Wednesday, April 26

Little League Elbow

Every August, the Little League World Series caps a long, pressure-filled season for the young players who are lucky and talented enough to make it to Williamsport. But the pressure is perhaps just as great on their coaches, not only to teach the right fundamentals, fill out the right batting order, and plot a winning game strategy, but also to protect their pitchers' arms from an injury known as Little League elbow -- an injury to the growth plate on the inside of the elbow joint (medial epicondyle) and the lateral compartment, primarily caused by excessive throwing. We asked Dr. Mitchel Storey, team physician for the Seattle Mariners and a member of the Association of Professional Team Physicians (PTP), to explain the basics of this injury and its prevention.

What causes Little League elbow?

Dr. Storey: The problem with young pitchers is that in many cases they're either throwing too hard too often or trying to build up their endurance too quickly. In my practice, I see many adolescent players with arm problems, and 90 percent of the time it can be linked to some sort of a sudden change in the intensity or duration of activity. For instance, a player will suddenly make his mind up that baseball is going to be his preferred sport. So he goes from playing with a high school team to playing on two summer teams plus his high school team. And now he's playing twice as often and throwing twice as much. I've also seen this affliction in cases where a player changes leagues where the pitcher's mound is farther from home plate or the mound is elevated. Sometimes it's a change of coaches that's the cause. And the pitcher ends up with a sore arm. The way baseball has taken over as a year-long sports focus has resulted in an accompanying increase in arm complaints.

What age group is most affected, and how?

Dr. Storey: Generally it's pre-high school players, anywhere from ages 10 to 15, with the peak incidence in the 12- to 14-year-old age group. Little League elbow is a process of damage to the joint surfaces. Pitchers' elbows at that age, as are most of their joints, are immature, so they have open growth plates and something of a tenuous blood supply to those growth plates. Little League elbow involves an overload on the medial side of the elbow, so that the ligament attached to the growth plate starts to pull away. And on the other side of the elbow there can be a compressive phenomenon that can cause a condition called osteochondritis dissecans, in which damage is followed by poor blood flow and small areas of bone death. When you see those components together -- some elongation of the ligament structures and perhaps some changes in the growth plate on the medial side along with some bony debris and damage to the outer half of the elbow -- now you're looking at the true definition of Little League elbow.

In some circumstances we'll see a significant avulsion of the medial elbow with a several-millimeter separation. It's typically an acute injury when the ligament gets pulled off like that. More often, the affected elbow will become sore and maybe show just a little extra widening of the growth plate as compared with the unaffected, nondominant arm. Comparison X-rays may be necessary.

What are the symptoms?

Dr. Storey: Typically it's a gradual onset. Generally the elbow is sore to the touch and may have some swelling. It especially hurts when the player throws the ball. The growth plate can traumatically separate when someone falls on the arm awkwardly, but that separation can also occur as a result of just one hard throw. In that case, there's a sudden onset of pain and the player feels something give way in the elbow. Pain may be associated with catching or locking.

The elbow will obviously feel better after being rested. In cases of osteochondritis dissecans and associated loose bodies in the elbow, the player may have some locking, catching, persistent swelling and/or loss of movement in the elbow.

How is Little League elbow diagnosed?

Dr. Storey: A clinical exam will often provide as much information as an X-ray will, but more often than not, we combine our clinical exam with an X-ray. The X-rays often show some of the bony changes that take place and help us to make a more complex diagnosis.

How is it treated?

Dr. Storey: We ask the patient to ice the elbow. Rest is obviously a big part of the treatment, and on rare occasions we may splint the elbow to assure rest. But we don't like immobilizing elbows too long because they often will get permanently stiff. The most important parts of treating Little League elbow are 1) helping the player understand why the problem exists and explaining in detail what's happening and 2) allowing him to continue range-of-motion in the elbow but avoid throwing. Anti-inflammatory medication will make the elbow feel better but doesn't speed up the healing process.

