eMedicine Specialties > Sports Medicine > Upper Limb

Little League Elbow Syndrome: Treatment & Medication

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
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Jan 5, 2009

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.

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.

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.

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