Little League Elbow

By admin On Feb 6, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Little League Elbow

Little League Elbow

Paul D. Sponseller MD

Basics

Description

“Little League elbow” refers to a group
of injuries about the elbow that arise in children and adolescents
(ages 7–15 years) from repetitive throwing or use of a racquet or bat (Fig. 1).
- Younger patients (7–11 years old) in that
  group often have an injury of the physis, whereas older adolescents
  (15–19 years old) are subject to avulsion fractures or ligament tears.
These injuries also are referred to as osteochondroses, or disordered behavior of growing cartilage under load.
Classification:
- Medial disease involves the MCL, the medial epicondyle, and the surrounding soft tissues.
- Lateral disease involves the radial head, the capitellum, the lateral epicondyle, and surrounding soft tissues.
Synonym: Osteochondritis (or osteochondrosis) of the radial head or capitellum (Panner disease)

General Prevention

League guidelines (1,2) on the frequency of pitching for juvenile players exist to minimize this disorder.
Elbow pain in juvenile athletes should be a guide to slowing down.

Epidemiology

Incidence

The incidence increases with the intensity of competition.

Fig.
1. Little League elbow results from valgus strain, which may cause
tendinitis medially or osteochondritis laterally in the growing elbow.

Risk Factors

Throwing or serving sports in young children and adolescents (e.g., baseball, football, javelin, and tennis) are risk factors.

Genetics

No Mendelian inheritance pattern is known.

Etiology

Medial epicondylar fragmentation or avulsion
Delayed or accelerated growth of the medial epicondyle
Delayed closure of the medial epicondylar growth plate
Osteochondritis (irregular ossification) of the capitellum
Deformation and osteochondritis of the radial head
Olecranon apophysitis with or without delayed closure of the olecranon apophysis

Diagnosis

Signs and Symptoms

Most patients present with medial elbow
pain, although some have lateral pain (see later), with diminished
throwing distance and decreased throwing effectiveness.
- The patient may present with vague
  lateral elbow pain and swelling (capitellar osteonecrosis [Panner
  disease; ages 7–12 years]) versus osteochondritis dissecans of the
  capitellum (ages 13–16 years).
Pain is aggravated by throwing.
Examination shows point tenderness over the medial epicondyle, swelling, and a flexion contracture often >30°.
The injury most often involves the dominant elbow.
Nocturnal pain is uncommon.
Burning around the medial elbow
associated with paresthesias or dysesthesias in the ulnar digits
signifies ulnar nerve involvement.
Duration of symptoms can help to differentiate injuries such as UCL ruptures (acute) and medial epicondylitis (chronic).
- Late-presenting lateral symptoms include locking, catching, and severe pain.
Posterior abnormalities suggest involvement of the olecranon and surrounding soft tissues.

History

Obtain detailed frequency of athletic elbow use.

Physical Exam

Document the elbow ROM, including flexion, extension, pronation, and supination.
Look for an effusion, as signified by loss of the normal lateral soft-tissue recess.
Pinpoint the location of tenderness.
Perform a neurovascular examination of the extremity.
Observe the patient performing the causative motion.
Stability of the elbow to valgus stress with the elbow in 25° of flexion helps assess the collateral ligaments.

Tests

Imaging

Radiography:
- Plain radiographs (AP and lateral) are obtained to rule out fractures, loose bodies, or osteochondritis dissecans.
- Stress radiographs may be helpful.
Bone scan is useful to assess asymmetrical activity.
MRI may be useful in evaluating injury to cartilage, physis, tendons, muscles, and ligaments (2).

Pathological Findings

Weak physes in growing children make
injuries to this area (fracture or osteochondritis) common, whereas
young adults with fused physes tend to develop more soft-tissue
injuries.
The pathologic process of Panner disease and osteochondritis dissecans is unknown but thought to arise from repetitive trauma.
Osteochondritis dissecans may progress to loose bodies with painful locking.

Differential Diagnosis

Elbow fracture (supracondylar humerus, olecranon)
Ulnar nerve subluxation
Ulnar nerve entrapment or posterior interosseous nerve entrapment
Tendinitis of the medial or lateral elbow muscle origin
Loose bodies in the joint

P.233

Treatment

General Measures

Most injuries resolve with 4–6 weeks of rest.
With severe pain, a regimen of 1–2 weeks of splint immobilization is helpful, followed by active ROM exercises.
Loose bodies often require surgical removal.
Occasionally, large osteochondritis
dissecans fragments and avulsion fragments with >2 mm of
displacement require surgical fixation.
Activity should be resumed on a gradual, stepwise basis.
Stability of the elbow should be assessed before the patient returns to competitive throwing.
If symptoms resume with activity after 6
weeks of rest, additional investigation into causes should be
investigated (via CT, MRI).

Special Therapy

Physical Therapy

After 6–8 weeks of rest, when the patient
is asymptomatic and has pain-free ROM, begin elbow strengthening
exercises with a progressive throwing program.
The therapist or trainer may be effective
in supervising the patient’s return to sports more closely than the
physician is able to do.

Medication

NSAIDs are the drugs of choice.
Steroid injections rarely are indicated.

Surgery

Many of these conditions may be treated
arthroscopically, including pinning of osteochondritis dissecans
fragments, removal of loose bodies, and removal of osteophytes.
Occasionally, open reconstruction or repair of the UCL is necessary for avulsion injuries.

Follow-up

Prognosis

Overall, most patients do well with rest.
Occasionally, one may develop slight flexion contractures and valgus deformity of throwing arm, which is rarely symptomatic.

Complications

Rare: Panner disease may lead to late deformity and collapse of the capitellum articular surface (3).
Osteochondritis dissecans fragments may displace and become a loose body in the joint, requiring removal.
Epicondyle fractures may progress to a nonunion, usually asymptomatic.

Patient Monitoring

Patients with Panner disease should have follow-up radiographs every 3–4 months to assess healing of the capitellum.

References

1. Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med 2003;33:75–81.

2. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000;30:117–135.

3. Hang DW, Chao CM, Hang YS. A clinical and roentgenographic study of Little League elbow. Am J Sports Med 2004;32:79–84.

Miscellaneous

Codes

ICD9-CM

726.32 Little League elbow

Patient Teaching

Instruct the patient in proper throwing mechanics.
Recognize symptoms early.
Rest from throwing activities (6–8 weeks) to avoid additional injury.
Advise a gradual return to competitive sports when the patient is asymptomatic.
Recurrence of symptoms often requires longer rest followed by strengthening exercises.

FAQ

Q: If a preteen pitcher has Little League elbow, should he be counseled to switch positions?

A:
Recurrence is likely, and switching should be discussed as an option.
However if it is a 1st presentation, a cycle of rest and graduated
resumption of pitching may be successful in some cases.