By Maureen Mahoney PA-C, ATC

It’s that time of year again; when the snow is melting and the grass is getting green. Kids are starting their spring sports, including one of my all-time favorites: baseball. One common over use injury in kids who play baseball is called Little League elbow which presents itself as pain in the inside aspect of the elbow, caused by repetitive throwing. Most commonly seen in pitchers, it can also be seen in any player.

Little League elbow, also known as medial epicondylar apophysis, is the result of repetitive stress to the growth plate of the bone on the inside of the elbow. It occurs when the ligament that is attached to the inner side of the elbow begins to pull the growth plate away from the rest of the bone. This can disrupt normal bone growth, resulting in pain, swelling, and deformity. Because the growth plate is much weaker than the ligaments and muscles that attach to it, growing bones are easily injured. Throwing athletes are at particular risk of this injury before puberty when they are still growing and the growth plates have not yet fused.

Maureen Mahoney, PA-C, ATC
Maureen Mahoney, PA-C, ATC

Little League elbow occurs most often in athletes between the ages of 8 to15, but can occur up to age 17 if the athlete’s growth plates are still open and not fused. Doing things like throwing too hard and too often, increasing the number of pitches per week too quickly, or throwing too many curve balls or sliders at a young age can all increase the chances of sustaining this injury. Players who play high-volume throwing positions, such as pitcher, catcher, or shortstop, are at highest risk, but any throwing athlete is susceptible.

The pain of Little League elbow usually begins gradually and is not linked to a specific injury. The player may feel aching, sharp pain, or may have swelling around the bony knob on the inner side of the elbow. The pain may initially be felt only when throwing really hard, but then may progress to being felt with any throwing motion. The inside of the elbow may also start to hurt when gripping or carrying heavy things, and there may be a loss of elbow motion. Occasionally, a distinct painful pop in the elbow may be felt while throwing.

If the above symptoms occur and do not improve with rest and activity modification, it is important to have this pain further evaluated by a medical professional. Advanced stages of the injury may include small fractures to the growth plate, bone chips, or early osteoarthritis and bone spurs.
Little League elbow is commonly diagnosed by clinical evaluation through a medical provider. X-rays of the elbow in symptomatic athletes will frequently show nothing abnormal, but the athlete may still have pain. X-rays, however, can help determine if the growth plate is still open or if it is widened from stress. They can also show other bone concerns such as bone chips or early arthritis. If needed, an MRI may be done to look for further damage to the bone.

Treatment by a medical provider and recovery time is based on individual circumstances, such as the patient’s age and the severity of the injury, but most treatment plans involve a recovery time of six weeks to three months including a period of rest, physical therapy, and a plan for return to throwing.

During the resting period, the athlete should not pitch or do anything that causes elbow pain. Continuing to throw may lead to further injury and jeopardize the child’s ability to play in the future.

Individualized physical therapy programs are very useful for these young throwing athletes. Players can usually return to throwing when they are pain-free and have full range of motion and strength. A slow, controlled return to throwing program involves progressing the number and distance of throws as well as the amount of force used. Any plan to return to throwing should be discussed with a medical provider.

In rare cases, surgery may be needed to reattach the ligament to the bone or remove a loose bone fragment.

Year round physical fitness and conditioning keeps your athlete healthy and strong, and can help prevent Little League elbow. It is recommended that young throwing athletes should have at least 3 to 6 months of “active rest” where they do not throw, but are able to play other sports. This gives their arms time to rest and recover.

Other tips for preventing Little League elbow:

  • Have player’s warmup with throws that are less than maximum effort and having them pitch with less than maximum throws.
  • High demand throwing position players should rest from throwing for 24 to 48 hours after a practice or game.
  • Athletes should be encouraged to avoid pitching though pain and they should not be allowed to throw again until they are pain-free. Do not allow your child to pitch on consecutive days or pitching on multiple teams with overlapping seasons. Studies have shown a direct link between elbow pain, and the number of pitches as well as the number of games in which a young player throws. There are established guidelines for youth baseball, which include limiting the number of pitches and type of pitches thrown, according to age. Make sure your child is learning and practicing good throwing and pitching techniques. Poor body mechanics can lead to injury.
  • Have young athletes avoid throwing curve balls and sliders until after puberty, when the growth plate in the elbow is fused with the bone. These types of pitches appear to cause the most stress to the shoulder and elbow and so they are not recommended until the athlete is older.

Both coaches and parents should pay careful attention to young throwing athletes who complain of arm pain. Be sure to seek out medical care for arm pain that does not go away or that comes back every time a child resumes throwing. Coaches and parents should pay close attention to changes in a player’s participation or performance because young athletes may hide injuries due to concern about being removed from play, or they may try to minimize their symptoms so they can continue to play.

If your young athlete is having elbow pain, have it further evaluated. Contact your primary care provider or sports medicine professional.
Additional information may be found from the American Academy of Pediatrics, the American Academy of Orthopaedic Surgeons, The USA Baseball Medical & Safety Advisory Committee, and at www.littleleague.org.

Maureen Mahoney, PA-C, ATC is a certified physician assistant at BMH Orthopaedics & Sports Medicine, a department of Brattleboro Memorial Hospital.  Maureen Mahoney can be reached at 802-251-8611.

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