The injuries with the growth plate are treated similar to fractures. Typically the recovery time is going to be six weeks or so for minor problems to as much as three months for the more significant problems. Some players have the luxury of being able to be designated hitters, and typically I'll let them do that once they can show me they have full range of motion in the elbow and I'm convinced that if they landed on their elbow they're not going to re-aggravate it. They can shag flies and take grounders, but throwing is the main limitation.

How long is it before the player can start pitching again?

Dr. Storey: It depends. If he has a growth plate separation or it looks like there's some damage, we'll rely on the normal healing process, which is going to be a minimum on four to six weeks, and we base this on clinical findings such as tenderness, the integrity of the ligaments, and muscular strength. We then try him on a return-to-throwing program. We usually put him on a short-toss, long-toss program to allow him to gradually build back his arm strength. He progresses to an on-the-mound throwing situation. It's not until he's gone through all those steps that he's allowed to go back to pitching.

Is surgery ever necessary?

Dr. Storey: On the medial side, if the growth plate gets separated by more than about four millimeters, reattaching it surgically is sometimes advocated. If the patient has loose bodies, that becomes a surgical situation for sure. The majority of these injuries are treated conservatively, without surgery.

How is the injury rehabilitated?

Dr. Storey: We generally start the patient on a strengthening program as soon as two weeks after the injury has been diagnosed, not only to benefit the elbow but also the shoulder, forearm and hand. Many times the exercises can be done at home after a couple of explanations, but most of the time the patient will benenfit from going to a physical therapist a few times, maybe more if he has complicated problems such as loss of movement or ligament stiffness.

How can Little League elbow be prevented?

Dr. Storey: For a pitcher, prevention is two-fold. No. 1 is to not overload the arm by having him throw too much. In Little League, there's always one pitcher who's best on the team, and the tendency is for the coach to put him out there every chance he can. So we try to limit young pitchers to no more than seven innings of competitive pitching in a week. We also give them pitch counts: Adolescent pitchers shouldn't throw more than 80 to 100 pitches per week. But if a kid starts a game and has a couple of rough innings and gets up to 80 or 100 pitches in five innings, well, now the seven-inning stipulation is obsolete. And we ask pitchers not to throw competitively between games they pitch. They can play at another position. They should also have an exercise routine to keep their arm strength up and build endurance.

No. 2, throwing curve balls and sliders puts a tremendous load on the elbow, so we try to keep youngsters throwing just fastballs and change-ups before they get into high school. We also emphasize good form. Obviously the worse your mechanics are, the more likely you are to have an injury. When your starting a sport, you're not efficient with your movements, and there's a big learning curve involved in throwing efficiently. Until you learn the mechanics and build up your arm strength and endurance, there's a higher incidence of injury.

If this condition is caught at the early stages, it's invariably a self-limited problem. Some kids and coaches drive harder than others, however. If the coach is telling the kid, "You're supposed to have elbow pain; it's normal," that kid is liable to get himself hurt before he realizes he's in trouble.

What are the long-term implications if this condition isn't allowed to heal?

Dr. Storey: On the inside of the elbow where the ligament attaches, even if that pulls away from the growth plate and then is allowed to heal by itself, there may be a knob there and a tendency to develop tendinitis down the road. The really worrisome problem, though, is if the player develops damage to the growth plate on the outside of the elbow. Those problems sometimes don't get better with time or will lead to an arthritic process in the joint. Loose bodies are the long-term result of chronically damaging that growth plate on the outer part of the elbow.

If a kid really has an interest in trying for a college scholarship and a major league career, he has to keep in mind that he can't go from playing weekend baseball to practicing every day with two teams without risking injury. Parents definitely have a major role in prevention. Some parents push too hard; if they see some talent in their kid, sometimes the dad will have him throwing more at home than he's supposed to and trying to teach him a curve ball. Parents have to be careful not to have their own aspirations delivered through their child.

Dr. Mitchel D. Storey, a member of the Association of Professional Team Physicians (PTP), has been team physician for the Seattle Mariners since 1984. He is medical director of the Sports Medicine Clinic in Seattle.

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