Introduction
- Rob Hopkins, PT, SCS
- Champ L. Baker, MD
Epidemiology
- •
Elbow injuries common in young throwers
- •
9 to 14 years old, predominantly male
- •
Primarily occurs in baseball; can also be seen in softball and volleyball
- •
Pitchers most often affected followed by catchers and position players
Pathophysiology
Intrinsic Factors
- •
Open physis at elbow ( Figure 10-1 )
FIGURE 10-1
Open physis.
- •
Inadequate hip mobility
- •
Weakness in hips/lower extremity
- •
Weakness in core
- •
Scapular dyskinesis/weakness
- •
Rotator cuff weakness
- •
Glenohumeral hypermobility
- •
Wrist flexor tightness/weakness
Extrinsic Factors
- •
Pitching too much/overuse
- •
Pitch selection, throwing curve ball or slider too soon
- •
Mound height
- •
Poor mechanics
Traumatic Factors
- •
Primarily an injury of overuse
Classic Pathological Findings
- •
Widening of physes on x-ray
- •
Loose body on x-ray ( Figure 10-2 )
FIGURE 10-2
Loose body on plain radiograph in a 14-year-old patient.
- •
MRI demonstrating a nondisplaced osteochondritis dissecans fragment ( Figure 10-3 )
FIGURE 10-3
Magnetic resonance image in a 14-year-old patient.
Clinical Presentation
- •
Intermittent elbow pain, possibly for years
- •
Loss of throwing velocity
- •
Loss of throwing control
- •
Loss of elbow extension ( Figure 10-4 )
FIGURE 10-4
Loss of extension in a patient with Little League elbow.
- •
History of overparticipation in baseball activities: multiple leagues, travel teams, showcases, specialty coaches
- •
Pain with pitching or throwing only, hitting and position play do not reproduce pain
Abnormal Findings
- •
Weakness in core, scapular stabilizers, rotator cuff
- •
Loss of total arm motion (TAM) secondary to loss of internal rotation
- •
Tenderness to palpation of medial epicondyle and pain on valgus stress test ( Figure 10-5 )
FIGURE 10-5
Physical findings include tenderness to palpation of the medial epicondyle ( A ) and pain on valgus stress ( B ).
- •
General kyphosis with forward shoulder and head posture and protracted and tilted scapula ( Figure 10-6 )
FIGURE 10-6
Patient’s posture shows weak core and thoracic kyphosis ( A ) and malpositioned winging scapula ( B ).
Pertinent Normal Findings
- •
Normal sensation through upper extremity
- •
No pain at rest
- •
Full elbow flexion
Imaging Studies
- •
Plain radiographs
- •
MRI if patient does not respond to nonoperative management
Differential Diagnosis
- •
Medial epicondylitis
- •
Ulnar neuritis
Treatment
Nonsurgical
- •
Rest
- •
NSAIDs
- •
Activity/position modification
- •
Physical therapy
- •
Pitching mechanics evaluation
- •
Interval throwing program (ITP)
Guidelines
- •
Severity of symptoms
- •
Patients desire to play
- •
Time of year/time in season
- •
Other sports patient participates in
Surgical Indications
- •
Persistent pain over the medial epicondyle after prolonged rest and attempt to return to throwing
- •
X-ray/MRI evidence of persistent widening of the medial metaphysis specifically in comparison to contralateral side ( Figure 10-7 )
FIGURE 10-7
Plain radiograph of affected elbow ( A ) shows widening of medial metaphysis when compared with contralateral elbow ( B ).
- •
Separation of medial epicondyle epiphysis if acute and retracted
- •
Persistent pain with activities of daily living even if not attempting sports
- •
Restricted sports
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Age of patient
- •
Desire to continue playing
- •
Other sports in which the patient participates
- •
Response to conservative measures
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Age of the patient and desire to return to throwing sport are important.
- •
Skeletal maturity age should be determined by skeletal films of the hand.
- •
Radiographic comparison with the contralateral elbow should be made.
- •
Surgeon should be prepared to address ulnar nerve symptoms at the time of surgery.
- •
Patients must be advised that it can be as long as 3 months before bony closure is achieved and return to throwing is possible. Although it may require less time, it may be up to 6 months before full release to return to sports is possible.
Evidence
Multiple Choice Questions
- QUESTION 1.
What is the age range of most patients with Little League elbow?
- a.
5 to 8 years
- b.
9 to 14 years
- c.
15 to 18 years
- d.
All ages are equal.
- a.
- QUESTION 2.
Which of the following is an extrinsic factor in the pathophysiology?
- a.
Overuse
- b.
Pitch selection
- c.
Pitching mechanics
- d.
All of the above
- a.
- QUESTION 3.
Which of the following is not in the normal clinical presentation?
- a.
Night pain
- b.
Loss of velocity
- c.
Loss of control
- d.
Loss of total arm motion
- e.
Night pain
- a.
- QUESTION 4.
The following are nonsurgical treatments except
- a.
change positions.
- b.
increase volume of throwing.
- c.
rest.
- d.
NSAIDs.
- a.
- QUESTION 5.
Which of the following findings will affect the choice of treatment?
- a.
Age
- b.
Desire to keep playing
- c.
Other sports played
- d.
Response to conservative management
- e.
All of the above
- a.
Answer Key
- QUESTION 1.
Correct answer: B (see Epidemiology )
- QUESTION 2.
Correct answer: D (see Extrinsic Factors )
- QUESTION 3.
