Elbow Injuries in Young Throwers

With the increasing participation and competitive level of today’s youth sports, more adolescent and pediatric patients are being evaluated and treated for a variety of elbow injuries. Each year over two million children participate in Little League activities. Previous surveys have shown elbow pain occurs in up to 20% of all little league throwers and a more recent study found a 26% frequency of elbow pain in 9-12 year-old baseball players.

Most of this pain is due to overuse. The most common elbow injury in young baseball players is medial epicondyle apophysitis, better known as “little league elbow.” This is an overuse injury to one of the growth plates on the inside of the elbow. While it is most frequently seen in baseball pitchers and throwers it can also occur in softball, tennis, golf or any other sport that puts significant stress on the elbow.

This type of injury occurs in young athletes because their growth plates (apophyses) are weaker than the muscles that attach to them. The stress placed on the growth plates from repetitive throwing can cause them to become inflamed and produce pain and swelling. If the child continues to throw through pain the growth plate may even begin to separate from the rest of the bone.

Along with pain, throwers often complain of decreased ability to throw as hard or as far in comparison to pre-injury levels. They may have pain with batting and even daily activities outside of sports. Swelling and loss of elbow motion may occur. Any child who experiences such symptoms should immediately be removed from sports activity and evaluated by a pediatric specialist. X-rays or other imaging studies may be taken to help assess the extent of damage to the injured joint. With mild injuries, non-surgical treatment is appropriate. This usually entails rest from throwing (and sometimes other activities), rehabilitation exercises to improve strength and flexibility and a gradual return to throwing as tolerated. This process typically takes at least 4-6 weeks. When significant displacement of the growth plate occurs, surgery may be needed to ensure proper positioning of the detached cartilage. In surgery, the detached fragment is reattached with pins, screws, or suture stitches. Throwing is often prohibited for six months after surgery.

Another common injury in young throwers is osteochondritis dissecans (OCD) which is the leading cause of permanent elbow disability in adolescent athletes.OCD is an erosion of cartilage and underlying bone in part of a joint. Over time, OCD may lead to bone chips in the joint (so-called “loose bodies”). OCD produces a gradual onset of pain usually on the outer aspect of the elbow, which is often worse during the cocking and early acceleration phase of throwing. Swelling, joint locking or stiffness are late (and more concerning) findings. X-rays and MRIs are frequently ordered by the treating physician to assess the joint surface and extent of damage. In children, prolonged rest (> 6 months) sometimes allows healing of the damaged bone. Cases that do not respond to rest or those in which loose fragments are present typically require surgery.

Acute fractures and dislocations within the elbow joint are seen less commonly and considered orthopedic emergencies. Swelling and disruption of the elbow structures can damage one or more of the major nerves in the elbow joint which control the forearm, wrist, and hand. Even partial damage to the blood supply can lead to a very serious condition called “compartment syndrome.” Failure to recognize this condition can lead to permanent loss of function.

As throwers reach their late teens and their growth plates close they are at higher risk of suffering from tendonitis and ligament injuries.These injuries can often be treated with rest and rehabilitation. Sometimes, as with certain tears of the ulnar collateral ligament (UCL), surgery may be necessary which can keep an athlete out of throwing for up to a year.

The key treatment of most elbow injuries is prevention.This responsibility is widespread, involving the team physician, coach, athletic trainer, parents and officials. Emphasis must be placed at an early age on preseason conditioning, proper throwing mechanics and proper warm up exercises. The main culprit of pediatric elbow injuries is simply allowing children to throw too much. Because of this, most youth leagues have pitch count rules in place. Complete pitch count guidelines should take into account the age of the thrower and include limits on the number of pitches that should be made during each game as well as the maximum number of pitches that should be thrown in a week, during the entire season and even throughout the year. Adhering to pitch count guidelines is critical for the longevity of a pitcher’s arm.

Consult your primary care physician for more serious injuries that do not respond to basic first aid. As an added resource, the staff at Nationwide Children’s Hospital Sports Medicine is available to diagnose and treat sports-related injuries for youth or adolescent athletes. Services are now available in multiple locations. To make an appointment, call (614) 355-6000 or request an appointment online.

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