eMedicine Specialties > Sports Medicine > Upper Limb

Little League Elbow Syndrome

Holly J Benjamin, MD, FACSM, FAAP, Assistant Professor of Clinical Pediatrics and Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, The University of Chicago and The University of Chicago Physicians Group; Appointed Director of Primary Care Sports Medicine, The University of Chicago
Igor Boyarsky, DO, Director of Triage, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center, University of California at Los Angeles; Christian Rank, MD, Staff Physician, Department of Emergency Medicine, Martin Luther King/Charles R Drew Medical Center; Eleby R Washington III, MD, FACS, Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science

Updated: Jan 5, 2009

Introduction

Background

Little league elbow (LLE) syndrome is a valgus overload or overstress injury to the medial elbow that occurs as a result of repetitive throwing motions. Over the past several decades, the number of organized sports for children has grown significantly, with millions of children participating in organized athletics each year. This increase in participation has been paralleled by an increase in sports-related injuries in the pediatric population.^{1,2,3,4,5,6,7,8,9,10,11}

Increased single-sport participation with year-round training, higher intensities at young ages, and longer competitive seasons are contributing factors to the increased injury rates seen in pediatric athletes. Conditioning and training errors also contribute significantly to the risk and frequency of injury. Although briefly discussed below, injuries to the lateral, posterior, and anterior elbow are separate entities and should not be confused with the medial injuries referred to as little league elbow syndrome.
 
During the throwing motion, valgus stress is placed on the elbow. This valgus stress results in tension on the medial structures (ie, medial epicondyle, medial epicondylar apophysis, medial collateral ligament complex) and compression of the lateral structures (ie, radial head, capitellum). Repeated stress results in overuse injury when tissue breakdown exceeds tissue repair. Recurrent microtrauma of the elbow joint can lead to little league elbow, a syndrome that encompasses (1) delayed or accelerated growth of the medial epicondyle (medial epicondylar apophysitis), (2) traction apophysitis (medial epicondylar fragmentation), and (3) medial epicondylitis.^{1,8,12,13,14,15}
 
Medial epicondylar apophysitis and stress fractures through the medial epicondylar epiphyses caused by repetitive valgus stress generally manifest with progressive medial pain, decreased throwing effectiveness, and decreased throwing distance.
 
Other causes of medial elbow pain include avulsion fractures of the medial epicondyle and ulnar collateral ligament (UCL) sprains or tears. Although a fracture is usually an acute traumatic event, a preceding history of medial elbow pain is common and is thought to be a risk factor for progression to acute fracture. Therefore, any thrower who is experiencing medial elbow pain should refrain from pitching until he or she has had a thorough evaluation.^1,3,5,8,16

A medial epicondyle fracture manifests as point tenderness and swelling over the medial epicondyle, often with an elbow flexion contracture greater than 15°. Repetitive medial stress can also cause attenuation and microstretching of the UCL complex, causing mild instability over time.¹
 
UCL injuries can manifest as acute ligament tears following a single valgus stress or as overuse sprains following repetitive valgus overloads. The clinical presentation is similar to little league elbow; however, the typical age range of the athlete is the older teenager who is skeletally mature. Suspected UCL injuries should be referred for further evaluation by a sports medicine specialist. Athletes with UCL injuries should not be allowed to pitch until they have been evaluated.
 
Although uncommon in children, neurologic injuries such as C8-T1 radiculopathy and ulnar neuritis can manifest as medial elbow pain and should be included in the differential diagnosis (see Differentials and Other Problems to Be Considered).
 
Lateral compression of the elbow most frequently results in injuries to the capitellum and radial head. Osteochondrosis of the capitellum (known as Panner disease) generally occurs in children aged 7-12 years and manifests as dull, achy, activity-related lateral elbow pain. Swelling, clicking, and decreased range of motion are uncommon associated symptoms. Panner disease tends to be a benign self-limited condition that does well over time and is treated with complete rest from inciting activities such as throwing and weight bearing on the elbow. Osteochondral injuries can also be observed in the radial head.
 
Osteochondritis dissecans (OCD) of the capitellum occurs in adolescents aged 13-17 years. This is a localized injury to subchondral bone that results from repetitive lateral compression of the elbow during overhead motions. These patients report a general dull elbow pain that worsens with activity, often have a flexion contracture of 15° or greater, and may have mechanical symptoms of clicking or popping. Loose body formation, residual capitellum deformity, and elbow degenerative joint disease are potential sequelae. Different treatment options are used based on the age and skeletal maturity of the patient and the type of lesion present. 

