Little League elbow can be career ending without proper intervention

Baseball is one of the most popular youth sports in the United States, with nearly five million children 5 to 14 years of age participating in organized and recreational programs annually. There are increasing concerns that overuse injuries are becoming more frequent in youth sports. Conditioning and training errors combined with rapidly changing physical characteristics contribute to the rising injury rates. Year-round training in a single sport and longer competitive seasons also are risk factors for injury. It is estimated that the incidence of baseball-related overuse injuries is 2 to 8 percent, but the annual incidence of elbow pain in the 9- to 12-year old baseball player is 26 to 40 percent.

It is important to understand the anatomy and chronologic order of ossification centers of the elbow. They can be remembered using the mnemonic CRITOE (capitellum, radius, internal-medial epicondyle, trochlea, olecranon, external-lateral epicondyle). Generally, the first center appears at 1 to 2 years of age, with the remaining appearing about every two years. As the patient approaches mid-to-late teens, the apophyses will ossify and close in order.

Little League elbow (LLE) is primarily a clinical diagnosis. Classic LLE refers to an apophyseal injury to the medial humeral epicondylar growth plate found in skeletally immature athletes. LLE may be used to describe a spectrum of disorders from a stress reaction to avulsion fractures of the medial epicondyle to osteochondritis dissecans of the capitellum and loose bodies. It occurs most often between 8 to 15 years of age. LLE mainly is seen in throwing athletes but also has been reported in racquet sports. It most frequently affects baseball pitchers but also can occur in other throwing field positions (catcher, third base, shortstop, etc.). This injury is not common in softball pitchers because of the different mechanics, but the injury can be seen in softball field players. This injury will cause pain with throwing, and it may lead to lifelong problems with the elbow.

The acceleration phase of throwing (moving the arm forward) places a valgus tension on the elbow, which compresses the lateral anatomy and stresses the medial structures. Sidearm throwing and improper throwing mechanics increase the forces placed on the elbow, increasing the risk of injury. The medial epicondyle in a skeletally immature athlete is very susceptible to the valgus stress overload that occurs with throwing, which may result in an avulsion fracture of the medial epicondyle. After physeal fusion, the ulnar collateral ligament and ulnar nerve are more likely to be injured. 

History

An accurate history is the key to diagnosing LLE. Remember that young athletes may try to minimize symptoms and disability for fear they may not be allowed to play or will appear "weak" to coaches and teammates. They often will not seek medical attention until they lose control or velocity of their throws or pitches. In order to get a complete history, it may be necessary to involve the athlete's parents, coaches and athletic trainers when possible.

Overuse injuries usually have an insidious onset with a progressive course, rather than immediate pain after a single event. Although the athlete may think one throw caused the injury, often there is acute or chronic pain prior to the injury. Frequently, however, athletes will complain only of pain while throwing. As LLE progresses, there may be pain after throwing that can last for several days. Often athletes will take a short break with a resolution of symptoms but will have symptoms return when they begin to throw again. Pain frequently is localized to the medial elbow. Harder and farther throwing may lead to more intense pain.

It is important to note the patients' sports and when they participate in them. Athletes who play the same sport more than two seasons of the year have a higher risk of developing overuse injuries. The proliferation of "fall ball" and indoor facilities has turned baseball and softball into year-round sports. It also is important to note what position the athlete plays, as high-throwing positions are most likely to be affected by LLE. Skilled pitchers are often at higher risk of injury because, in the quest for a victory, they may pitch more frequently and for a longer duration than their teammates.

It is important to note pitch counts. (See Table 1.) Pitch counts are for game-quality pitches. However, the number of pitches thrown in practice or in "backyard practice" after a game also is important. Many athletes play on multiple teams during a season, and they frequently will not combine the number of pitches for a global pitch count. Instead they may follow pitch counts for each league, which can add up to a young pitcher throwing two to three times more than the recommended number of pitches.

Physical

On inspection, the elbow usually appears completely normal and symmetric with the opposite arm. Medial swelling may be present. Flexion (135+ degrees), extension (-15 to 0 degrees), pronation (90 degrees) and supination (90 degrees) usually are normal. There may be pain with palpation over the medial elbow and pain with resisted wrist flexion and pronation. The ulnar collateral ligament (UCL) should be assessed using a valgus stress test with the arm at 30 degrees and 0 degrees, and compared to the contralateral arm. A thorough neurovascular exam should be obtained. It may be necessary to examine the neck and shoulder if there are concerns about referred pain.

An athlete who has not thrown in several days may have a normal physical exam or an exam that reveals only minimal discomfort. A normal physical exam does not exclude LLE. 

Imaging modalities

Up to 85 percent of patients with LLE will have normal radiographs. Initial evaluation should include AP, lateral and oblique radiographs of the elbow. It often is helpful to obtain comparison views of the contralateral elbow in the skeletally immature patient to help evaluate the integrity and development of the various apophyses. Abnormalities on plain films are very concerning and may warrant surgical consultation. MRI is a useful tool to help evaluate the UCL and may provide additional information on osteochondral lesions and avulsion fractures but is not needed with classic LLE.

