parents and coaches
- Correct biomechanics
- Improve core strength and cardiovascular fitness
Operative
- Indications
- Failure of conservative measures
- Technique
- Avulsion fracture: ORIF of medial epicondyle
- UCL Injury: UCL reconstruction
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Proximal Humeral Epiphysiolysis
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