Osteochondritis dissecans lesions can be separated into type I, which has no displacement and no articular cartilage fracture; type II, which has evidence of articular cartilage fracture or partial displacement; and type III, which is completely displaced with loose bodies in the joint.

Posterior elbow injuries also occur as a result of throwing. During the follow-through stage of throwing, extension overload and valgus stress can result in injury of the olecranon. These athletes present with posterior elbow pain, clicking, and possible loss of elbow extension. Loose bodies and olecranon nonunion can occur in younger athletes. Older athletes may experience olecranon fractures or secondary osteophyte formation. These injuries are sometimes treated surgically.^{1,3,4,5,6,7,9,10,11,17}

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Sports Injury Center. Also, see eMedicine's patient education article Repetitive Motion Injuries.

Related eMedicine topics:
Floating Elbow
Tendonitis
Ulnar Nerve Entrapment

Frequency

United States

Annually, an estimated 4.8 million children aged 5-14 years participate in baseball and softball. The incidence of all baseball-related overuse injuries is 2-8% per year. The incidence of overuse injuries in the 9- to 12-year-old range for baseball is 20-40%, and in the adolescent age group is 30-50%. The true incidence of sports-related injuries is unknown because a large number of athletes never seek medical care. Early recognition of little league elbow syndrome is important, because it leads to better outcomes and decreases the risk of persistent functional disabilities in the athletes.

International

No data are available for the annual incidence of little league elbow syndrome in the international community.

Functional Anatomy

Evaluation of the young adolescent elbow presents some anatomic challenges to the healthcare provider in that the elbow consists of numerous ossification centers and cartilaginous physes. Becoming familiar with the chronologic order of appearance and ossification of these growth centers is important. Consider the mnemonic CRITOE (ie, capitellum, radius, internal epicondyle, trochlea, olecranon, external epicondyle).

Each of the ossification centers appears at a relatively predictable time starting around age 1-2 years, with 2-year intervals between the next center's appearance. Closure of each of the apophyses occurs from age 14 to 16 years, with the medial epicondyle specifically closing at approximately age 15 years. The elbow likely reaches full skeletal maturity by the late teen years, at which time injuries to the UCL are far more common. Until then, the young thrower is at risk for little league elbow syndrome.^1,4,12,16,18

The static stabilizers around the elbow include the bony articulations, the joint capsule, and the various ligament bundles. The medial (ulnar) collateral ligamentous complex consists of the anterior oblique bundle, posterior oblique bundle, and transverse ligament. These structures are the primary medial support of the elbow during valgus stress. The lateral (radial) ligamentous complex, composed of the lateral collateral, lateral ulnar collateral, and accessory lateral collateral ligaments, provides support during varus stress.

The dynamic stabilizers primarily include the muscles that cross the elbow joint, such as the triceps, biceps, and brachioradialis. The flexor-pronator group stabilizes against valgus stress, and the extensor-supinator group stabilizes against varus stress.

Elbow biomechanics include flexion/extension range of motion and pronation/supination. Slight hyperextension 5-15° through flexion of approximately 150° is within normal limits. Baseball pitchers with years of throwing experience often have relative 5-10° flexion contractures on their dominant side; however, in the young thrower, a flexion contracture can be a sign of injury. Pronation of 75° and supination of 85° is normal. Varus-valgus laxity of 3-4° is normal.

Sport-Specific Biomechanics

One should be familiar with the stages of throwing to understand the complexities of the biomechanical forces that contribute to the young thrower's risk of injury, such as in little league elbow syndrome. The pitching or throwing motion can be divided into 6 stages. Medial elbow injuries are the most common type seen in throwers and occur most commonly in the cocking and acceleration phases of throwing, owing to the presence of maximum valgus extension or distraction forces.^{1,12,13,14,15}