Correct answer: B (see Clinical Presentation )
- QUESTION 4.
Correct answer: A (see Treatment )
- QUESTION 5.
Correct answer: E (see Findings That Affect Choice of Treatment)
Nonoperative Rehabilitation of Epiphysiolysis of the Medial Epicondyle (Little League Elbow)
- Rob Hopkins, PT, SCS
- Champ L. Baker, MD
Phase I (weeks 0 to 2)
Protection
- •
No sports activities
- •
A sling is rarely, if ever, needed. A sling may be used when necessary for elbow pain. Discontinue as soon as patient is pain free at rest.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 6) | PHASE III (weeks 6 to 12) | PHASE IV (weeks 12+) |
|---|---|---|---|
|
|
|
|
Treatment for Pain/Swelling
- •
Ice, compression
- •
Over-the-counter pain medication/NSAIDs
Techniques for Progressive Increase in Range of Motion
Manual Therapy
- •
Joint mobilization of shoulder, primarily posterior capsule if glenohumeral internal rotation deficit (GIRD) is present
Soft Tissue Techniques
- •
Massage to facilitate edema reduction and release adhesions
Stretching/Flexibility Techniques
- •
Proprioceptive neuromuscular facilitation (PNF) muscle energy techniques and self-stretching to gain full elbow and shoulder range of motion (ROM)
Other Therapeutic Exercises
- •
Lower extremity strength and flexibility
- •
Core strength/stability
- •
Maintain cardiovascular endurance
Muscle Activation of Primary Muscles Involved
- •
Concentric activation of elbow flexors and extensors, wrist supination and pronation, wrist flexion and extension
Sensorimotor Exercises
- •
Manual joint replication activities at wrist and elbow
Open (OKC) and Closed (CKC) Kinetic Chain Exercises
- •
OKC exercises at this time
Techniques to Increase Muscle Strength, Power, and Endurance
- •
No activities for primary injury site
- •
Continue to maintain or increase lower body and core power and endurance.
Neuromuscular Dynamic Stability Exercises
- •
None at this time
Plyometrics
- •
None at this time
Functional Exercises
- •
Patient is encouraged to use upper extremity for all activities of daily living (ADLs). Patient is restricted from sports activities only at this time.
Sports-Specific Exercises
- •
None at this time
Milestones to Progress to Next Phase
- •
Pain free at rest
- •
Normal elbow ROM
- •
Nontender to palpation
Phase II (weeks 2 to 6)
Protection
- •
None
Treatment for Pain/Swelling
- •
Ice, compression, over-the-counter pain medication/NSAIDs
Initial Guidelines for Progressive Increase in ROM
Patient should have normal elbow ROM at this time.
Manual Therapy Techniques
- •
Joint mobilization of shoulder, primarily posterior capsule if GIRD is present
Soft Tissue Techniques
- •
Massage to facilitate edema reduction and release adhesions at elbow
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
PNF/muscle energy techniques and self-stretching to gain full shoulder ROM
Other Therapeutic Exercises
- •
Lower extremity strength and flexibility, focus on hips
- •
Core strength/stability
- •
Rotator cuff, deltoid, and scapular stabilization
- •
Maintain cardiovascular endurance
Muscle Activation of Primary Muscles Involved in Injury Area
- •
Concentric activation of elbow flexors and extensors, wrist supination and pronation, wrist flexion and extension progressing to eccentric as able
Sensorimotor Exercises
- •
Manual joint replication activities at wrist and elbow
Open (OKC) and Closed (CKC) Kinetic Chain Exercises
- •
OKC exercises for upper extremity
- •
CKC exercises for scapular stabilization and core
Increase Muscle Strength, Power, and Endurance
- •
Upper body exercises (UBE)
- •
Begin resisted activities for entire upper extremity, Thera-Band, free weights, etc
- •
Continue to maintain or increase lower body and core power and endurance
Neuromuscular Dynamic Stability Exercises
- •
None at this time
Plyometrics
- •
None at this time
Functional Exercises
- •
Patient should have no functional limitations. Patient is restricted form sports activities only at this time.
Sport-Specific Exercises
- •
None at this time
Milestones/Criterion-Based Rehabilitation Guidelines to Progress to Next Phase
- •
Pain free at rest
- •
Normal elbow ROM
- •
Nontender to palpation
- •
Complete Phase II exercises without increase in symptoms
Phase III (weeks 6 to 12)
Protection
- •
None
Treatment for Pain/Swelling
- •
Ice, compression
- •
Over-the-counter pain medication/NSAID
Techniques for Progressive Increase in ROM
Patient should have normal elbow ROM at this time.
Manual Therapy Techniques
- •
Joint mobilization of shoulder, primarily posterior capsule if GIRD is present
Soft Tissue Techniques
- •
Massage to facilitate edema reduction and release adhesions at elbow
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
PNF/muscle energy techniques and self-stretching to gain full shoulder ROM ( Figure 10-8 )
FIGURE 10-8
Sleeper stretch for stretching posterior capsule is begun during Phase II.
Other Therapeutic Exercises
See Figure 10-9 .
- •
Lower extremity strength and flexibility, focus on hips
- •
Core strength/stability
- •
Rotator cuff, deltoid and scapular stabilization
- •
Maintain cardiovascular endurance
Related posts:
Adhesive Capsulitis and Glenohumeral Arthritis
Patellar Instability
Midfoot Strains and Sprains and Lisfranc Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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