Little League Elbow
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Definition/Description[edit|edit source]
Little league elbow is a term used to describe lesions in the medial aspect of the elbow in preadolescent and adolescent baseball pitchers.[1]Most commonly seen in children under the age of 10. The phenomenon is correlated to chronic forces of valgus overload produced during the early and late cocking phases of throwing. This valgus force places tension on the medial structures (medial epicondyle, medial epicondylar apophysis, medial collateral ligament) and compression of the lateral structures (radial head, capitellum). Little league elbow encompasses delayed or accelerated growth of the medial epicondyle, medial epicondlyar fragmentation and medial epicondylitis. The type of injury pattern depends on the stage of the developing elbow.
Epidemiology/Etiology[edit|edit source]
Over the past 20-30 years there has been an increase sport related injuries; 30 million school aged children participate in sports in the US. Across all ages, the peak incidence of emergency department visits for sport-related injures occurs at ages 5-14 years and tapers gradually with age.[2]Each year over 2 million children participate in little league. In 1976, baseball leagues based in Houston, TX and Eugene, OR reported symptomatic elbow pain in 17-20% of all little league throwers. A more recent study found a 26% frequency of elbow pain in 9-12 year old baseball players.[3]
Characteristics/Clinical Presentation[edit|edit source]
Little League Elbow refers to elbow pain and encompasses different anatomical and clinical presentations. The term “Little League Elbow” is meant to include prevention and includes the physician, coach, trainer, parents, and officials. Proper throwing mechanics and adherence to pitch counts should be emphasized at a young age.[1]
Most Common Presentation[edit|edit source]
Medial sided injuries
Related to valgus overload in early and late cocking phases of throwing
Presentation depends on age
• Younger Children: apophysitis
• Older Children: epicondylar avulsion fracture
• Not common to see ligamentous or flexor/pronator injuries in children
Signs/Symptoms
• Medial sided elbow pain
• Decreased throwing speed or distance
• Point tenderness
• Effusion
• Flexion contracture (noted up to 15 degrees)
• Widening and/or fragmentation of apophysis on radiographs
Other Presentations[edit|edit source]
Lateral sided injuries
Late cocking and early acceleration phases of throwing produces compressive forces.
Deceleration during follow-through produces shear forces on the radiohumeral joint.
Examples: Panner's disease, OCD of the capitellum or radial head.
Signs/Symtoms of Panner's disease:
• Self-limiting
• Dull, activity-related pain in lateral elbwo
• Minimal effusion
• Flexion contracture
• Fragmentation of capitellar epiphysis on radiograph
Signs/Symtoms of OCD:
• Insidious onset.
• Dull, activity-related pain in lateral elbow.
• Poorly localized pain.
• May develop into locking, decreased ROM, flexion contracture >15 degrees.
Posterior injuries
Acceleration and deceleration phases of throwing produces shearing forces.Uncommon in child athletes; more common in older children/adolescents. Injuries may include: olecranon apophysitis, posteriormedial impingement, avulsion fractures.
Signs/Symptoms:
• Widening of apophysis on radiograph.
• Pain in extension.
• Localized tenderness in posterior elbow.
(Use by permission from Barbara J. Hiller of MMMI)
Differential Diagnosis[edit|edit source]
为鉴别诊断应强调基础d on anatomy, radiographs, history/MOI, age, location of pain, and other factors such as position(s) played, number of throws per week and pitch types.[1][4]
Medial[edit|edit source]
Medial epicondyle
- apophysitis
- avulsion fracture
- fragmentation
- growth disturbance
- delayed ossification
- accelerated growth
Ulnar collateral ligament
Common flexor origin
Ulnar nerve neuritis
Radiculopathy of C8, T1
Lateral[edit|edit source]
Capitellum
- Osteochondrosis (Panner’s disease)—rare; usually age 8-11 y/o.
- Osteochondritis dissecans (OCD)—more common in 10-14 y/o.
- Traumatic osteochondral fracture.
Radial head
- OCD
- Deformation
Lateral extension overload
Extension origin
Posterior[edit|edit source]
Olecranon
- Apophysitis/osteochondrosis.
- Avulsion fracture/lack of apophyseal fusion.
- Posteromedial impingement/osteophytes.
Anterior[edit|edit source]
Flexion contracture/capsular contracture
Outcome Measures[edit|edit source]
Visual Analog Scale for Pain Assessment
NPRS (Numeric Pain Rating Scale)
Website with free PDF documents
Examination[edit|edit source]
During childhood, medial elbow pain is usually secondary to micro-injury at the apophysis or ossification center of the medial epicondyle. In contrast, valgus overload during adolescence more commonly produces complete or partial avulsion fractures of the medial epicondyle. Once the medial epicondyle fuses during young adulthood, injuries to the musculotendinous and/or ligamentous complex predominate.[1][5]
- Pain is the most common presenting complaint and the chronicity or duration of pain must be assessed. An acute onset of symptoms is more suggestive of an avulsion type injury, whereas longstanding pain may signal a chronic, overuse type phenomenon. Location of pain will lead the evaluating therapist through the appropriate differential diagnosis.