1. Windup begins with the pitcher balancing his weight over his rear leg, with the elbow flexed and the forward leg flexed at least 90°.
2. Stride starts with the lead leg beginning to descend toward the plate, and the 2 arms separate. The elbow moves from extension into flexion of 80-100°.
3. Cocking occurs when the humerus is in extreme abduction and external rotation and the elbow is flexed. The lead foots contacts the ground, the pelvis and trunk rotate, and elbow torque transfers valgus force across the elbow joint. During this phase, medial tension and lateral compression forces are applied to the elbow.
4. Acceleration is the shortest pitching phase, lasting from maximal external shoulder rotation to ball release. In this phase, the trunk rotates as the elbow extends. Maximum elbow angular velocity is comparable during fastballs, sliders, and curveballs, but it less during the change-up pitch. Velocity comes from rotation of the trunk, shoulder, and hips. Varus torque forces during this phase act to resist the valgus extension "overload" phenomenon and can contribute to posterior elbow (olecranon) impingement.
5. Deceleration is initiated at ball release and ends when the shoulder has reached full internal rotation. The body must decelerate the arm and dissipate forces in the elbow and shoulder.
6. Follow-through is the final phase of the baseball pitch and ends with the pitcher reaching a balanced fielding position with full-trunk rotation and the body weight fully transferred from the rear leg to the forward leg. During follow-through, the elbow flexes into a relaxed position and crosses the body.

Clinical

History

• Little league elbow syndrome occurs most commonly in pitchers, but it is also seen in infielders, catchers, and outfielders. This condition can also occur in other overhead or throwing sports, such as tennis and football (quarterback position). It is important to identify the player's position on the sports team during history taking, because this makes determining the magnitude of the stress placed on the elbow and the subsequent risk of injury easier.
• Skeletal age is an indicator of the stage of skeletal maturity and is a major determining factor in regard to these potential types of injuries. Little league elbow injuries during childhood are usually due to repetitive microtrauma to the apophysis and ossification center of the medial epicondyle. During adolescence, increased throwing force and valgus stress result in avulsion, delayed union, or nonunion of the medial epicondyle. In young adulthood, the medial epicondyle is fused, and injuries to the UCL are more common.
• Throwing history is important. Types of pitches, an accurate pitch count of approximate numbers of competitive pitches per game per week and/or season is necessary information. (See the 2008 USA Baseball Medical & Safety Advisory Committee recommendations for youth pitch counts.¹¹ )The level of play and time of season should be noted. Recent changes in pitch types, counts, or other alterations in training should be carefully noted. For example, fastballs and change-up pitches result in less medial elbow stress than curveballs and sliders. Curveballs thrown at a young age, regardless of previous pitching experience, are associated with an increased risk of little league elbow syndrome and more serious injuries such as medial epicondylar avulsion fractures due to shear forces over a immature growth plate.
• It is vital to obtain the location, timing, and duration of symptoms (usually pain). Elbow pain in a thrower is usually a chronic overuse injury. However, an acute inciting event that changes or worsens the symptoms may prompt an athlete to seek an evaluation. Pain is most commonly localized to the medial epicondyle, although patients may also present with lateral or posterior elbow pain. Medial elbow pain during the cocking and/or acceleration phases of throwing is typical. Pain during the deceleration phase is more likely to be associated with posterior elbow injuries. Radiation of symptoms is important to note, because patterns such as radiation of symptoms into the forearm with flexor-pronator tendinitis are common, as are paresthesias into the ring and little fingers with ulnar neuritis.
• Handedness is important only because symptoms usually manifest in the dominant extremity.
• Past history of injuries such as shoulder, back, or knee injuries that can easily alter the biomechanics of throwing may place the elbow at increased risk for overuse injuries. A general health assessment is also important.

Physical

• Inspection is important to note the carrying angle and any flexion contractures that may be present relative to the opposite side. During the initial examination, evaluate for muscle atrophy or hypertrophy, bony deformities, or the presence of swelling and ecchymosis.^1,18,19  
• Palpation of bony structures should include both epicondyles, the olecranon process, the capitellum, and the radial head. Soft-tissue palpation should include the UCL (felt best with the patient's elbow in 50-70° of flexion), the biceps tendon, the triceps tendon, and the flexor-pronator and extensor-supinator muscle complexes. 
• Strength testing of the various muscles should be performed.
• Neurologic testing should include evaluation of the ulnar nerve. Palpation for tenderness, stability testing, and a Tinel test via percussion over the ulnar groove for paresthesias consistent with ulnar neuritis constitute a thorough examination.
• Special tests include valgus stress testing to evaluate injury to the UCL. The patient may be prone, supine, or upright. The stress test should be performed with the elbow in 20-30° of flexion with a valgus force exerted on the elbow. Opening up on the injured side, compared with the opposite uninjured side, is most reflective of an injury to the UCL. Pain without instability during valgus stress testing is more commonly seen with little league elbow syndrome.
• Two special tests to note are the milking maneuver , which is performed with the patient seated, and the valgus extension overload test.
  • For the milking maneuver, the examiner grasps the thrower's thumb with the arm in the cocked position of 90° of shoulder abduction and 90° of elbow flexion. Then the examiner applies a valgus stress by pulling down on the thumb.
  • For the valgus extension overload test, the examiner stabilizes the humerus from the outside and then pronates the forearm during extension while applying valgus stress. Pain is more likely associated with posterior impingement if this test result is positive. 
• Conduct a complete examination of the neck, shoulders, wrist, and hand. A general inspection should include an assessment of height and weight, because a larger body habitus is associated with an increased risk of elbow injury. 
• Perform a complete neurologic and vascular examination of the neck and upper extremity.

