Why Little Leaguer's elbow?
The elbow is the most frequently injured area of the body in children and adolescents who play baseball. Throwing a baseball over and over can lead to chronic (long-standing) elbow pain, changes to the elbow joint, and instability in the elbow. Doctors describe this type of injury as "Little Leaguer's elbow."

Anatomy and causes of injury
The ends of three bones - the ulna, radius, and humerus - meet to form the elbow joint (Fig. 1). In children, the bone ends have areas called physes (growth plates) where the bone grows (Fig. 2). Throwing a baseball over and over can stress these growth plates and lead to injury in improperly conditioned elbows. The biggest risk factor for injury is a misguided training regimen - too much, too soon.

What is the most common injury?
A stress fracture (crack in bone caused by overexertion) of the end of the humerus (upper arm bone) is the most common injury. When a youngster repetitively throws a ball, the ligaments (tissues connecting bones) and tendons (tissues connecting muscle to bone) put tension on this bone end. Over time, this tension causes inflammation of the growth plates and, ultimately, a stress fracture (Click here for Figure).

This fracture often causes activity-related pain on the outer side of the elbow, tenderness over the affected portion, and diminished pitching effectiveness. The symptoms usually disappear after resting the elbow for two to three weeks. If the symptoms do not end with rest or if the stress fracture is displaced significantly, the young athlete may need surgery.

Cartilage injuries
Over time, repetitively throwing a ball may injure the circulation at the cartilage (tissue that covers and protects the bone ends). The cartilage is fragmented, and small pieces of tissue may become loose in the joint. Symptoms usually include acute (recent), activity-related pain; tenderness in the outer portion of the elbow; and decreased elbow motion. Loose tissue may cause a sensation of catching in the joint.
To treat these disorders, the child first must rest the elbow until the symptoms subside. Next, he or she does exercises to improve elbow motion, eventually participating in a supervised throwing program. If this treatment fails to relieve symptoms or if loose tissue continues to catch in the joint, the injured child may need surgery.

Forearm injuries
As the triceps muscles pull across the elbow, they can put stress on the back of the joint. Repetitive stress can cause inflammation of the end of the ulna (forearm bone) and stress fractures. These disorders cause mild pain and tenderness in the back of the elbow. Often, the symptoms go away with rest, the use of ice and nonsteroidal anti-inflammatory medications (such as ibuprofen), and participation in a carefully monitored throwing program. If the child has a fracture that does not heal, he or she may need to have surgery.

What can we do to prevent this disorder?
Parents and coaches must work with children and adolescents to prevent Little Leaguer's elbow. Little League Baseball, Inc. limits pitching to six innings per week, with mandatory rest periods between the player's pitching appearances. In addition to limiting throwing, prevention can include assessing the way the young athlete throws the ball and initiating an appropriate, gradually increasing, pre-season throwing program. Ultimately, education is the key to prevention. Players, parents, and coaches need to learn about the potential hazards of throwing injuries and excessive pitching. Through education, adults can help children and adolescents have fun and avoid injury.

Luis Miranda, M.D.
Columbus, Georgia