Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Little League Elbow

Basics
Description
  • Little League elbow refers to a group of injuries about the elbow that arise in children and adolescents (ages 7-15 years) from repetitive throwing or use of a racquet or bat.
    • Younger patients (7-11 years old) in that group often have an injury of the physis, whereas older adolescents (15-19 years old) are subject to avulsion fractures or ligament tears.
  • These injuries also are referred to as osteochondroses, or disordered behavior of growing cartilage under load.
  • Classification:
    • Medial disease involves the MCL, the medial epicondyle, and the surrounding soft tissues.
    • Lateral disease involves the radial head, the capitellum, the lateral epicondyle, and surrounding soft tissues.
  • Synonym: Osteochondritis (or osteochondrosis) of the radial head or capitellum (Panner disease)
General Prevention
  • League guidelines on the frequency of pitching for juvenile players exist to minimize this disorder.
  • Elbow pain in juvenile athletes should be a guide to slowing down.
Epidemiology
Incidence
The incidence increases with the intensity of competition.
 
Risk Factors
Throwing or serving sports in young children and adolescents (e.g., baseball, football, javelin, and tennis) are risk factors.
 
Genetics
No Mendelian inheritance pattern is known.
 
Etiology
  • Medial epicondylar fragmentation or avulsion
  • Delayed or accelerated growth of the medial epicondyle
  • Delayed closure of the medial epicondylar growth plate
  • Osteochondritis (irregular ossification) of the capitellum
  • Deformation and osteochondritis of the radial head
  • Olecranon apophysitis with or without delayed closure of the olecranon apophysis
Diagnosis
Signs and Symptoms
  • Most patients present with medial elbow pain, although some have lateral pain (see later), with diminished throwing distance and decreased throwing effectiveness.
    • The patient may present with vague lateral elbow pain and swelling (capitellar osteonecrosis [Panner disease; ages 7-12 years]) versus osteochondritis dissecans of the capitellum (ages 13-16 years).
  • Pain is aggravated by throwing.
  • Examination shows point tenderness over the medial epicondyle, swelling, and a flexion contracture often >30°.
  • The injury most often involves the dominant elbow.
  • Nocturnal pain is uncommon.
  • Burning around the medial elbow associated with paresthesias or dysesthesias in the ulnar digits signifies ulnar nerve involvement.
  • Duration of symptoms can help to differentiate injuries such as UCL ruptures (acute) and medial epicondylitis (chronic).
    • Late-presenting lateral symptoms include locking, catching, and severe pain.
  • Posterior abnormalities suggest involvement of the olecranon and surrounding soft tissues.
History
Obtain detailed frequency of athletic elbow use.
 
Physical Exam
  • Document the elbow ROM, including flexion, extension, pronation, and supination.
  • Look for an effusion, as signified by loss of the normal lateral soft-tissue recess.
  • Pinpoint the location of tenderness.
  • Perform a neurovascular examination of the extremity.
  • Observe the patient performing the causative motion.
  • Stability of the elbow to valgus stress with the elbow in 25° of flexion helps assess the collateral ligaments.
Tests
Imaging
  • Radiography:
    • Plain radiographs (AP and lateral) are obtained to rule out fractures, loose bodies, or osteochondritis dissecans.
    • Stress radiographs may be helpful.
  • Bone scan is useful to assess asymmetrical activity.
  • MRI may be useful in evaluating injury to cartilage, physis, tendons, muscles, and ligaments.
Pathological Findings
  • Weak physes in growing children make injuries to this area (fracture or osteochondritis) common, whereas young adults with fused physes tend to develop more soft-tissue injuries.
  • The pathologic process of Panner disease and osteochondritis dissecans is unknown but thought to arise from repetitive trauma.
  • Osteochondritis dissecans may progress to loose bodies with painful locking.
Differential Diagnosis
  • Elbow fracture (supracondylar humerus, olecranon)
  • Ulnar nerve subluxation
  • Ulnar nerve entrapment or posterior interosseous nerve entrapment
  • Tendinitis of the medial or lateral elbow muscle origin
  • Loose bodies in the joint
Treatment
General Measures
  • Most injuries resolve with 4-6 weeks of rest.
  • With severe pain, a regimen of 1-2 weeks of splint immobilization is helpful, followed by active ROM exercises.
  • Loose bodies often require surgical removal.
  • Occasionally, large osteochondritis dissecans fragments and avulsion fragments with >2 mm of displacement require surgical fixation.
  • Activity should be resumed on a gradual, stepwise basis.
  • Stability of the elbow should be assessed before the patient returns to competitive throwing.
  • If symptoms resume with activity after 6 weeks of rest, additional investigation into causes should be investigated (via CT, MRI).
Special Therapy
Physical Therapy
  • After 6-8 weeks of rest, when the patient is asymptomatic and has pain-free ROM, begin elbow strengthening exercises with a progressive throwing program.
  • The therapist or trainer may be effective in supervising the patient’s return to sports more closely than the physician is able to do.
Medication
  • NSAIDs are the drugs of choice.
  • Steroid injections rarely are indicated.
Surgery
  • Many of these conditions may be treated arthroscopically, including pinning of osteochondritis dissecans fragments, removal of loose bodies, and removal of osteophytes.
  • Occasionally, open reconstruction or repair of the UCL is necessary for avulsion injuries.
Follow-up
Prognosis
  • Overall, most patients do well with rest.
  • Occasionally, one may develop slight flexion contractures and valgus deformity of throwing arm, which is rarely symptomatic.
Complications
  • Rare: Panner disease may lead to late deformity and collapse of the capitellum articular surface.
  • Osteochondritis dissecans fragments may displace and become a loose body in the joint, requiring removal.
  • Epicondyle fractures may progress to a nonunion, usually asymptomatic.
Patient Monitoring
Patients with Panner disease should have follow-up radiographs every 3-4 months to assess healing of the capitellum.
 
Miscellaneous
Codes
ICD9-CM
726.32 Little League elbow
 
Patient Teaching
  • Instruct the patient in proper throwing mechanics.
  • Recognize symptoms early.
  • Rest from throwing activities (6-8 weeks) to avoid additional injury.
  • Advise a gradual return to competitive sports when the patient is asymptomatic.
  • Recurrence of symptoms often requires longer rest followed by strengthening exercises.
FAQ
Q: If a preteen pitcher has Little League elbow, should he be counseled to switch positions?
A: Recurrence is likely, and switching should be discussed as an option. However if it is a 1st presentation, a cycle of rest and graduated resumption of pitching may be successful in some cases.

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