Little League Elbow

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Search Strategy

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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.  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, medical 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.  Each year over 2 million children participate in little league elbow. In 1976, little league elbow based in Houston TX and Eugene OR demonstrated 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.

Differential Diagnosis

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Outcome Measures

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DASH Outcome Measure

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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.

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 physician through the appropriate differential diagnosis.

Physical exam begins with the inspection 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. Elbow 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°. General evaluation of the neck, ipsilateral shoulder and wrist is also important, as well as a complete neurological assessment, specifically the ulnar nerve.

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.

Medical Management

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Physical Therapy Management

Treatment throughout recovery(4):

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

Medial Epicondyle Apophysitis

Rest

• 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

• 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 (4), nerve mobilizations, grade 3 and 4 mobilizations at elbow and wrist joints
  

Progressive strengthening

• 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
  

Ulnar collateral ligament:

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/wrist ext/flex, FA sup/pron, plyo's *****
  

Return to Activity:

• Axe throwing protocol
• Reinholt throwing protocol

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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