Young throwing athletes can experience elbow problems particularly with the common practice of year-round participation in competitive sports. In adults and young adults, repetitive throwing can lead to injury of the ulnar collateral ligament (also known as the medial collateral ligament) of the elbow, while the adolescent athlete typically injures the growth plate (medial apophysis) of the elbow where the ulnar collateral ligament attaches to the medial epicondyle. This growth plate injury in children is known as medial apophysitis of the elbow, commonly referred to as “Little Leaguer’s elbow.” Another less common condition of overuse that can affect young throwers typically between the ages of 10 to 15 years old is osteochondritis dissecans, a condition that results from loss of blood supply to a focal area of bone.
The throwing motion produces a significant stress to the elbow joint. During the throwing arc of motion, a significant concentrated force occurs to the medial aspect of the elbow (the inner elbow) during peak acceleration of the throw. This stress to the ulnar collateral ligament of the elbow on a repetitive basis can eventually exceed the strength of the ligament resulting in small tears, attenuation, or rupture which prevents one’s ability to throw at the highest level of competition. For the adolescent who is still growing, the weakest point is the growth plate of the medial epicondyle, the part of the bone which anchors the attachment of the ulnar collateral ligament and forearm flexor muscles. With repetitive throwing, the excessive pull of the medial collateral ligament and forearm muscles on this growth plate can cause an inflammatory reaction (apophysitis) or stress fracture. As an extreme example of injury, a medial epicondyle fracture with separation of the growth plate from the bone can result from a more substantial force produced such as pitching a fastball.
Osteochondritis dissecans of the elbow can also occur from the repetitive stress of throwing. The cause of osteochondritis dissecans is not entirely understood but is believed to result from a loss of blood flow to an area of bone due to repetitive compression forces within the joint. During the throwing arc of motion, compressive forces occur on the outer aspect of the elbow (away from the body) while traction or pulling forces occur along the ulnar collateral ligament and inner aspect of the elbow. As the immature bones of the outer elbow (radial head and capitellum) repetitively impact together, fragmentation of the bone and cartilage within the joint can occur. Essentially, a ”pot hole” occurs within the joint which can lead to a permanent defect and damage to the joint.
The most common complaint associated with throwing injuries of the elbow is pain. ”Little Leaguer’s elbow” causes pain on the inside aspect of the elbow and osteochondritis dissecans typically on the outer aspect of the elbow. However, chronic injury to the outer aspect of the elbow can coincide with long standing weakening or attenuation of the ulnar collateral ligament causing pain on both the inner and outer elbow. Pain may vary in severity and may depend on activities performed, but pain does occur with any attempted throwing. Additional symptoms can include reduced elbow range of motion, intermittent locking of the elbow, and numbness and tingling into the hand, particularly the ring and small fingers if the ulnar nerve along the inner elbow (”the funny bone” nerve) becomes secondarily irritated.
Initial treatment, particularly in children, focuses on nonsurgical protocols. If a throwing injury to the elbow is left untreated and throwing continues, major complications can result and possibly jeopardize a child’s ability to return to throwing sports. Complete rest is always recommended if any pain occurs with throwing. All throwing should STOP until symptoms have resolved. If symptoms are persistent after a few days from the initial event or occurs again when throwing resumes, all throwing should be STOPPED again. Evaluation by a doctor specializing in elbow or sports injuries should be obtained to initiate treatment. Typically an x-ray of the elbow is obtained to assess the growth plates and the bone supporting cartilage. An MRI of the elbow, particularly if x-rays are normal, may be obtained to better assess for stress reactions of the growth plates, injuries to the ligaments, or possible areas of loss of vascular flow to the bone supporting cartilage.
Depending on the type of injury identified, initial treatment typically involves rest and stretching. The timeline for return to throwing or competitive sports may vary for each individual and will be determined based on the degree of injury and response to initial treatment. Later treatment in the recovery process typically includes a strengthening program, continued stretching, and refining one’s throwing technique if necessary. Most importantly, patient education emphasizing general guidelines for throwing and preventive measures is discussed.
Surgery may be necessary for the extreme or more significant injuries such as fracture of the medial epicondyle (see below), complete rupture of the ulnar collateral ligament in older adolescents or young adults, or for the treatment of advanced osteochondritis dissecans.
Dr. Katz specializes in the treatment of sport related injuries to the elbow and has been involved with youth sports. Have trust in Dr. Katz to diagnose your problem and to help choose the best course of treatment.