Working Diagnosis:
Little League Elbow Syndrome

Treatment:
Discussion was had with the patient and his mother about his diagnosis of Little League Elbow Syndrome and the nature of the treatment course. Patient underwent conservative treatment course including ice, NSAIDs, avoiding overhead throwing for 4 weeks while working with physical therapy on range of motion. Specifically physical therapy focused on improving his internal rotation deficit.

Outcome:
At subsequent follow-up 4 weeks later, the patient had improved internal rotation and no residual medial elbow symptoms. Repeat x-rays showed interval narrowing of previously widened medial epicondylar apophysis. Case Photo #3 He was then started on a 4 week return to throwing protocol and recommendations about pitch count were provided. Patient has done well without recurrence of symptoms.

Author's Comments:
Little League Elbow Syndrome is a common issue among overhead throwing athletes, between the ages of 9 and 15. It is presenting earlier in a child's life due to earlier sports specialization and increased prevalence of year-round leagues. It is defined as an apophysitis of the medial epicondylar growth plate due to a valgus overload (1). In skeletally immature athletes, traction from the thick anterior band of the UCL causes increased stress on the medial epicondylar apophysis. In severe cases, medial epicondylar fragmentation and avulsion fracture may occur (2). A study of 298 pitchers conducted by Lyman et al. demonstrated elbow pain was prevalent in 25.5% of the pitchers and more than 68% was on the medial side (4).

Glenohumeral Internal Rotation Deficit (GIRD) is loss of internal rotation of the throwing shoulder compared to the non-throwing shoulder (6). GIRD is defined as a difference of 20 degrees of internal rotation between the throwing and non-throwing arm (3,5). GIRD can be caused from posteroinferior capsular contracture, repetitive anterior capsule stretching, and adaptation from humeral retroversion (6). GIRD is commonly associated with excessive external rotation, but has been found to occur prior to the development of increased external rotation (5,6). Changes of ROM occur frequently in the pediatric population due to the adaptions of the immature skeletal system of these athletes in response to high torques and forces (3). Tajika et al. conducted a study which demonstrated that internal rotation differences was one of the risk factors associated with elbow injuries detected by ultrasound including osteochondritis dissecans and medial epicondylar fragmentation (6). An externally rotated shoulder places increased tension on the UCL and compresses the radiocapitellar joint, and with repetitive overuse and movement patterns can lead to injury (3). This is an important reminder that elbow pain in youth sports is often more greatly related to shoulder biomechanics that true elbow pathology.

In evaluation of pediatric elbow pain when growth plates are still open, there is benefit in obtaining x-rays from both the affected and unaffected sides and comparing the apophyseal space. Widening of the medial epicondyle apophysis greater than 2mm suggests underlying pathology, and widening of 3-5mm warrants surgical consultation for possible surgical intervention (1). MRI is often never indicated unless there is not resolution of symptoms with rest, or inability to advance through return to throwing protocol. If an MRI was obtained, widening of the physics with increased T2 fluid signals would be appreciated.

Because of the high incidence of medial elbow pain in pediatric pitchers with the research supporting it is related to overuse and pitch types, the USA Baseball Medical and Safety Advisory Committee has produced guidelines regarding pitching volume and age at which certain pitches should be learned (1). Although these recommendations exist, a study conducted with Japanese Little League Baseball found no correlation between elbow pain and coach's knowledge and compliance with these recommendations (7). Management of Little League Elbow involves complete rest from pitching for 4-6 weeks along with adjunctive therapies of ice and NSAIDs. After the initial period of rest, athletes should follow a gradual return to play pitching protocol over 6-8 weeks. If an athlete has a return of symptoms during this time, they should cease all pitching activities for 2-3 days then continue protocol (1).

Editor's Comments:
When reviewing pediatric elbow x-rays with concerns for apophysitis it is important to recall the order of elbow ossification centers. The Capitellum will ossify when the patient is 1-2 years old, the Radial head during years 2-4, Medial (Inner) epicondyle during years 4-6, Trochlea during years 8-11, Olecranon during years 9-11, and finally the Lateral (External) epicondyle during years 10-11. A common mnemonic is "CRITOE" using the first letter of each ossification center and the years 1, 3, 4, 7, 9, and 11 per region.

References:
1. Benjamin HJ, Briner WW. Little league elbow. Clin J Sport Med. Jan 2005;15(1):37-40. doi:10.1097/00042752-200501000-00008
2. Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg. Apr 2012;20(4):223-32. doi:10.5435/JAAOS-20-04-223
3. Keller RA, De Giacomo AF, Neumann JA, Limpisvasti O, T-bone JE. Glenohumeral Internal Rotation Deficit and Risk of Upper Extremity Injury in Overhead Athletes: A Meta-Analysis and Systematic Review. Sports Health. 2018 Mar/Apr 2018;10(2):125-132. doi:10.1177/1941738118756577
4. Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. Nov 2001;33(11):1803-10. doi:10.1097/00005768-200111000-00002
5. Nakamizo H, Nakamura Y, Nobuhara K, Yamamoto T. Loss of glenohumeral internal rotation in little league pitchers: a biomechanical study. J Should Elbow Surg. 2008 Sep-Oct 2008;17(5):795-801. doi:10.1016/j.jse.2008.02.013
6. Tajika T, Kobayashi T, Yamamoto A, et al. A clinical and ultrasonographic study of risk factors for elbow injury in young baseball players. J Orthop Surg (Hong Kong). 04 2016;24(1):45-50. doi:10.1177/230949901602400112
7. Yukutake T, Yamada M, Aoyama T. A survey examining the correlations between Japanese little league baseball coaches' knowledge of and compliance with pitch count recommendations and player elbow pain. Sports Health. May 2013;5(3):239-43. doi:10.1177/1941738113480341

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