Little League Elbow Syndrome

OVERVIEW

Little league elbow (LLE) syndrome is a valgus overload or overstress injury to the medial elbow occurring as a result of repetitive throwing motions. Microtrauma from either overuse or improper throwing mechanics (throwing arm trailing behind trunk rotation) can cause injury. The recent trend in increased single-sport athletes, year-round training, increased demands from young pitchers, and higher intensity of training at younger ages have lead to the increased rate of injury to the throwing arms of young athletes.

ANATOMY

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The elbow consists of numerous ossification centers and cartilaginous physes (growth plates). Closure of each apophysis occurs from age 14-16 years, with the medial epicondyle specifically closing at approximately age 15 years. Until the elbow reaches full skeletal maturity (late teen years), the patient is at risk for LLE syndrome. After skeletal maturity is reached, injury to the ulnar collateral ligament is more common.

The valgus stress placed on the elbow during throwing results in tension on the medial structures (medial epicondyle, medial epicondylar apophysis, medial collateral ligament complex) and compression of the lateral structures (radial head, capitellum). Repeated stress results in overuse injury when tissue breakdown exceeds repair.

This can lead to LLE syndrome, which encompasses: 

  1. Delayed or accelerated growth of the medial epicondyle (medial epicondylar apophysitis)
  2. Traction apophysitis (medial epicondylar fragmentation), and
  3. Medial epicondylitis.

EPIDEMIOLOGY

  • An estimated 4.8 million children aged 5-14 years play baseball or softball every year
  • Incidence of overuse injuries is 20-40% in the 9-12 year-old range and 30-50% in the adolescent age group
  • True incidence of sports-related injuries of all kind is unknown because a large number of young athletes never seek medical care

CLINICAL PRESENTATION

  • LLE syndrome most commonly occurs in pitchers. LLE can also occur in tennis and football (quarterbacks) players.
  • Accurate throwing history is important to document: types of pitches, number of pitches, recent changes in training/throwing.
  • Pain to palpation is most commonly localized to the medial epicondyle. Valgus testing of the elbow will exacerbate the pain

DIAGNOSIS

  • Diagnosis is often clinical
  • Differential diagnosis should include elbow dislocation, osteochondritis dissecans, ulnar collateral ligament injury, and avulsion fractures of the medial epicondyle
  • Plain radiographs, however, are usually indicated, particularly if symptoms have been present for >3 weeks, if an acute inciting injury is reported, or significant bony tenderness is present on exam
  • With LLE, routine radiographs show no bony irregularities

TREATMENT

  • Rest, icing of the elbow, and NSAIDs
  • Long-term rest (6-weeks) may be necessary to allow for complete healing of the elbow
  • Physical therapy is an option if pain persists after rest
  • Surgical treatment is occasionally necessary to remove loose bone fragments, bone grafting, or reattachment of a ligament to the bone
  • Prognosis is great with proper treatment:
    • Most cases resolve with rest and conservative management
    • Osteoarthritis is a potential long-term consequence
    • Functional disability and permanent growth or angular deformities are rare complications

PREVENTION

It is important to educate the parents, players, and coaches about the symptoms of LLE syndrome, the importance of preventing overuse, and significance of proper throwing techniques. General guidelines for the number of pitches a child can safely throw in a week in practice and competitive play is 75 for 8-10 year olds, 100 for 11-12 year olds, and 125 for 13-14 year olds. The number of curve balls and other movement pitches should be limited, as these tend to put more stress on the elbow. Proper warm-up time and proper strength and flexibility exercise should be maintained.

REFERENCES

  1. Shanley E, Thigpen C. Throwing injuries in the adolescent athlete. Int J Sports Phys Ther. 2013 Oct;8(5):630-40.
  2. Olsen SJ, Flisig GS, Andrews JR, et al. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006 Jun;34(6):905-12.
  3. Congenis J. Treating and preventing little league elbow. Phys Sportsmed. 1994;22(3):54-64.
  4. Rudzki JR, Paletta GA Jr. Juvenile and adolescent elbow injuries in sports. Clin Sports Med. 2004 Oct;23(4):581-608.
  5. 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.