Little Leaguer's Elbow (Medial Apophysitis)
Robert G. Hosey
Brian Macy
BasicsDescription
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Classic definition: Valgus stress lesion of the medial epicondylar physis
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On a continuum with avulsion fracture of the medial epicondyle
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Now used as a catch-all phrase for elbow pain in a young athlete:
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Medial epicondylar fragmentation and avulsion
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Delayed or accelerated apophyseal growth of the medial epicondyle
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Delayed closure of the medial epicondylar growth plate
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Osteochondrosis and osteochondritis of the capitellum (Panner's disease)
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Deformation and osteochondritis of the radial head
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Hypertrophy of the ulna
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Olecranon apophysitis
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Epidemiology
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In a longitudinal study, ∼26% of 9–12-yr-old pitchers report “elbow pain” following a game.
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Of the symptomatic elbows, about 67% were referred to the medial aspect.
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In total, ∼1% of pitchers during a season saw a physician for “elbow pain,” and these were diagnosed with medial epicondylitis.
Risk Factors
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Position: Shows magnitude of stress (pitcher > catcher > infielder > outfielder)
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Activity level: Types of pitches, number of pitches, innings pitched, typical pitching rotation
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Increased age and weight
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Handedness: Occurs most commonly in the dominant arm, unless it is a traumatic event
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Family history of osteochondrosis
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Glenohumeral internal rotation deficit (GIRD)
Etiology
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There are 6 distinct secondary centers of ossification in the elbow.
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The medial epicondyle may arise from more than one ossific nucleus and is commonly the last epiphyseal center to fuse with the humeral shaft in the normal child; it may fuse as late as 17 yrs of age.
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The medial epicondyle is the site of attachment for the flexor muscle origins and the ulnar collateral ligament.
Commonly Associated Conditions
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Flexion contracture
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If avulsion fragment is incarcerated in the joint, it can severely damage the articular surface.
DiagnosisHistory
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Age: Important because of the different ages at which each growth center appears and/or closes
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Location: Most commonly, pain is located in the medial epicondyle; however, sometimes pain presents laterally or posteriorly.
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Duration (pain characteristics): The length of time that the athlete has had pain is usually an indirect measure of the severity of the problem. If the pain occurs during and after throwing as well as when the athlete is not throwing, it is an ominous sign.
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Radiation: If pain or numbness radiates into the last 2 fingers, consider ulnar nerve damage.
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Mechanism (acute vs chronic): Acute pain in the young athlete in the medial elbow is more consistent with avulsion fracture of the medial epicondyle.
Physical Exam
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Pain in medial elbow
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Pain accentuated during early and late cocking of throwing motion
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Decrease in control of pitches or throwing distances
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Bilateral comparison of the elbows
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Inspection: Note presence of swelling, muscle atrophy/hypertrophy, symmetry, carrying angle (normal = 5–10 degrees in males, 10–15 degrees in females); ecchymosis is indicative of an avulsion.
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Palpation: Medial/lateral epicondyles (point tenderness along medial epicondyle consistent with avulsion fracture), olecranon process, radial head, collateral ligaments, ulnar nerve
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Range of motion: Flexion/extension (flexion contracture >15 degrees consistent with avulsion fracture); supination/pronation usually normal; assess for ulnar collateral ligament stability with valgus stress at 20 degrees of flexion
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Evaluation of the shoulder to assess for scapular dyskinesia, GIRD, and rotator cuff strength
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Neurologic: Check sensation along the ulnar nerve distribution; check Tinel's sign at the cubital tunnel; check interosseous muscle strength in the hand.
Diagnostic Tests & Interpretation
Imaging
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Radiography is indicated if there is decreased range of motion, or there is a suspicion of an avulsion fracture.
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Anteroposterior/lateral views of the elbow
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Appearance of growth centers: CRITOE:
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Capitellum: Appears at 1–2 yrs of age
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Radial epiphysis (3–4 yrs)
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Inner epicondyle (medial epicondyle, 5–6 yrs)
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Trochlea (9–10 yrs)
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Outer epicondyle (lateral epicondyle >10 yrs)
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Obtain bilateral elbow views if needed for comparison.
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Assess for presence of anterior and especially posterior fat pads, which signify the presence of an effusion.
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Compare medial epicondylar ossification centers.
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Assess for displacement of epicondylar fragment.
P.361
Differential Diagnosis
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Medial epicondylitis
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Avulsion fracture
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Ulnar collateral ligament sprain/tear
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Ulnar nerve injury
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Osteochondritis dissecans (may have lateral pain)
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Avascular necrosis of the capitellum (may have lateral pain)
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Neoplasms
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Referred pain: Neck vs shoulder vs wrist
Treatment-
Long-term treatment:
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Pitch-count guidelines
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Acute treatment:
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Typically, 4–6 wks of rest
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Followed by progression of noncompetitive throwing program
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Ice and NSAIDs as needed
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Additional Treatment
Additional Therapies
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Treatment depends on the amount of displacement of the medial epicondylar physis.
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If fragment is minimally displaced (2–5 mm):
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Apply posterior splint until acute symptoms resolve (2–3 wks)
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Gradual active motion
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Radiologic healing by 6 wks; at this time start aggressive active motion
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When union is obvious, allow the patient to throw if pain-free
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Allow return to competitive play when there is normal range of motion/strength/endurance while throwing
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If fragment is displaced more than 5 mm:
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Open reduction and internal fixation
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2 cancellous screws to prevent rotation
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Allow early gradual active motion
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After 6 wks, aggressive rehabilitation program
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Ongoing CareClosed reduction is associated with pseudoarthrosis, causing pain and instability, as well as formation of double epicondylar epiphyses.
Additional Reading
Benjamin HJ, Briner WW. Little league elbow. Clin J Sport Med. 2005;15:37–40.
DaSilva MF, Williams JS, Fadale PD, et al. Pediatric throwing injuries about the elbow. Am J Orthop. 1998;27:90–96.
Klingele KE, Kocher MS. Little league elbow: valgus overload injury in the paediatric athlete. Sports Med. 2002;32:1005–1015.
Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. 2001;33:1803–1810.
Papavasiliou VA. Fracture-separation of the medial epicondylar epiphysis of the elbow joint. Clin Orthop Relat Res. 1982:172–174.
CodesICD9
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726.31 Medial epicondylitis
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732.6 Other juvenile osteochondrosis
Clinical Pearls
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In the adolescent, the type of pitch affects incidence because proper technique and muscle control have not yet been learned. Breaking pitches, such as the screwball, in the untrained adolescent pitcher will place more stress on the medial aspect of the elbow, increasing the likelihood of developing medial elbow pain.
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At present, most youth baseball leagues have rules that limit the number of innings per week and length of time between pitching appearances. In addition, specific pitch count recommendations have been published and been adopted by the Little League (see http://www.littleleague.org/Assets/forms/pubs/RR/Changes/BB/09.pdf).
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Best prevention is to follow established pitching guidelines set forth by Little League. An offseason conditioning and throwing program may also be helpful. If pain does begin to occur, the player should stop throwing and see a physician.