Review Question - QID 214122

The patient in the vignette has clinical signs and symptoms of Little League elbow. Studies have shown that throwing greater than 80 pitches per game at this age places young pitchers at risk for developing this condition.

Little League elbow is comprised of a constellation of medial elbow injuries that include medial epicondyle stress fractures, ulnar collateral ligament (UCL) injuries, and flexor-pronator mass strains. These injuries are common in young pitchers due to repetitive valgus loading during the throwing motion which causes repetitive microtrauma to the immature skeleton leading to tension overload of the medial structures. Since the medial epicondyle apophysis does not fuse until age 16-18, young pitchers are more likely to get injuries to the apophysis than actual UCL injuries. Typical symptoms of this condition include medial elbow pain and decreased throwing velocity with or without valgus elbow instability. Treatment consists of active rest, a gradual return to activity with a focus on proper mechanics and core stability, and following safe adolescent pitching principles.

Kerut et al. discussed prevention strategies for common adolescent pitching injuries, most notably involving the UCL. They note that these injuries become evident in high school and college, but begin at the youth level. They cite that based on several studies, the USA Baseball Medical & Safety Advisory Committee has published guidelines for pitching that include limits on pitch count (80 pitches per start) as well as recommendations for the number of rest days between pitching. They also recommended the restriction of breaking balls prior to puberty, the importance of instruction for proper pitching mechanics, and at least three months of rest after a season.

Lyman et al. performed a prospective cohort study to evaluate the association between pitch counts, pitch types, and pitching mechanics and shoulder and elbow pain in young pitchers. They reviewed 467 young baseball pitchers (ages 9 to 14) for one season. They noted that 50% of the subjects experienced elbow or shoulder pain during the season. The curveball was associated with a 52% increased risk of shoulder pain and the slider was associated with an 86% increased risk of elbow pain. There was a significant association between the number of pitches thrown in a game and the rate of elbow pain and shoulder pain. The authors concluded that pitchers in this age group should avoid throwing breaking pitches (curveballs and sliders) because of the increased risk of elbow and shoulder pain.

Wilk et al. reviewed the rehabilitation following injury or surgery to the throwing elbow. They note that rehabilitation of the elbow, whether following injury or postsurgical, must follow a progressive and sequential order, building on the previous phase, to ensure that healing tissues are not compromised. They state that emphasis should be placed on restoring full motion, muscular strength, and neuromuscular control while gradually applying loads to healing tissue.

Bruce and Andrews performed an overview of the UCL injury in the throwing athlete. They note that repetitive valgus forces on the throwing elbow place significant stress on that joint leading to structural damage and injury to the UCL. They review injury prevention strategies in youth pitchers and discuss UCL reconstruction as a viable option to return the throwing athlete to competition.

Figure A is an AP radiograph of the elbow which reveals medial epicondyle apophysis widening consistent with Little League elbow.

Incorrect Answers:
Answer 1: Fastball speeds greater than 85 mph places the adolescent thrower at risk for Little League elbow.
Answer 2: Greater than 8 months of competitive pitching every year places the adolescent thrower at increased risk for Little League elbow.
Answer 4: Throwing breaking pitches (curveball, slider), not changeups, prior to puberty places the adolescent thrower at increased risk for Little League elbow.
Answer 5: Delayed ossification of medial epicondyle apophysis has not been shown to place the adolescent thrower at increased risk for Little League elbow.