Little League Elbow

Little League Elbow is a condition involving inflammation or injury to the growth plate on the inner side of the elbow, commonly caused by repetitive valgus stress, during overhead throwing motions in young athletes, particularly baseball players (typically affects children ages 9-14). It can also occur in weight lifters, gymnastics and some field events other athletic activities.

Conditions Which Are Collectively Termed Little League Elbow

• Medial epicondylar apophysitis
• Medial epicondyle avulsions
• Ulnar collateral ligament (UCL) sprains/tears
• Wrist flexor/pronator strains

Key Areas Affected in Little League Elbow

• Capitellum and radial head - repetitive stress can lead to osteochondritis dissecans
• Medial epicondyle - vulnerable to avulsion from valgus stress

 

Injury Mechanism

When pitching, the action of valgus stress (an outward bending force) places unique forces on the elbow. Medially, it causes stretching and strain on the inner structures of the elbow, while laterally, it compresses the outer side. This combination of forces can lead to two types of injuries:

1. Acute injuries like fractures, may happen from a single, high-impact pitch.
2. Repetitive stress injuries emerge from the cumulative effect of many pitches over time. These can gradually weaken and damage tissues without immediate signs of trauma.

For young athletes, there are additional concerns. Growth spurts can temporarily reduce flexibility at the joints while increasing muscle-tendon tightness. This combination makes the elbow more vulnerable to injury. Moreover, injuries in the growth plates can disrupt blood supply to certain areas, leading to a condition called osteonecrosis (bone tissue death), which may compromise joint health long-term.

 

Causes of Little League Elbow

• Repetitive throwing motions - especially from overuse in young athletes
• Improper throwing mechanics - leading to excessive stress on the elbow joint
• Frequent pitching - high volume of pitches or pitching without adequate rest
• Early specialization in baseball - focusing on pitching at a young age without cross-training
• Inadequate warm-up or conditioning - which may reduce flexibility and strength in the arm
• Throwing curveballs or sliders too early - which can increase strain on the elbow ligaments and growth plate

 

Signs and Symptoms of Little League Elbow

• Progressive medial elbow pain.
• Reduced throwing effectiveness and velocity.
• Tenderness is seen over medial epicondyle and pain occurs with resisted wrist flexion.
• Slight flexion contracture is noticed.
• Weak grip strength due to discomfort in the elbow.
• Locking or catching sensation.

 

Little League Elbow Diagnostic Questionnaire

 

Differential Diagnoses 

• Medial epicondylitis (Golfer's elbow)
• Ulnar collateral ligament (UCL) sprain
• Osteochondritis dissecans of the elbow
• Panner’s disease
• Olecranon stress fracture
• Flexor-pronator mass strain
• Ulnar neuritis

 

Physiotherapy Management of Little League Elbow

Physiotherapy management focuses on pain relief, reducing inflammation, restoring range of motion, improving strength and preventing recurrence.

Initial Rest and Activity Modification

• Instruct the patient to completely stop throwing and any other activities that exacerbate elbow pain.
• Substitute throwing with other non-impact activities (e.g., stationary biking) to maintain general fitness while protecting the elbow.

Pain Management

• Cryotherapy: Apply ice packs to the medial elbow for 15-20 minutes, 3-4 times per day, especially after activity.
• Compression and Elevation: Use compression sleeves or wraps to manage swelling, if present.
• NSAIDs (if recommended by a physician): Non-steroidal anti-inflammatory drugs may be suggested by a physician to manage pain.

Range of Motion Exercises

• Gentle Passive and Active ROM: Begin with pain-free elbow flexion and extension movements to maintain mobility without stressing the growth plate.
• Stretching: Include gentle wrist flexor and pronator stretching as tolerated to alleviate tension along the elbow.

Strengthening Exercises (Once Pain is Reduced)

• Isometric Exercises: 

Start with isometric exercises for the wrist flexors, extensors, and forearm muscles to build initial strength without joint movement.

• Progressive Resistance Training:

Wrist Flexion and Extension: Use light dumbbells or resistance bands to strengthen wrist flexors and extensors.

Forearm Pronation and Supination: Utilize resistance bands to strengthen the muscles involved in forearm rotation.

Elbow Flexion and Extension: Gradually introduce bicep curls and tricep extensions as pain allows.

Scapular and Shoulder Strengthening: Incorporate scapular stabilizing and shoulder rotator cuff exercises, such as rows, scapular retractions, and external rotations, to improve throwing mechanics and reduce stress on the elbow.

Neuromuscular Re-education and Proprioception

• Closed Kinetic Chain Exercises: Gradually introduce weight-bearing exercises, such as wall push-ups, to enhance joint stability.
• Proprioceptive Drills: Use wobble boards or stability balls under the hands to improve proprioception and control around the elbow and shoulder.

Throwing Mechanics and Technique Training

• Biomechanical Analysis: Assess and correct any improper throwing mechanics, focusing on shoulder and trunk movement to reduce stress on the elbow.
• Throwing Program: Implement a gradual, structured throwing program once the athlete is pain-free, starting with low-intensity, short-distance throws and slowly progressing to full-intensity pitching.

The athlete should be pain-free, have full range of motion, good strength in the shoulder and elbow, and demonstrate proper throwing mechanics before resuming competition. Continue to monitor symptoms during the return-to-sport phase and modify the throwing program if any discomfort or pain recurs.

 

Prevention of Little League Elbow

• Evaluate and improve pitching techniques.
• Limit the number of pitches to prevent overuse.
• Educate coaches, parents and athletes on Little League elbow risks.
• Start with warm-up and slight stretching before performing the activity.
• Gradually increase throw number, distance and intensity.
• Cease pitching if elbow or shoulder pain occurs, decrease throws afterward.
• If pain persists, advise complete rest and seek radiographic evaluation.
• Ensure full recovery in strength, range of motion and pain-free throwing.
• Implement preseason stretching and strengthening programs before competition.