Causes

• Training errors, such as abrupt changes in intensity, duration, or frequency of throwing activity are frequently associated with sports injuries. Poor coaching and lack of preseason conditioning can also contribute to an increased risk of injury.
• Strength and flexibility imbalances can indirectly cause elbow injuries, as can injuries to other areas of the body (current and/or previous injuries).
• Anatomic malalignment of the lower extremities can cause little league elbow syndrome.
• Improper footwear or playing surface can result in an insecure platform for stability in throwing activities.
• Associated disease states or preexistent injury can be causative.
• Growth patterns are sometimes implicated as the cause of little league elbow syndrome. Physeal or growth cartilage at the epiphysis or apophysis is less resistant to repetitive trauma than fused adult bone at ligamentous and tendinous insertions; thus, skeletally immature athletes more commonly develop growth plate (apophyseal) injuries. In addition, rapid growth (growth spurts) causes increased muscle and tendon tightness around a joint, resulting in loss of flexibility, biomechanical imbalance, and an increased risk of injury.

Differential Diagnoses

Elbow and Forearm Overuse Injuries
Elbow Dislocation
Humeral Capitellum Osteochondritis Dissecans
Lateral Epicondylitis
Medial Epicondylitis
Ulnar Collateral Ligament Injury

Other Problems to Be Considered

Cervical strain with radiculitis
Child abuse
Cubital tunnel syndrome or ulnar nerve subluxation at the cubital tunnel
Posterior interosseous nerve or radial nerve entrapment syndrome
Stress fracture
Septic arthritis
Ulnar neuritis

Workup

Laboratory Studies

• Laboratory studies are rarely needed in the evaluation of elbow pain in athletes. If ordered, an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level may indicate an acute inflammatory condition such as septic bursitis, which is more commonly observed in patients with olecranon bursitis. This condition manifests as posterior elbow pain, swelling, and decreased range of motion. Patients with olecranon bursitis should be referred to a hand specialist for incision and drainage, possible surgical excision, and antibiotic treatment.

