The Little League Elbow

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The Little League Elbow

• Thad Barkdull, MD
• Fellow, NCC Tri-Service Primary Care Sports
  Medicine Fellowship
• MAJ, MC, USA

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Goals

• Understand the history/mechanism of injury
• Develop a thorough differential diagnosis for a
  painful elbow
• Understand the findings to look for on physical
  exam
• Understand management and return to play criteria
• Know when to refer

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History

• 11 year old Hispanic male complains of right
  elbow pain for the past 2 weeks. He states that
  the pain is better with rest, but worse when he
  pitches with his little league baseball team. He
  has been pitching for 2 years now, and started in
  a new league about 1 month.

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Other questions about his history?
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Important History

• Hand dominance
• Other sports participation
• Past trauma/injury history
• Number of pitches/type of pitches
• How many teams
• Side arm or overhead pitcher

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DDx

• What can cause elbow pain in the young athlete?

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• UCL sprain/tear
• Medial epicondyle avulsion fracture
• C8-T1 radiculopathy
• Ulnar neuritis
• Osteochondrosis of medial epicondyle
• Medial epicondylitis (golfers elbow)
• Muscle strain/tear (flexor/pronator group)
• Fascial Compartment Syndrome
• Posteromedial olecranon osteophytosis
• Septic arthritis
• Tumor

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Physical Exam

• Appearance
• Palpation
• Range of Motion
• Provocative Tests

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• Slight swelling over medial epicondyle and
  tenderness to palpation. The UCL was also tender
  to palpation. There was some slight tenderness
  over the flexor bundle distally. There was no
  evidence of gross atrophy of the muscle.
• Strength was 5/5 with extension and supination,
  4/5 with pronation and flexion, limited by pain.
  Normal distal sensation, pulses. Negative
  tinels with percussion of ulnar groove.
• Pain with valgus stress at 20 degrees, no laxity
• No neck tenderness, crepitus or step off, no
  gross shoulder pain or instability, nor any
  wrist/hand pathology noted.

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• What studies will assist with this diagnosis?

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Final Diagnosis?
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Management

• Acute
• PRICEMM
• Encourage especially rest and ROM
• Rehabilitation
• Non-painful ROM
• ADLs without pain
• Usually 4-8 weeks
• Assess pitching mechanics with professional

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Return to Play

• When able to perform sport specific activity
  without pain
• Educate athlete, coaches, and family
• Sports activity no more than 9 months/year
• No more than about 100 pitches per game or in
  practice, including outside of practice
• No more than six innings per week 3 innings in a
  game no pitch next day 4 innings 3 days of
  rest No sliders or curve balls for the young
  athlete

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Maximum Pitch Counts--Game Competition (adapted from USA Baseball recommendations) Maximum Pitch Counts--Game Competition (adapted from USA Baseball recommendations) Maximum Pitch Counts--Game Competition (adapted from USA Baseball recommendations) Maximum Pitch Counts--Game Competition (adapted from USA Baseball recommendations) Maximum Pitch Counts--Game Competition (adapted from USA Baseball recommendations)
Age, y Pitch Approved to Throw Pitches per Game Pitches per Week Pitches per Season
810 Fastball 50 75 1000
11-12 Change-up 75 100 1000
13-14 Curve 75 125 1000
15-16 Slider, forkball, splitter, knuckleball 90 - -
17-18 Screwball 105 - -
 
 
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RED FLAGS

• Hot Joint
• Increased laxity
• Exam doesnt match history
• No improvement with appropriate, compliant
  therapy
• Fracture on radiograph

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Conclusion

• Ensure full history of arm usage in sport
• Usually good history, exam, radiographs are
  sufficient
• Consider further modalities only with failure to
  improve with rest (also consider compliance)
• EDUCATE EDUCATE EDUCATE