The amount of time playing sports and the higher levels of competition at younger ages are causing an increase in the number of sports injuries in kids. This includes little league elbow. It is overuse injury in young athletes who play overhead sports. Primarily it affects baseball players. To learn more about this condition, read on. Let’s start with anatomy!
The elbow
The elbow joint is where the humerus, ulna, and radius come together. The humerus is the upper arm bone and forms individual joints with the ulna and radius, which are the forearm bones. Movements of the elbow include flexion and extension. Flexion is when the forearm and upper arm come closer together (bending the elbow) and extension is when they are moved farther apart (straightening the elbow).
The upper parts of the radius and ulna will also form a joint, which allows for the movements of pronation and supination. Pronation is rotating the forearm, so the palm faces downward, and supination is forearm rotation where the palm faces upward.
The medial epicondyle
At the elbow, there are two big bony bumps on either side of the joint. These are the epicondyles at the end of the humerus. Epicondyles are large bony bumps where the tendons of muscles and ligaments attach. There is a lateral epicondyle and a medial epicondyle. The medial epicondyle is the one closest to the body when the arms are beside the body with the palms up. The lateral epicondyle will be farther from the body in this position.
The muscles that are used to extend the wrist are attached to the lateral epicondyle, while the muscles that are used to flex the wrist and pronate the forearm are attached to the medial epicondyle. The ulnar collateral ligament, also, attaches to the medial epicondyle. Ligaments are strong, connective tissue that attach bone to bone. They are important in stabilizing joints. The ulnar collateral ligament plays a vital role in stabilizing the medial area of the elbow.
The medial epicondyle apophysis
There is a growth plate at the medial epicondyle called an apophysis. An apophysis is an area of growth for a protuberance of bone on a larger bone. This protuberance of bone is not associated with a joint but is usually the site of a tendon or ligament attachment. The common tendon from the wrist flexors and pronators attaches to the medial epicondyle at the area of the apophysis.
The apophysis is the weakest area of this bone, tendon, muscle group. As the wrist flexors, pronator teres, and ulnar collateral ligament pull on the medial epicondyle over and over, it causes microvascular tears, swelling, inflammation, and pain at the apophysis. This apophysis does not close or ossify until the age of 14 to 15 which makes it more susceptible to injury.
What is little league elbow?
Little league elbow is an irritation of the apophysis at the medial epicondyle. It is also called medial epicondyle apophysitis. It is an overuse injury caused by an excessive and repetitive force on the medial epicondyle. This injury is almost always associated with sports. Sports that involve overhead throwing are the most likely to cause irritation at the medial epicondyle. These include:
- Tennis
- Baseball
- Softball
- Volleyball
- Football
- Swimming
Of course, baseball is the activity most commonly associated with medial epicondyle apophysitis. This is how little league elbow received its name.
Little league elbow occurs in kids ages 6-15. Elbow pain and irritation tend to increase with age. The prevalence of little league elbow peaks between the ages of 11-12. This condition is more likely to occur in males because so many males play baseball.
What are the symptoms of little league elbow?
There are many symptoms associated with little league elbow. These include:
- Pain in the medial elbow that is slowly getting worse
- Pain that increases with throwing
- Pain is worst at cocking phase
- Decreased endurance with throwing
- Tenderness at the medial elbow
- Stiffness at the elbow – especially in extension
- Difficulty or unable to completely straight the elbow
What are the risk factors for little league elbow?
There are many risk factors associated with little league elbow. These include:
- Participating in overhead throwing sports – primarily baseball
- Baseball pitcher
- High volume of pitches
- High baseball pitch velocity
- Pitching even when arm is fatigued
- Being on multiple teams
What could happen if my child keeps playing?
With continued playing the apophysis will continue to get more inflamed and can partially separate from the humerus. This can eventually lead to an acute avulsion fracture of the medial epicondyle. This is a complete separation of the medial epicondyle from the humerus. If the medial epicondyle becomes significantly displaced or the elbow becomes unstable, surgery could be required.
Who should my child see?