Imaging Studies

• Plain radiographs are useful for detecting fractures, calcified loose bodies, heterotopic ossification, growth plate irregularities, developmental stages of ossification centers (CRITOE), arthritis, tumors, and infectious conditions (eg, osteomyelitis). 
• Plain radiographs are indicated for most cases of athletic elbow pain, particularly if symptoms have been present for more than 3 weeks, if an acute inciting injury is reported, or if significant bony tenderness with or without a joint effusion is present.^1,20 Note that with little league elbow syndrome, the diagnosis is often a clinical one, and routine radiographs show no bony irregularities. Also important are comparison views of the unaffected elbow in young preadolescent and adolescent athletes in order to properly assess the developmental stages of the ossification centers. Some possible radiographic abnormalities, noting the normal ossification center, age of appearance, and age of closure, that affect one's initial management strategies are as follows:
• Capitellum – Age of appearance, 1 year; age of closure, 14 years 
• Radius – Age of appearance, 3 years; age of closure, 16 years 
• Internal epicondyle – Age of appearance, 5 years; age of closure, 15 years 
• Trochlea – Age of appearance, 7 years; age of closure, 14 years 
• Olecranon – Age of appearance, 9 years; age of closure, 14 years 
• External epicondyle – Age of appearance, 11 years; age of closure, 16 years 
• Widening or distal displacement of the medial epicondyle is a worrisome radiographic finding seen in the setting of a medial epicondyle avulsion fracture and warrants a referral to a sports orthopedic surgeon for surgical consultation. 
• Valgus stress radiographs may be useful in the skeletally mature athlete. The findings are often subtle, but 2 mm of joint widening or more may indicate a UCL injury. Proximal UCL ossicles are sometimes seen as a result of repetitive microtrauma. 
• Osteochondritis dissecans manifests as a bony, craterlike defect in the capitellum and may possibly be associated with compression changes in the radial head. Osteochondritis dissecans lesions, when detected, should be referred to a sports-medicine specialist, and additional imaging with magnetic resonance imaging (MRI) is usually indicated. Outcomes vary, depending on the size of the lesion, the degree of displacement, the presence of any associated loose bodies, and the patient's skeletal maturity. 
• Osteochondrosis of the capitellum (Panner disease) shows fragmentation of the capitellar ossification center and a smaller and irregular epiphysis. Severe cases may show advanced avascular necrosis of the capitellum. Interestingly, this disease is often self-limited in the 8- to 11-year-old athlete; these patients often do well with time and conservative management. 
• Osteophytes are sometimes seen in the olecranon on the lateral elbow radiograph and are often correlated with cases of posterior elbow impingement. 
• MRI provides great detail of the structural integrity of the articular cartilage surface, the bone marrow and subchondral bone, the muscles, tendons, ligaments, muscles and nerves.  
• Computed tomography (CT) scanning has dramatically advanced with the advent of helical scanners. CT scanning is most useful for characterizing bony tumors, myositis ossificans, and fracture morphology. Contrast tomography can be used, but it is no longer favored except in certain individualized cases.  
• Ultrasonography can be useful for imaging the soft tissues around the elbow. Instability with dynamic ultrasonography during valgus stress and ulnar nerve instability with dynamic motion have been studied, but these techniques are not routinely used in the United States.  
• Radionuclide bone scanning is a sensitive but nonspecific imaging modality to identify the presence of a bony injury. Bone scanning is rarely used for elbow injuries, because alternative imaging techniques are more likely to aid in diagnosis.

Procedures

• Arthroscopy of the elbow can be used as both a diagnostic and treatment procedure. Arthroscopy can be used to determine the size and location of the bony lesions intra-articularly. Arthroscopy can also help determine whether loose fragments are present in the joint. Sometimes, arthroscopy can be used for surgical excision or fixation of bony fragments. Most patients have some form of imaging studies performed before an arthroscopic evaluation; therefore, arthroscopy is primarily used as a form of treatment.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The most important part of treatment for little league elbow syndrome is physical therapy. Rehabilitation in general follows a logical and sequential progression to quickly and safely return the athlete to a preinjury level of function.

The initial treatment phase involves limiting immobilization as much as possible, with initiation of range-of-motion exercises and joint mobilizations as necessary to prevent joint contractures. For athletes with hypermobility, joint stabilization exercises may be beneficial. Treatment of pain and inflammation with icing regularly, 20 minutes 1-2 times per day is important. Anti-inflammatory medications may used as needed to treat pain and may also help treat inflammation when present.
 
Appropriate upper extremity stretching and strengthening exercises can be initiated as tolerated with the use of dumbbells or light resistance bands. Elbow braces are of limited benefit but may be used for comfort or to promote active full range of motion. A core strengthening program should also be initiated immediately. Athletes should be able to start core exercises before the ability to perform specific elbow strengthening exercises.

Occupational Therapy

Occupational therapy for little league elbow syndrome can include efficient, practical ways to perform activities of daily living. Usually occupational therapy is of limited benefit to athletes with little league elbow syndrome, and the incorporation of upper extremity therapy with core strengthening and a biomechanical throwing analysis is of maximal benefit to the athlete. This integrated treatment approach is usually coordinated through physical therapy.

Medical Issues/Complications

Most complications from little league elbow syndrome arise from a thrower attempting to return to pitching too soon before rehabilitation is complete, or they result from a pitcher who continues to play while symptomatic. The presence of pain while performing competitive pitching is highly correlated with an increased risk of medial epicondylar avulsion fracture and the subsequent need for surgical stabilization. Athletes should be counseled to stop or avoid pitching at any time when elbow pain is present, and these individuals should seek an evaluation by a healthcare professional before returning to pitching.