Differential diagnosis

To make a diagnosis of LLE, one should feel comfortable ruling out other injuries in the differential diagnosis. (See Table 2 on Page 7.) Avulsion fractures of the medial epicondyle show a widening of the growth plate on the affected side when compared to the contralateral side. Medial epicondylitis occurs after the growth plate has fused. UCL injuries should have pain and laxity on physical exam and are more likely to occur in older adolescents. Ulnar neuropathy may result from compression or a traction injury, but patients will complain of medial pain with radiculopathy or numbness in the fourth and fifth digits. Panner disease is avascular necrosis of the capitellum, which occurs in athletes younger than 10 years and often causes lateral elbow pain. Osteochondritis dissecans also usually presents as lateral pain that worsens with activity.

Management

The most important part of treatment involves complete rest from throwing and pitching, often for at least four to six weeks. It is important to allow the athlete to participate in general aerobic conditioning and improve core strength. Physical therapy can help the athlete progress and complete the proper exercises. Ice and OTC anti-inflammatory medications may be useful in the treatment of LLE.

After the period of rest, the athlete should have full, pain-free range of motion and strength. The athlete may then begin a six- to eight-week throwing program, with an emphasis on proper throwing or pitching mechanics. Any return of symptoms warrants stopping the throwing program and being re-evaluated.

Education of patients, coaches and parents is very important. Improper treatment or noncompliance with treatment may result in functional disability or permanent deformity. Osteoarthritis is a potential long-term complication as well. Education may help prevent future injury in the same athlete, siblings or teammates.

Prevention

It is necessary for players to recognize the importance of year-round physical fitness and that young athletes must develop overall physical fitness skills before sports specific skills. Supervised low weight, high repetition resistance training programs can be helpful. Year-round same-sport competition should be discouraged, as it dramatically increases the risk for overuse injuries. Throwing athletes should have a period of "active arm rest," or spend one season doing activities that do not involve overhead motions (volleyball, swimming, quarterback, etc). 

Pitching and throwing mechanics should be emphasized at a young age. It is important for pitchers to first learn control or getting the ball in the strike zone. Next, they should begin to work on command or being able to place a pitch in certain areas of the strike zone. After mastering control and command, they may begin increasing pitch velocity. However, pitch speed over 80 mph in a skeletally immature athlete is correlated with LLE. Finally, as physical maturity is increasing, generally around 14 to 16 years of age, athletes may begin working on ball movement or breaking pitches (curveball, slider, etc.). USA Baseball and Little League pitch count guidelines (See Table 1 on Page 5.) were revised for the 2008 season and should be followed carefully. There are also specific guidelines for rest after pitching. It is ideal for pitchers to exit the game when they are done pitching. Pitchers who remain in the game at another position should not play catcher and ideally should avoid other high-throwing positions like third base and shortstop.

Most importantly, athletes should never pitch or play through pain. The "win at all costs" and "no pain, no gain" attitudes have permeated the youth sports culture. Even mild or intermittent medial elbow pain should result in a high index of suspicion and appropriate, early intervention. When caught early, a player can completely recover from this disorder, but when athletes ignore symptoms or are noncompliant with treatment, LLE can be career ending.

References

Walter KD, Congeni JA. Don't let Little League shoulder and elbow sideline your patient permanently. Contemporary Pediatrics. 2004, 21(9): 69.

Benjamin HJ, Briner WW. Little League elbow. Clin J Sport Med. 2005, 15(1): 37.

Christopher NC, Congeni JC. Orthopedic emergencies: overuse injuries in the pediatric athlete: evaluation, initial management, and strategies for prevention. Clin Pediatr Emerg Med. 2002, 3.

Whiteside J, Andrews JR, et al. Elbow injuries in young baseball players. Phys Sports Med. 1999, 27.

Micheli LJ, Glassman R, Klein M. The prevention of sports injuries in children. Clin Sports Med. 2001, 20.

Lyman S, Flesig GS, Andrews JR, et al. Effect of pitch type, pitch count, and pitching mechanics on risks of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002, 30: 463.

American Academy of Pediatrics, Committee on Sports Medicine. Risk of injury from baseball and softball in children. www.aappolicy.org, 2001.

USA Baseball. www.usabaseball.com, 2004.

Little League. Changes to the 2008 regular season pitching regulations for baseball divisions of Little League. www.littleleague.org, 2007.

Kevin Walter, MD, is a pediatric sports medicine specialist and program director of Pediatric and Adolescent Sports Medicine at Children's Hospital of Wisconsin. He also is an assistant professor of Orthopedics and Pediatrics at the Medical College of Wiconsin and a member of Children's Specialty Group.

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