Little League Elbow

Chris Reed MPT, OCS, ATC
Agile Physical Therapy

With the major league teams beginning to play their first spring games here in March and little league teams all over the country being assembled, I thought this month we would cover a topic that is often kept quiet: Little League Elbow.

So what is Little League Elbow (LLE)? It is an injury to the growth plate at the distal end of the humerus, called the medial epicondylar apophysis. This is the area that the wrist flexor muscles and the forearm pronator muscles attach. The growth plate is stressed in sports that require throwing motions.

During the throwing motion, the elbow undergoes a valgus stress along the medial side resulting in traction being applied to the structures along the medial aspect of the elbow. When this motion is repeated over time, microtrauma to the medial elbow structures results. If not enough rest is allowed, then the microtrauma can result in medial epicondylar apophysitis, medial epicondylar fragmentation, or medial epicondylitis.

Wells and Bell review the four phases of the pitching motion and how breakdowns in certain phases can lead to the development of LLE. Young pitchers rush during the windup phase and decrease the efficiency of their lower extremities to generate force. The cocking phase has not been linked to the development of LLE. The acceleration phase is where most little leaguers breakdown. During this phase, there are high levels of valgus stress across the elbow. Often the little leaguer will “open up” too soon allowing the body to move ahead of the arm increasing the stress across the shoulder and the elbow. In the final phase, follow-through, the little leaguer often strides short of midline. This results in decreased pelvic rotation and the loss of momentum resulting in the pitcher throwing mainly with his arm.

Other factors that can lead to the development of LLE include the angle of the arm and the types of pitches thrown. It has been shown that there is increased stress across the elbow when a pitcher throws with a side-arm delivery as opposed to pitching with a three-quarter or vertical arm position. Throwing curve balls and other “breaking” pitches have been shown to place increased valgus stress across the medial elbow that increases the risk of developing LLE.

This condition is often found in boys between the ages of 10-15 years. It is most commonly associated with baseball pitchers, but may also be found in golfers, swimmers, and less commonly in tennis and other racquet sport players. Often the little leaguer will complain of pain around the medial part of the elbow, especially with the overhead throwing motion. Swelling along the medial part of the elbow is often associated with this injury as well. Pain with gripping or holding heavy objects may also be experienced.

Prevention is the best treatment for LLE. This is best accomplished during the preseason with a stretching and strengthening program of the elbow and forearm muscles. It is also beneficial to educate parents, coaches, and little leaguers themselves about the condition, proper pitching techniques, and the importance of keeping pitch counts.

There are several different pitching guidelines that are available:
1. Little League International has established optional pitching guidelines in 2006 that can be found at:
http://www.littleleague.org/media/Pitch_Count_Regulation_06.pdf

2. Dr. James Andrews has established pitching guidelines in 1996 that can be found at: http://www.toc.md/pitch.pdf

3. Finally, the American Sports Medicine Institute established pitching guidelines that can be found at: fpbaseball.org/PitchingGuidelines.doc

Once a little leaguer has developed LLE, the best initial treatment is rest and ice. The little leaguer should not be allowed to return to throwing (including during practice) until symptoms have resolved completely. Once the acute phase has resolved, a program of stretching and light strengthening for the forearm flexors and extensors should be initiated. Consultation with a Physical Therapist or Athletic Trainer can help to develop a program tailored to the child’s needs.

References:
1. Little League Elbow Syndrome. Available from URL: http://www.emedicine.com/SPORTS/topic62.htm (Accessed March 2007).
2. Little League Elbow. Available from URL:
http://healthgate.partners.org/browsing/browseContent.asp?
fileName=11703.xml&title=Little%20League%20Elbow (Accessed March 2007).
3. Little League Elbow. Available from URL:
http://www.columbuschildrens.org/GD/Templates/Pages/
Childrens/SportsMed/SportsMedLongContent.aspx?page=4229 (Accessed March 2007).
4. Wells MJ, Bell GW. Concerns on Little League Elbow. Journal of Athletic Training. 1995;30(3):249-53. Available from URL:
http://www.pubmedcentral.nih.gov/picrender.fcgi?
artid=1317870&blobtype=pdf (Accessed March 2007).