Little League Elbow Syndrome Workup

Updated: Aug 30, 2018
  • Author: Holly J Benjamin, MD, FAAP, FACSM; Chief Editor: Craig C Young, MD  more...
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Workup

Laboratory Studies

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  • 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

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  • 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, 22]

    • 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.

  • Wei et al conduct a study to better characterize the involvement and relationship of medial elbow structures in Little League elbow through magnetic resonance (MR) imaging. The study concludes that MRI of Little League elbow demonstrated more abnormalities compared with radiographs. The authors add that increased number of findings, however, should not change clinical management. MR evaluation of the ulnar collateral ligament demonstrates no role for reconstruction in Little League elbow. In addition, given the close proximity of the ligament to the physis, any surgical procedure involving the UCL origin should be performed with caution. [23]

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Procedures

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  • 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. [24]

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