Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Little League Elbow Syndrome Treatment & Management

  • Author: Holly J Benjamin, MD, FAAP, FACSM; Chief Editor: Craig C Young, MD  more...
 
Updated: Mar 25, 2015
 

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.

Next

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.

Previous
Next

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.

Previous
 
 
Contributor Information and Disclosures
Author

Holly J Benjamin, MD, FAAP, FACSM Associate Professor of Pediatrics and Orthopedic Surgery, Director of Primary Care Sports Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Holly J Benjamin, MD, FAAP, FACSM is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Igor Boyarsky, DO Emergency Room Physician, Kaiser Permanente Southern California

Igor Boyarsky, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Academy of Anti-Aging Medicine, American Osteopathic Association

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, National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

  2. Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med. 2005 Jan. 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. 1996 Aug. 22(3):499-513. [Medline].

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

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

  7. Rudzki JR, Paletta GA Jr. Juvenile and adolescent elbow injuries in sports. Clin Sports Med. 2004 Oct. 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. 1997 Oct. 16(4):613-33. [Medline].

  10. American Academy of Pediatrics. Risk of injury from baseball and softball in children. Pediatrics. 2001 Apr. 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. 2004 Oct. 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. 2004 Oct. 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. 2004 Oct. 23(4):531-44, viii. [Medline].

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

  16. Behr CT, Altchek DW. The elbow. Clin Sports Med. 1997 Oct. 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. 1999 Oct. 18(4):795-809. [Medline].

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

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

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

  21. Wei AS, Khana S, Limpisvasti O, Crues J, Podesta L, Yocum LA. Clinical and magnetic resonance imaging findings associated with Little League elbow. J Pediatr Orthop. 2010 Oct-Nov. 30(7):715-9. [Medline].

  22. Byram IR, Kim HM, Levine WN, Ahmad CS. Elbow Arthroscopic Surgery Update for Sports Medicine Conditions. Am J Sports Med. 2013 Apr 9. [Medline].

  23. 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.

  24. Fleisig GS, Andrews JR, Cutter GR, Weber A, Loftice J, McMichael C, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. Am J Sports Med. 2011 Feb. 39(2):253-7. [Medline].

 
Previous
Next
 
Table.
Maximum Pitch Counts — Game Competition



(Adapted From USA Baseball Recommendations) [11]



Age, y Pitch Approved to Throw Pitches per Game Pitches per Week Pitches per Season Pitches per Year
9–10 Fastball 50 75 1000 2000
11-12 Change-up 75 100 1000 3000
13-14 Curveball 75 125 1000 3000
15-16 Slider, forkball, splitter, knuckleball 90 - -  
17-18 Screwball 105 - -  
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.