What is it?
Little league elbow is a diagnosis used to describe an overuse injury that affects the medial elbow of children and adolescents. The primary cause of little league elbow (LLE) is repetitive valgus overload, causing painful osteocartilaginous injury or ligamentous irritation.
A condition like little league elbow affects the growth plates which in children are believed to be 2-5 times weaker than the surrounding tissue.
Elbow injuries affect up to 40% of youth pitchers. Medial side of the elbow is the most common overuse elbow complaint in young athletes, particularly throwers. The action of overhand pitching places compressive stress on the lateral compartment of the elbow, and tremendous valgus stress on the medial elbow. This causes tensile distraction on the medial column structures. These forces are most intense during the late cocking and early acceleration phases of throwing.
Medial elbow pain affects 20-58% of youth baseball players, with increasing incidence throughout adolescence and adulthood. LLE is the most common in baseball pitchers but also affects other position players. Elbow overuse injuries often strike players that are given an abundant amount of playing time. You will also see this in players that often channel into single sport participation with year-round training and longer competitive seasons.
Children throwing over 600 pitches per season more than double their risk for elbow injury. Research shows that pitch count, rest in between pitch outings, and proper body mechanics are the most important considerations when it comes to preventing injury.
Clinical Presentation
The classic presentation of LLE is a young or adolescent baseball or softball player complaining of medial elbow pain in their throwing arm. The athlete may begin to express frustration because of decreased velocity, accuracy, and distance.
Clinical evaluation will show point tenderness over the medial epicondyle. This is often associated with localized swelling, elbow stiffness, and sometimes, the inability to achieve full extension. Resisted wrist flexion and pronation will likely exacerbate symptoms.
Repeated throwing and using your arm that does not have a mechanically sound base or foundation will lead to a loss of velocity, accuracy, and integrity of the components. For most cases of LLE, the medial epicondyle (inside of the elbow) is the weakest biomechanical link within the kinetic chain and is the first to exhibit symptoms.
Diagnosis
Radiographs may be appropriate if the patient is unresponsive to initial conservative treatment or if alternate pathology is suspected. Patients presenting with significant swelling and fixed flexion positioning should be imaged without delay to rule out fractures. Advanced imaging can help confirm diagnostic suspicions and potentially identify cartilage, ligament, and tendon injuries.
Management
LLE typically responds well to conservative management. Similar to other overuse injuries, elimination of the provoking movement is the key to management. Although unpopular, the most expedient management requires that the athlete ceases all throwing activity. LLE patients may need to selectively restrict throwing for up to four to six weeks. However, athletes should otherwise remain active.
Initial rehab includes a range of motion exercises accompanied by anti-inflammatory measures.
Early strengthening should include extension and supination based exercises until the patient can tolerate flexion and pronation. Eventually, rehab should progress to include isotonic strengthening of the wrist flexors, extensors, and supinators with lower resistance and high repetition exercises. Eccentric strengthening exercises may be appropriate, particularly when there is tendon involvement in more mature LLE patients.
Any efforts to repair and strengthen the elbow will likely fail without implementing functional development of the proximal shoulder girdle and core. Shoulder external rotation and retraction exercises have been shown to help rehabilitate and prevent elbow injuries. Young throwers should prioritize hip and trunk rotation over generating greater velocity from the shoulder and elbow.
Medial elbow injuries can be triggered or worsened when an athlete fails to properly engage the core and leg muscles responsible for balance and power generation. Single leg proprioception will benefit pitchers. In addition, shoulder, trunk and lower extremity flexibility is important and stretches to address any deficiencies is indicated.
A gradual return to throwing may be initiated when there is no longer point tenderness over the medial elbow. Patients should not advance training more than 10% per workout and may return to play when they reach sport-specific levels of performance. Following return to activity, monitoring pitch count and rest days are crucial.
Young pitchers should not pitch on consecutive days or in multiple games per day. Players should have a 2-4 month off-season that does not involve throwing.
Steroid injections for the management of LLE should be avoided, as they may create further ligament or cartilage damage. LLE treatment is managed conservatively and there is rarely operative.