Shoulder and Elbow cases little league elbow

A 9-year-old, baseball pitcher presents to the office with 4 weeks of elbow pain of his throwing arm. He denies locking or catching symptoms. Examination reveals tenderness to palpation about the medial elbow, normal range of motion, and no instability with moving valgus stress. Radiographs are normal.

What is the most likely underlying pathology in this condition?

1. Microtraumatic vascular insufficiency of the capitellum

2. Medial epicondylar apophysitis

3. Idiopathic osteochondrosis of the capitellum

4. Ulnar collateral ligament disruption

5. Olecranon apophysitis and osteochondrosis

 

Discussion

The correct answer is (B). This patient has little league elbow which results from

repetitive valgus stress in skeletally immature athletes. In this condition, chronic traction from the flexor-pronator mass leads to medial epicondylar apophysitis. Injuries in this age group result from medial tensile or lateral compressive overload. Osteochondritis dissecans (Answer A) usually affects adolescents older than age 13 years, and typically manifests as pain in the lateral compartment. Likewise, Panner’s disease (Answer C) also affects the capitellum and presents with lateral pain. Ulnar collateral ligament injuries are uncommon in skeletally immature athletes. Posterior compartment injuries (Answer E) are also uncommon and typically present with pain on terminal extension.

What is the most appropriate initial management for the patient in the question above?

1. Epicondylar debridement

2. Open reduction internal fixation

3. Rest, cessation of throwing activities

4. MRI

5. Corticosteroid injection

 

Discussion

The correct answer is (C). Conservative management is the mainstay of initial treatment for little league elbow. This consists of 2 to 4 weeks of rest and oral anti-inflammatories, followed by focused stretching and strengthening exercises. Athletes may return to throwing at 6 weeks if symptom free. Symptoms may persist after inadequate periods of rest and immobilization. Surgery, MRI, or injections are not routinely warranted as the first line of treatment in this condition.

Which of the following is not a risk factor for developing arm pain in young pitchers?

1. High number of innings pitched

2. High number of pitches per game

3. Staying in games after pitching, at other positions besides pitcher or catcher

4. Pitching with arm fatigue

5. Taller, heavier athletes

 

Discussion

The correct answer is (C). Multiple studies have looked at risk factors for shoulder and elbow injuries among adolescent pitchers. The 10-year-cumulative risk for an

adolescent pitcher developing a serious injury is 5%. Studies have consistently found that arm overuse is a risk factor for joint injuries, and preventative strategies have focused on limiting pitch counts and avoiding pitching with arm fatigue. Taller, heavier athletes appear to be at higher risk as well as pitchers who throw with greater velocity. Inconsistent reports have been published regarding the link between breaking pitches and arm injury. Data seems to indicate that pitchers may remain in games and play other positions beside catcher without significantly increased risk for shoulder or elbow injury.

What is the most common radiographic finding with little league elbow?

1. Fragmentation and separation of the capitellum

2. Olecranon osteophytes

3. Loose body

4. Medial epicondyle fracture

5. Fragmentation and separation of the medial epicondyle

 

Discussion

The correct answer is (E). Fragmentation and separation of the capitellum can be seen with osteochondritis dissecans or Panner’s disease, with the distinguishing factor being the amount of capitellar involvement. Osteochondritis dissecans involves a focal articular defect, whereas Panner’s disease involves the entire capitellum. Olecranon osteophytes are encountered with valgus extension overload. Loose bodies may be seen in later stages of osteochondritis dissecans. Medial epicondyle avulsion fracture is a rare cause of acute elbow pain in skeletally immature athletes and is treated according to amount of displacement. Fragmentation and separation of the medial epicondyle is the characteristic radiographic finding of little league elbow (see Fig. 2–118). Previous studies have found separation or widening of the physis in over 50% of players while fragmentation occurred in roughly 20%.

 

 

 

Figure 2–118 Medial epicondylar separation seen in little league elbow.

 

Objectives: Did you learn...?

 

 

Recognize chronic overuse injuries in adolescent athletes? Manage a patient with little league elbow?

 

Counsel pediatric athletes on risk factors for arm injury?