Little League Elbow Syndrome Workup

  • Author: Holly J Benjamin, MD, FACSM, FAAP; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Apr 19, 2011
 

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.
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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.
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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.
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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  Primary Treating Physician, East Los Angeles Center for Orthopedic and Rehabilitation

Igor Boyarsky, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and 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, and National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, 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, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

References

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  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.

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  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.

  22. 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. Feb 2011;39(2):253-7. [Medline].

 
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Table 1
Maximum Pitch Counts — Game Competition



(Adapted From USA Baseball Recommendations)[11]



Age, yPitch Approved to ThrowPitches per GamePitches per WeekPitches per SeasonPitches per Year
9–10Fastball507510002000
11-12Change-up7510010003000
13-14Curveball7512510003000
15-16Slider, forkball, splitter, knuckleball90--
17-18Screwball105--
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