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Medial Epicondylar Apophysitis (Little League Elbow)

Little League elbow (medial epicondylar apophysitis) is a term used to describe an overuse injury often sustained by children and adolescent baseball players, usually those who spend a lot of time pitching. Excessive overhead throwing places too much strain on the growth plate of the medial epicondyle, which is a bony protuberance on the inner side of the elbow. The muscles of the forearm attach onto the medial epicondyle by way of tendons, as does one of the ligaments in the elbow that provides stability to the joint when throwing.

A growth plate (apophysis) is an area of supple, delicate cartilage found near each end of the long bones in a growing child. Growth plates determine the eventual length and shape of each long bone. During periods of growth, and particularly during an adolescent growth spurt, they are particularly vulnerable to damage as they are weaker than the surrounding ligaments and connective tissues. They are in fact the weakest part of the skeleton. Over time the cells in the apophysis harden, and by the time the child has stopped growing, the apophysis has been entirely replaced by solid bone.

Injuries to the growth plate are therefore unique to children and young people who have yet to finish growing.

When a ball is thrown overhead, tendons and ligaments pull on the growth plate in the medial epicondyle. Too much throwing without proper periods of rest between sessions can irritate and inflame the tendons and ligaments, tearing fibers. Small fragments of bone can be pulled away from the medial epicondyle. Small cracks can develop in the apophysis and sometimes, if the damage is severe enough, the apophysis may actually become detached from the humerus.

Although this is a common injury for adolescent baseball players, any young person who repetitively throws overhead is at risk. For example, water polo, football or volleyball players may also suffer Little League elbow.

Symptoms may develop if the rate of pitching has suddenly increased or the type of throw has changed, for example if curve balls or sliders have been introduced at too young an age.

  • Pain felt on the inner side of the elbow when throwing. The pain may appear suddenly or it may develop over a period of time
  • Possible difficulty straightening the elbow completely
  • Possible swelling with redness and warmth
  • Diminished ability to throw
  • Tenderness to the touch at the medial epicondyle
  • Possible locking of the elbow
Your doctor can usually diagnose Little League elbow by asking about the symptoms, type, and amount of participation in sporting activities, and any previous injuries to the elbow. The elbow would then be physically examined for range of motion, areas of tenderness, and stability of the joint.

X-rays will be taken to view the growth plates in the elbow. These can often appear normal, even when the apophysis has suffered some damage. X-ray pictures will show any other bone injury, such as a stress fracture. Very occasionally an MRI (magnetic resonance imaging) scan may be taken in order to see the growth plates in greater detail, or to assess the ligaments and tendons in the elbow.

It is important to treat this condition in order to avoid further complications.

The primary treatment for Little League elbow is to rest the elbow for at least four to six weeks, by not throwing anything at all. This will give the apophysis time to heal.

Crushed ice, placed in a bag and wrapped in a towel, can be applied to the injured area for as long as is comfortable, several times a day. This will help reduce any swelling.

NSAIDs (non-steroidal anti-inflammatory drugs) can be administered, according to instructions, for relief from inflammation and pain.

The elbow can be wrapped in a compression sleeve or elastic bandage. This will make the patient more comfortable.

When the period of rest is over and there is no pain, a specialized program of physical therapy can be started. This will probably include instruction on proper throwing technique, exercises to strengthen the body core, and stretching and strengthening exercises for the elbow.

A return to throwing and pitching will depend on the severity of the initial injury, but is normally possible within three to four months. The return should be gradual and ideally should be under the supervision of a sports physical therapist.

Surgery for Little League elbow is rarely necessary. Situations that might call for surgery are if a fragment of bone has broken away and is impeding elbow function, or a ligament needs to be reattached to the bone. Surgery would be performed arthroscopically, using narrow instruments inserted through small incisions around the elbow. A period of rehabilitation post-surgery would be necessary before a return to sports could be considered.

Do 10 repetitions for 1 set. Build up to 3 sets per day.
Flex, extend, and side-to-side:
Simply bend the wrist forwards and hold the stretch for 5 seconds. Then bend the wrist backwards and hold the stretch for 5 seconds. Move the wrist from side to side (as in a handshake) and hold at the furthest point at each side for 5 seconds.
Strengthening: Sit in a chair with your elbow resting on the arm of the chair or on a table, with your wrist hanging over the edge. Do the following exercises:
1. Hold a can in your hand with your palm down. Keeping your forearm on the table, slowly bend the wrist backwards towards you. Hold for 5 seconds.
2. Hold a can in your hand with your palm up. Keeping your forearm on the table, slowly bend the wrist towards you. Hold for 5 seconds.
3. Hold the can in your hand and slowly rotate your palm up and then down.
4. Stand for this exercise. Hold the can in your hand. With your arm straight down at your side and your thumb pointing forward, slowly raise the can by bending your elbow. Slowly lower the can.

As Little League elbow is an overuse condition, by restricting the amount of throwing, re-injury can be prevented. The accepted guideline is 75 pitches per week for children 8-10 years old, 100 for children 11-12, and 125 for 13-14 year olds.

Curve balls and sliders should not be thrown until a child is in high school, by which time the apophysis would have hardened into bone.

Warming up properly before pitching will decrease the chances of injury.

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