Surgical Intervention

Medial epicondylar fractures may require either closed reduction and casting or surgical reattachment with fixation if displacement, elbow instability, or failure of conservative treatment occurs.^1,3,17

Type II osteochondrotic lesions are treated surgically if the loose body interferes with motion or causes mechanical symptomatology (eg, locking, buckling). Techniques of surgical treatment include removing loose bodies, drilling to stimulate active repair, bone grafting when architectural support is needed, or reattachment with absorbable or nonabsorbable Kirschner wires (K-wires). Type III lesions are usually treated with loose body removal, with or without drilling, curettage, or reattachment with K-wires.

When loose bodies or osteophytes are present in patients with olecranon injuries, surgical removal may be indicated in those who are symptomatic. Bone grafting may also be used in cases of olecranon nonunion when rest and immobilization have failed.

It is important to note that all throwers who have had surgical treatment for elbow pain require some form of progressive rehabilitation following the principles outlined above, including a thorough biomechanical pitching analysis. Pitchers should be counseled that many do not return to the previous level of throwing following surgical treatment of elbow injuries; however, outcomes vary based on the individual circumstances.

Consultations

Consultation with a rheumatologist is sometimes indicated in children who have chronic elbow pain and swelling that cannot be explained by an appropriate sports-related mechanism of injury. Infectious disease specialists can be helpful in the rare cases of joint or bursal infections, which do occur at the elbow.

Recovery Phase

Rehabilitation Program

Physical Therapy

During the recovery phase of treatment, the athlete with little league elbow syndrome should begin a progressive throwing program. Usually, this phase occurs at approximately week 4-8 of treatment. The criteria to progress to the more advanced recovery phases include full, nonpainful range of motion, no tenderness to palpation, normal symmetric upper extremity strength, good core stabilization, and good balance.

The return to throwing begins with a careful assessment of pitching mechanics by a rehabilitation specialist, such as an experienced physical therapist, certified athletic trainer, or a pitching coach. Video analysis can provide a more detailed and sophisticated analysis of throwing. Long tosses and noncompetitive pitches should emphasis neuromuscular core stability and proper arm positioning through each of the 6 phases of throwing, from windup to follow-through (see Sport-Specific Biomechanics).

Medical Issues/Complications

Most complications arise out of a thrower attempting to return to pitching too soon before rehabilitation for little league elbow syndrome is complete or result from a pitcher who continues to play while symptomatic. The presence of pain while performing competitive pitching is highly correlated with an increased risk of medial epicondylar avulsion fracture and the subsequent need for surgical stabilization. Athletes should be counseled to stop or avoid pitching at any time when elbow pain is present, and they should seek an evaluation by a healthcare professional before returning to pitching.

Surgical Intervention

Surgical treatment is usually not indicated in the recovery phase, unless the patient’s recovery is halted by either new or previously unrecognized symptomatology, such as loose bodies or osteophytes. Such symptoms can be treated as described previously (see Acute Phase Surgical Intervention). Indeed, a lack of further progression in the recovery phase sometimes indicates a previously unrecognized problem with regard to the child’s elbow. This situation may require further diagnostic studies, which may include repeat plain radiographs, MRIs in younger children, and/or bone scans or CT scans.

Other Treatment (Injection, manipulation, etc.)

Joint injections and manipulations are not appropriate forms of treatment in patients with little league elbow syndrome.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase of recovery from little league elbow syndrome should include careful observation for any recurrence of symptoms, including pain, loss of strength, loss of endurance, loss of power, or neuromuscular fatigue. The patient must be vigilant to maintain proper throwing biomechanics at all times for noncompetitive and competitive pitching. Careful attention should be paid to pitch counts and types, as outlined below, based on the age, ability, and playing level of the athlete. Failure to follow the appropriate guidelines as outlined or any attempt to pitch through relapses in symptoms can result in an increased risk of reinjury.

Medical Issues/Complications

A gradual recurrence of symptoms of little league elbow syndrome indicates a treatment failure or an improper diagnosis. Athletes with recurrent symptoms should be evaluated by a sports medicine specialist and should refrain from all competitive throwing. Even with a reasonable long-term maintenance program, complications such as posttraumatic arthritis, permanent flexion contractures, and growth or angular deformities may occur.

