Working Diagnosis:
Chronic non-union of the right medial epicondyle in the setting of medial epicondyle apophysitis.

Treatment:
Our patient was prescribed an oral antiinflammatory to be taken once daily for the first two weeks of his rest period. After three weeks of rest from throwing, his elbow pain resolved and he was allowed to start a progressive throwing program.

Outcome:
Over the course of two weeks, the patient was then able to successfully complete the prescribed progressive throwing program at which time, his throwing velocity and accuracy returned to his pre-injury baseline. There was no recurrence of symptoms at the time of his six month follow up appointment.

Author's Comments:
This case provides an example of what can occur when little league elbow goes untreated and turns into a chronic condition. Little league elbow initially presents in the skeletally immature throwing athlete and is caused by repetitive valgus stress to the medial epicondyle apophysis. Diagnosis can be made upon x-ray imaging which reveals apophyseal widening with possible fragmentation or avulsion of the medial epicondyle. These findings are typically found in conjunction with clinical findings of focal tenderness to palpation of the medial epicondyle. Most patients are trialed on a combination of NSAIDs, ice, rest from throwing, physical therapy to optimize throwing mechanics, and a progressive throwing program prior to return to full play.

Editor's Comments:
With the increase in the demands of youth sports, there has been an increase in sports related over-use injuries. Specifically, the annual incidence of nine to twelve year old baseball players is 20-40% while 50-70% of adolescent baseball players experience elbow pain annually.

The elbow anatomy consists of a complex, diarthrodial joint constructed by the distal humerus, proximal ulna, and radial head. The secondary ossification centers at the elbow typically appear in the following order and can be remembered by the mnemonic CRITOE: capitellum by age 2, radial head by age 4, medial/internal epicondyle by age 6, the trochlea by age 7, olecranon by age 9 and the lateral/external epicondyle by age 10. These ossification centers slowly fuse by 14-15 in girls and 15-17 in boys.

Medial epicondyle apophysitis, or Little League Elbow, is common in the young thrower between six and fifteen years of age, however, most overhead sports can cause pain at the medial epicondyle, including tennis, volleyball, football, and javelin throwing. Medial epicondyle apophysitis is caused by repetitive valgus load of the elbow prior to closure of the apophysis. In the throwing athlete, athlete will likely have pain in the late cocking or acceleration phases due to the increase valgus force and load on the elbow. The medial epicondyle may appear widened as compared to the contralateral side on plain radiographs and as demonstrated in the case, may fail to close upon maturity. As the apophysis close, injuries to the ulnar collateral ligament increase.

Management of medial epicondyle apophysitis typically includes four to six weeks of no throwing or overhead activities, physical therapy, home exercises and once pain free a slow individualized throwing progression. Return to sport usually takes eight to twelve weeks depending on the severity of the injury.

Prevention should include taking time to rest and recover at least two to three months during a year by not participating in overhead sports, playing other non-overhead sports, or working on strength, athleticism, and mechanics in the off season. Avoidance of throwing if fatigued or in pain is wise as ignoring these can lead to prolonged recovery or worsening injury. Adhering to pitch counts, avoiding radar guns, and only playing on one team during a season can limit the stress to the elbow and shoulder. Utilizing a structured warm-up including focusing on the core, scapular, and rotator cuff muscles can further help prevent upper extremity injuries.

References:
Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med. 2005;15(1):37-40.
Greiwe RM, Saifi C, Ahmad CS. Pediatric sports elbow injuries. Clin Sports Med. 2010;29(4):677-703.

Looney AM, Rigor PD, Bodendorfer BM. Evaluation and management of elbow injuries in the adolescent overhead athlete. SAGE Open Med. 2021;9:20503121211003362

Marshall KW. Overuse upper extremity injuries in the skeletally immature patient: beyond Little League shoulder and elbow. Semin Musculoskelet Radiol. 2014;18(5):469-477.

Patel RM, Lynch TS, Amin NH, et al. The thrower's elbow. Orthop Clin North Am. 2014;45(3):355-376.

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