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Little League Elbow

Throwing athletes place significant stress on the throwing arm, affecting both adults and younger players. In adults, this stress is primarily absorbed by the ligaments and tendons, often resulting in tendinitis or ligament strain. However, in growing children, the stress is concentrated on the vulnerable areas of the bones, specifically the cartilage at the ends of the bones known as growth plates. Unlike the ligaments and tendons that attach to them, the cartilage of the growth plates is relatively weaker. Consequently, during the throwing motion, the growth plates are the weak links in the elbow, as opposed to the ligaments in adults. Once the growth plates fuse and the bones reach maturity, athletes are more prone to ligament and tendon injuries rather than growth plate-related issues.

Little League Elbow, also known as Medial Apophysitis, is an overuse injury that affects the growth plate located on the inner side of the elbow in young athletes involved in throwing activities. While baseball pitchers are most commonly affected, catchers, infielders, outfielders, and other throwing athletes can also experience this injury.

Repetitive stress on the growth plate during the acceleration phase of throwing a baseball is the primary cause of Little League Elbow. This phase subjects the growth plate to the highest levels of stress and strain.

The elbow is a complex joint formed by the meeting of three bones: the upper arm bone (humerus) and the two forearm bones (radius and ulna). The radius is situated on the outer (lateral) side of the elbow, while the ulna is positioned on the inner (medial) side. At the back of the elbow, you can feel the prominent bony tip called the olecranon, which is part of the ulna bone.

In addition to the bones, the elbow joint relies on various ligaments and muscles for its proper function and stability. These structures work together to support and control the movements of the elbow, allowing for range of motion while maintaining stability during activities.

The elbow bone’s development and maturation involve three primary growth plates:

  1. Medial Epicondyle: This growth plate is located on the inner side of the elbow and plays a role in the growth and development of the inner portion of the distal humerus bone.
  2. Lateral Epicondyle: Situated on the outer side of the elbow, this growth plate contributes to the growth and development of the outer aspect of the distal humerus bone.
  3. Olecranon: The olecranon is the bony prominence at the back of the elbow. It has its own growth plate, which aids in the development of the ulna bone, one of the two forearm bones.

Injuries to these growth plates typically occur while they are still “open,” meaning they have not yet reached skeletal maturity. Generally, these growth plates do not fully mature until individuals are around 14 to 18 years old.

During throwing motions, the elbow experiences significant stress in various areas. There are three primary areas where this stress commonly occurs:

  1. Valgus Stress: Valgus stress is the force exerted on the inner side of the elbow when the arm is externally rotated during the late cocking and early acceleration phases of throwing. This stress is absorbed by the medial (inner) side of the elbow and the ulnar collateral ligament (UCL), which plays a crucial role in stabilizing the inner side of the elbow during the throwing motion. In adults, injuries to the UCL are often referred to as “Tommy John” injuries. In younger athletes with open growth plates, such as in Little League Elbow (Medial Apophysitis), the repeated stress and pulling forces on the medial epicondyle growth plate can lead to inflammation, pain, and potential growth plate injuries. In severe cases, excessive valgus stress can cause an avulsion fracture, where a small piece of bone is pulled away from the main bone, taking a fragment of the growth plate with it.
  2. Compressive Forces: The outer aspect of the elbow experiences compressive forces during throwing. These forces occur as the bones and joint surfaces press against each other throughout the throwing motion. The highest compression typically occurs at the end of the cocking phase and the beginning of the acceleration phase. Excessive throwing frequency and intensity can result in damage to the growth plates on the outer aspect of the elbow.
  3. Tensile Force: The triceps muscle exerts excessive tensile (pulling) force on the tip of the elbow, specifically the olecranon, during the acceleration phase of throwing. This can lead to injury in the olecranon growth plate located at the back of the elbow.

These stresses highlight the vulnerability of the growth plates in the elbow during throwing and emphasize the importance of proper mechanics, adequate rest, and appropriate training to minimize the risk of injuries in young athletes.

Little League Elbow should be considered in any throwing athlete, particularly baseball pitchers, typically between the ages of 9 to 14, who presents with elbow pain. The location of the pain often indicates the specific source and location of the injury. The most common site of pain is along the inner side of the elbow, known as Little League Elbow (Medial Apophysitis). Other symptoms may include swelling or a limited range of motion in the affected elbow.

Diagnostic X-rays may show either unremarkable findings or widening of the growth plate. However, the most crucial aspect is to maintain a high level of suspicion for the diagnosis, irrespective of the results of diagnostic tests. Early intervention is essential to ensure the swiftest and most complete recovery.

It is important for medical professionals and coaches to be vigilant in recognizing the signs and symptoms of Little League Elbow, as prompt diagnosis and appropriate treatment can significantly contribute to the athlete’s rehabilitation and overall well-being.

The primary treatment approach for Little League Elbow is non-operative. It begins with a period of complete rest from throwing, typically lasting 4 to 6 weeks, which is essential. Following this initial rest period, and only when the patient is completely free of pain, a structured program involving strengthening exercises and gradual return to throwing should be initiated. This rehabilitation phase usually spans over 6 to 8 weeks.

During the rehab period, if the athlete experiences any recurrence of pain, it is important to temporarily halt the program until they are symptom-free. Returning to competitive throwing in a game situation typically takes around 12 weeks for an injured athlete.

Prevention plays a crucial role in managing Little League Elbow. Special attention should be given to the number of pitches thrown and the specific types of pitches used by the pitcher. Higher-stress pitches such as curveballs or breaking balls should be avoided until the pitcher reaches the appropriate age of skeletal maturity. Implementing these preventive measures can significantly reduce the risk of developing Little League Elbow and promote the long-term health and well-being of young athletes.

It is important to adhere to the recommendations set forth by Little League® Baseball, the world’s largest organized youth sports program.

Protect young throwing athletes.

Prevent injuries!