immature (growing) athletes are susceptible to unique elbow injuries that
occur as a result of repetitive throwing. These pediatric elbow injuries
are common and are often caused by stressing the joint too much, too frequently,
or with poor technique. Injury can occur to the growing bone and to articular
cartilage, as well as to the muscles, tendons, and nerves.
The weak link in a skeletally immature
bone is the growth plate, or growth center (Fig. 1), that part of the bone
where growth occurs and, consequently, a frequent site of chronic overuse
injury. Injury to the growth center can cause pain, deformity, or shortening.
The term Little League elbow, somewhat generalized and overused, is applied
to many different types of elbow injuries and diagnoses.
Medial elbow injuries
The medial (inside) aspect of the
elbow is subjected to tremendous force in baseball (Fig. 2). During the
throwing motion, tension develops over the medial aspect of the elbow,
often causing pain and injury. The growth plate on the medial side can
experience a spectrum of injuries, ranging from stress fractures to complete
fracture with avulsion (the tearing away of a part of bone from its attachment
point) and displacement of the bone. Young throwers often experience decreased
throwing performance, usually followed by pain and swelling of the elbow
and an inability to completely straighten the joint. In addition, the patient
may experience tenderness on the inside of the elbow. Symptoms may be exacerbated
by continued throwing. X-rays can reveal widening of the growth plate or
complete avulsion with separation. Because every child is at his or her
own unique stage in growth and development, x-rays of the uninvolved elbow
should always be obtained for comparison.
Conservative treatment for medial
elbow growth plate injuries includes rest, immobilization, and reconditioning
with a gradual return to throwing. Surgery may be necessary for significantly
displaced bone fragments.
Repetitive throwing causes compressive
forces on the lateral (outside) aspect of the elbow, which, over time,
may compromise the blood supply to the articular cartilage and underlying
bone. Known as osteochondritis dissecans, this condition is usually seen
in 10- to 14-year-old patients. The patient typically complains of pain
on the outside of the elbow. Loss of motion, particularly when the elbow
is being extended, is also common. Swelling and locking of the joint may
also occur. X-rays will usually show the area in question and can assist
in the diagnosis. Conservative treatment, to include cessation of sports,
immobilization, maintenance and regaining of range of motion, is indicated
if the involved segment of bone remains in its normal location and there
are no other signs of loose particles within the joint. Surgery, however,
may be indicated if (1) loose particles exist within the joint, (2) the
involved bone segment has separated, or (3) conservative treatment has
failed. Most patients can expect a full return to activity.
Avulsion and stress fractures
The posterior (back) aspect of
the elbow is also subjected to significantly increased forces during throwing
and, like the medial side of the elbow, can experience injuries ranging
from stress fractures to avulsion fractures. The patient may experience
pain in the back of the elbow as well as increased discomfort when attempting
to extend the elbow against force. X-rays show changes, particularly a
widening or fragmentation of the growth center (Fig. 3). Treatment consists
of immobilization until the pain and tenderness have resolved. If, however,
the fracture fragment has shifted away from the bone, surgery may be required
to replace it.
Prevention is the key to protecting
young, throwing athletes. Educating the athlete as well as coaches and
parents is critical. Proper training with respect to technique and limiting
the number of pitches per week should be encouraged.
David C. Rehak, MD
Hutchinson M, Ireland M. Overuse
and throwing injuries in the skeletally immature athlete. American Academy
Orthopaedic Surgery Instructional Course Lectures. 2003;52:25-36.
DeSalva E, Williams J, Fidelly P,
Holsten M, Urledge M. Pediatric throwing injuries about the elbow. The
American Journal of Orthopaedics. 1998;(Feb): 90-96.