- Physical therapist – Physical therapy can be helpful in decreasing the pain and swelling at the elbow. Your child’s PT can determine any ROM or strength deficits and use manual therapy, as well as, stretching and strengthening exercises to address the deficits. A PT can also evaluate pitching form and guide the child in returning to sport safely.
- Pediatric orthopedist – If your child’s pain is severe or you suspect an avulsion fracture, then you will need to see a pediatric orthopedist. Imaging will be needed to determine the extent of the injury.
What can I do?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to decrease irritation at the apophysis. A 4-to-6-week rest of the elbow is usually recommended. If your child is not able to participate in your activity or sport, then they can supplement with non-irritating activities such as walking, running, or biking while the elbow is healing. After 6 weeks a gradual return to throwing program should begin with limitations on the number of pitches. Recurrence of this condition is very common and return to sport can be very slow. If pain does not resolve, switching to a different position or waiting until apophysis fuses around the age of 15 might be the best course of action.
- Ice – Ice can help decrease pain and symptoms at the elbow. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- Soft tissue mobilization – Soft tissue mobilization helps release the muscles around the elbow and decreases the tension on the medial epicondyle. Use a massage ball, lacrosse ball, tennis ball, or your own fingers to massage painful areas all around the elbow. Spend a good 3 to 5 minutes rolling. Do not roll so hard that you bruise the area, but it should be a pretty painful sensation. Roll out the area no more than a few times a week. See the video below.
- Elbow stretches – The elbow might have limited motion in certain directions. Typically, extension or straightening the elbow is the hardest to fully regain. However, depending on the person, then flexion, pronation, or supination might also be tight. See the video below in how to stretch the muscles around the elbow.
- Wrist flexion and extension stretching – You can also need to stretch out the wrist flexors and extensors. These muscles attach at or near the elbow and could be tight. See the video below.
- Strengthening the muscles around the elbow and wrist – Strengthening the muscles around the wrist and elbow are also important in being able to return to your activity. Decrease your resistance or number of repetitions if the pain is moderate to severe during the exercise or returns after the exercise. Using dumbbells or resistance bands can increase strength and difficulty. See the video below.
- Strengthen the scapular stabilizers– Elbow injuries tend to occur because of weakness of the scapular stabilizers. These are the stabilizing muscles of the shoulder that allow the arm to reach, lift, and hold without injury or irritation. Using loop resistance bands and resistance bands can increase strength and difficulty.
In review
- The elbow joint is where the humerus, ulna, and radius come together.
- Movements of the elbow include flexion and extension.
- The upper parts of the radius and ulna will also form a joint which allow for the movements of pronation and supination.
- Epicondyles are large bony bumps where the tendons of muscles and ligaments attach.
- There is a lateral epicondyle and a medial epicondyle.
- The epicondyles are attached to the sides of the lateral and medial condyles of the humerus.
- The muscles that are used to extend the wrist are attached to the lateral epicondyle while the muscles that are used to flex the wrist and pronate the forearm are attached to the medial epicondyle.
- The ulnar collateral ligament, also, attaches to the medial epicondyle.
- There is a growth plate at the medial epicondyle called an apophysis.
- Little league elbow is an irritation of the apophysis at the medial epicondyle.
- It is an overuse injury caused by an excessive and repetitive force on the medial epicondyle.
- Baseball is the activity most commonly associated with medial epicondyle apophysitis.
- It is more prevalent in boys with peak incidence at age 11-12.
- Symptoms include pain in the medial elbow that increases with throwing.
- Can lead to avulsion fracture of the medial epicondyle if not treated.
- Physical therapy can help treat this condition and aid in return to sport.
- A pediatric orthopedist would be needed if the condition is not responding to PT or a fracture is suspected.
- There are things that your child can do.
- Relative rest
- Ice
- Soft tissue mobilization
- Elbow stretches
- Wrist stretches
- Strengthening of the muscles around the elbow and wrist
- Scapular strengthening
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://pubmed.ncbi.nlm.nih.gov/34033354/
https://www.physio-pedia.com/Little_League_Elbow