Consultations

Consultation with a sports orthopedic surgeon or sports medicine specialist may be necessary if the individual with little league elbow syndrome cannot be easily kept in the maintenance phase.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications in little league elbow syndrome. The primary effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) is in the treatment of pain. Some cases of little league elbow syndrome have an inflammatory component that responds to the anti-inflammatory properties of NSAIDs.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may also exist, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Ibuprofen (Motrin, Ibuprin, Advil)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist; not to exceed 3.2 g/d

Pediatric

20-70 mg/kg/d PO divided tid/qid; start at lower end of the dosing range and titrate; not to exceed 2.4 g/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in the presence of congestive heart failure, hypertension, and decreased renal and hepatic function; caution in patients with coagulation abnormalities or during anticoagulant therapy

Naproxen (Naprosyn Naprelan, Anaprox)

For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of COX, which is responsible for prostaglandin synthesis.

Dosing

Adult

250-500 mg PO bid; may increase to 1.5 g/d for limited periods

Pediatric

2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.

Ketoprofen (Actron, Orudis, Oruvail)

For the relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.

Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<12 years: 0.1-1 mg/kg PO q6-8h

>12 years: Administer as in adults.

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy

Follow-up

Return to Play

Return to throwing activities in individuals with little league elbow syndrome should be carefully monitored by the patient and his or her family in conjunction with an educated trainer, the coach, and a pediatric sports medicine or orthopedic specialist. The return to competitive pitching should begin when an athlete has fully completed his or her rehabilitation program. As the athlete returns to competition, careful attention to pitch types, pitch counts, a proper rotation schedule, and maintenance of core strength and flexibility is necessary.²¹

Complications

Even with a reasonable long-term maintenance program, complications such as posttraumatic arthritis, permanent flexion contractures, and growth or angular deformities may occur following little league elbow syndrome.

Prevention

Prevention can be accomplished by educating parents, players, and coaches about the symptoms and sequelae of little league elbow syndrome. Emphasis should be placed on proper throwing techniques during practices and games. Pitch counts, pitch types, and a proper rotation schedule should be followed. The number of competitive pitches thrown in practice and the number of innings per week, per season, and per year should be monitored. The prescreening physical examination affords an excellent opportunity for the physician to provide this information.

Proper warm-up time and proper strength and flexibility exercises should be maintained during the off-season or initiated at least 6 weeks before the first practice. Pitching should be limited to 9 months per year maximum, and an off-season interval throwing program is important. Proper biomechanics should be emphasized at all times. Athletes should be encouraged to seek medical care when symptoms of throwing-related elbow pain develop.

Prognosis

Prognosis for recovery from little league elbow syndrome is guarded and depends on the specific pathologic process. In general, disorders that affect the articular surfaces of the elbow, such as the capitellum and radial head, as well as those that affect the normal growth and development of the elbow have the worst long-term prognosis. Over the short term, most cases of little league elbow syndrome resolve with rest and conservative management. Osteoarthritis is a potential long-term complication. Functional disability and permanent deformity can result from proper or improper management.

Education

Little league elbow syndrome, as well as other sports-related injuries, can be discussed with parents and players during the preparticipation physical examination. This is an excellent opportunity for physicians to educate their patients about causes, symptoms, and prevention of sports injuries.²¹

Miscellaneous

Medicolegal Pitfalls

• Medicolegal issues can arise in conjunction with making the diagnosis of little league elbow syndrome. Initially, at the time of diagnosis, the issues of causation are not usually arguable. The issues of responsibility can be argued, especially when the child has been participating in an organized and adult-supervised baseball or football league. The question arises as to whether the child is responsible for his or her own elbow, whether the parents are responsible for the child's injury, or whether the league is legally responsible when these injuries occur.
• After treatment has been initiated and the patient enters the maintenance phase of rehabilitation, the issue of whether the child can return to organized sports activity can have legal implications. If the physician allows a child with radiographic or physical evidence of a continued problem to return to the sport, even with the absence of symptoms, then the physician can potentially be held liable for the progression of pathology (eg, loose body formation from osteochondritis dissecans). Therefore, all of the potential risks of resuming activity should be explained before the child returns to sports competition.Documentation in the medical chart of a detailed discussion regarding guidelines for the patient's return to play and appropriate limitations for pitching should occur, as should documentation of the parents’ understanding and acceptance of the risks.

References

1. Bradley JP. Upper extremity: elbow injuries in children and adolescents. In: Stanitski CL, DeLee JC, Drez D Jr, eds. Pediatric and Adolescent Sports Medicine. Vol 3. Baltimore, Md: WB Saunders Co; 1994:242-61.

2. Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med. Jan 2005;15(1):37-40. [Medline].