- Physical exam begins with theobservationof both elbows, assessing for overall alignment and carrying angle of the upper extremities. The presence of swelling, atrophy, or hypertrophy should be identified.
- Range of motionshould be tested and documented, comparing flexion, extension, pronation and supination to the contralateral, non-painful elbow.
- Palpationof all bony protuberances, including the medial epicondyle, the radiocapitellar joint and the posterior olecranon apophysis, may reveal tenderness and true pathology.
- Ligamentous stabilityis also evaluated, ideally testing the lateral ligamentous structures with a varus stress applied to an internally rotated, pronated arm, and medial structures via a valgus stress applied to an externally rotated, supinated arm with the elbow flexed ~25°. Moving valgus stress test should be provocative in these patients.
总体评价的脖子,侧应er and wrist is also important, as well as a complete neurological assessment, specifically the ulnar nerve.
Following a complete history and physical exam, routine radiographic evaluation in the form of anterioposterior, lateral and oblique views is indicated. As stated previously, contralateral elbow films are invaluable in differentiating true pathology from normal or slightly variable development. Stress radiographs may aid in the evaluation of underlying instability. Magnetic resonance imaging (MRI) is often indicated to evaluate the displacement of fractures, delineate the extent of OCD or identify the presence of loose bodies within the joint. MRI can also be diagnostic for medial collateral ligament avulsions or isolated disruptions. Rarely, ultrasound or a three-phase bone scan can be helpful to identify certain overuse injuries.[1] Anytime a young throwing athlete presents with medial elbow pain, it should result in a high suspicion of Little League Elbow. Early recognition and intervention are extremely important and can lead to better treatment outcomes and decrease the risk of permanent damage or persistent functional disability.[1]Because these types of injuries are most commonly age dependent, the medical management will ultimately depend on the underlying cause of the symptoms.[1] [7] Most researchers agree that medial epicondylar displaced fractures >5mm will require some type of surgical fixation.[6]Some advocate for operative treatment with displacement fractures >2mm, and others indicate surgical fixation if any instability is present, regardless of displacement, for fear that the athlete may not be able to return to full activities if conservative management results in only a fibrous union formation.[6] Early mobilization[12] Progressive strengthening[1][11] Rest Immediate motion Intermediate phase Advances phase Klingele K, Kocher m小联盟肘:外翻overload injury in the paediatric athlete. Sports Medicine [serial online]. December 2002;32(15):1005-1015. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 19, 2011 Little league elbow is the name used to describe a group of elbow problems related to the stress of throwing in young athletes. Throwing can cause medial symptoms as well as lateral and posterior symptoms. The medial symptoms are related to the repetitive valgus distraction forces on the medial elbow. Microtrauma from overuse or improper throwing mechanics can cause injury. The predominant risk factors for elbow injuries that require surgery in young baseball players during high school and college are regularly pitching with arm fatigue, competitively pitching for more than eight months a year, and averaging more than 80 pitches per appearance.[16]There continues to be controversy on whether surgical intervention actually has better long-term benefits over conservative management and when surgical intervention is necessary. Universally, the BEST treatment is prevention through patient education and/or early diagnosis with proper treatment.Medical Management[edit|edit source]
Conservative Management:Universally referred to as the first and most preferred treatment approach. Treatment commonly consists of complete rest from throwing activities for a minimum of 4-6 wks, ice, non-steroidal anti-inflammatory medication (NSAIDs), elbow extension brace if a flexion contracture is present, immobilization if symptoms are severe and referral for Physical Therapy.[4][6][7]
Surgical Intervention:It is rare that a young athlete should need surgery for Little League Elbow, and there continues to be controversy on whether surgical intervention is actually more beneficial than conservative management.
• Loose cartilaginous bodies
• Avulsion fractures
• Osteochondritis dissecans
• As a last resort when conservative treatment has not improved symptoms.
Retrospective Studies:In a 2001 retrospective review of 42 patients, Farsetti et al. concluded that conservative management of medial epicondyle fractures displaced >5mm had similar long-term results to those treated surgically after approximately 34 years post-op.[8]
In a 2009 retrospective study of 139 cases, Louahem et al. found surgical results to be excellent in 130 cases and good in 9 cases with union of the fracture and reports of the elbow being stable and pain-free after approximately 3.9 years.[9]Physical Therapy Management[edit|edit source]
Throughout Recovery[10][edit|edit source]
Medial Epicondyle Apophysitis[edit|edit source]
Ulnar Collateral Ligament[12][edit|edit source]
Return to Throwing:[edit|edit source]
Prevention:[edit|edit source]
Key Research[edit|edit source]
Clinical Bottom Line[edit|edit source]
References[edit|edit source]