summary Little league elbow refers to a continuous spectrum of injuries to the medial side of the elbow seen in adolescent pitchers, which includes: medial epicondyle stress fractures, ulnar collateral ligament (UCL) injuries and flexor-pronator mass strains. Diagnosis is made clinically with tenderness over the medial elbow made worse with valgus stress and supplemented with MRI studies. Treament is a trial of rest, activity modification, decrease in innings pitched, and physical therapy. Epidemiology Demographics younger patients are more likely to have apophysitis or avulsion injuries, rather than UCL sprains Etiology Pathophysiology consists of 3 potential sites of injury medial epicondyle stress fractures ulnar collateral ligament (UCL) flexor-pronator mass strains due to repetitive valgus loading with throwing causing repetitive microtrauma to the immature skeleton causes tension overload of the medial structures Risk factors Greater than 80 pitches per game More than 8 months of competitive pitching per year Fastball speed > 85mph Continued pitching despite arm fatigue/pain Participating in showcases Presentation Symptoms elbow pain in throwing arm decreased throwing speed, accuracy, and distance Physical exam tenderness to palpation about medial elbow pain with valgus stress instability with valgus stress notes more severe involvement should be checked in varying degrees of elbow flexion to extension Imaging Radiographs recommended views AP/lateral elbow findings may show physeal widening may show fragmentation or avulsion of the medial epicondyle MRI will show increased edema of the medial epicondyle apophysis can be used to confirm UCL insufficiency Treatment Nonoperative rest, activity modifications, PT indication is the mainstay of treatment technique coach and parent education is critical to limit number of innings pitched per week use minimal immobilization to maintain elbow ROM Operative ORIF of medial epicondyle indication for medial epicondyle avulsion fractures UCL reconstruction indication for UCL disruption and insufficiency Technique Pediatric UCL reconstruction similar to adult treatment commonly using palmaris longus autograft Complications Ulnar nerve neuropathy Continued pain and instability Loss of motion Inability to return to same level of play