3. Congeni J. Treating and preventing little league elbow. Phys Sportsmed. 1994;22(3):54-64.

4. Emery HM. Considerations in child and adolescent athletes. Rheum Dis Clin North Am. Aug 1996;22(3):499-513. [Medline].

5. Micheli LJ. Overuse injuries in children's sports: the growth factor. Orthop Clin North Am. Apr 1983;14(2):337-60. [Medline].

6. Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. Jul 2000;84(4):983-1007, viii. [Medline].

7. Rudzki JR, Paletta GA Jr. Juvenile and adolescent elbow injuries in sports. Clin Sports Med. Oct 2004;23(4):581-608, ix. [Medline].

8. Stanitski CL. Combating overuse injuries: a focus on children and adolescents. Phys Sportsmed. 1993;21(1):87-106.

9. Stanitski CL. Pediatric and adolescent sports injuries. Clin Sports Med. Oct 1997;16(4):613-33. [Medline].

10. American Academy of Pediatrics. Risk of injury from baseball and softball in children. Pediatrics. Apr 2001;107(4):782-4. [Medline]. [Full Text].

11. USA Baseball Medical & Safety Advisory Committee. Youth baseball pitching injuries. November 2008. USA Baseball.com. Available at http://mlb.mlb.com/usa_baseball/article.jsp?story=medsafety11. Accessed January 5, 2009.

12. Alcid JG, Ahmad CS, Lee TQ. Elbow anatomy and structural biomechanics. Clin Sports Med. Oct 2004;23(4):503-17, vii. [Medline].

13. Ben Kibler W, Sciascia A. Kinetic chain contributions to elbow function and dysfunction in sports. Clin Sports Med. Oct 2004;23(4):545-52, viii. [Medline].

14. Hutchinson MR, Wynn S. Biomechanics and development of the elbow in the young throwing athlete. Clin Sports Med. Oct 2004;23(4):531-44, viii. [Medline].

15. Loftice J, Fleisig GS, Zheng N, Andrews JR. Biomechanics of the elbow in sports. Clin Sports Med. Oct 2004;23(4):519-30, vii-viii. [Medline].

16. Behr CT, Altchek DW. The elbow. Clin Sports Med. Oct 1997;16(4):681-704. [Medline].

17. Maloney MD, Mohr KJ, el Attrache NS. Elbow injuries in the throwing athlete. Difficult diagnoses and surgical complications. Clin Sports Med. Oct 1999;18(4):795-809. [Medline].

18. Cain EL Jr, Dugas JR. History and examination of the thrower's elbow. Clin Sports Med. Oct 2004;23(4):553-66, viii. [Medline].

19. Colman WW, Strauch RJ. Physical examination of the elbow. Orthop Clin North Am. Jan 1999;30(1):15-20. [Medline].

20. Fritz RC, Breidahl WH. Radiographic and special studies: recent advances in imaging of the elbow. Clin Sports Med. Oct 2004;23(4):567-80, ix. [Medline].

21. Ronai J. Eight essentials of post-pitching recovery. USA Baseball.com. Available at http://mlb.mlb.com/usa_baseball/article.jsp?story=medsafety2. Accessed July 17, 2008.

Keywords

little league elbow syndrome, little league elbow, medial epicondylitis, valgus elbow extension overload syndrome, medial elbow apophysitis, ulnar collateral ligament injuries, lateral elbow compression injuries, overuse elbow injuries, Panner’s disease, Panner disease, LLE syndrome, LLE, elbow injury, baseball injury, pitcher’s elbow, pitching injury

Contributor Information and Disclosures

Author

Holly J Benjamin, MD, FACSM, FAAP, Assistant Professor of Clinical Pediatrics and Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, The University of Chicago and The University of Chicago Physicians Group; Appointed Director of Primary Care Sports Medicine, The University of Chicago
Holly J Benjamin, MD, FACSM, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Igor Boyarsky, DO, Director of Triage, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center, University of California at Los Angeles
Igor Boyarsky, DO is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, American Osteopathic Association, American Society of Addiction Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Christian Rank, MD, Staff Physician, Department of Emergency Medicine, Martin Luther King/Charles R Drew Medical Center
Christian Rank, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Eleby R Washington III, MD, FACS, Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science
Eleby R Washington III, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, International College of Surgeons, and National Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Andrew D Perron, MD, Residency Director, Department of Emergency Medicine, Maine Medical Center
Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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