An estimated 20% of injuries to upper extremities involve the elbow, and approximately 10% involve the wrist; the majority of these injuries are overuse type of injuries.1–4 Sports in which overuse injuries of the elbow and wrist in an adolescent occur are listed in Table 23-1. Also, in racquet sports (such as tennis or badminton) and in gymnastics, the elbow is subject to significant stress resulting in overuse injuries.

Definitions and Epidemiology

Repetitive throwing action can result in multiple injuries of elbow and are summarized in the Table 23-2.5–11 Collectively, varying degrees of these injuries represent the “little leaguer elbow,” which is a less preferred and nonspecific term.

Mechanisms

The secondary ossification centers around the elbow include the capitellum, radial head, medial epicondyle of the humerus, trochlea, olecranon, and lateral epicondyle. These generally fuse between ages 14 and 17. Elbow injuries in athletes involved in throwing sports have been extensively studied, specifically for the pitcher in youth baseball.5,6,10 The motion of throwing (pitching) in baseball is characterized by a complex series of movements. This is divided into windup, cocking, acceleration, release, and follow-through phases (Figure 23-1). During each phase different structures are stressed resulting in different injuries. (Table 23-3). On the medial side of the elbow the medial collateral ligament, the immature (unfused) epicondyle, and the ulnar nerve are affected because of repeated traction. On the lateral side there is repeated impact at the radiocapitellar area, and posteriorly there is extension overload affecting mainly the triceps insertion, and olecranon.

Clinical Presentation

The history in athletes who present with elbow pain should include mechanism of the injury, how and when the pain started, the severity of the pain, and the duration of pain. In throwing athletes, ask when during the throwing motion pain is most intense. Ask where is the pain located, medial, lateral, or posterior? Ask if there was swelling, catching, or locking. These may indicate intra-articular pathology such as loose bodies. Ask about the training routine, how many hours per week, or recent change in training. Recent increase in training intensity is associated with increased risk for overuse injury. Ask about any neurovascular symptoms such as pain and paresthesia in the forearm or fingers.

The young athlete with a throwing-related injury (typically between the ages of 12 and 15 years) most commonly presents with pain on the medial elbow; some athletes also have forearm pain. The pain is aggravated by the throwing activity, and there is deterioration in performance, throwing speed, and distance. Initially this pain resolves with rest, but recurs with resumption of throwing.

On examination of the elbow, there is generally no swelling or limitation of motion. Tenderness can be localized over the medial collateral ligament and over the medial epicondyle. If the ulnar nerve is involved there may be paresthesias in the ulnar nerve distribution and a positive Tinel sign is elicited. There may be tenderness along the ulnar nerve at elbow. There may be elbow flexion contracture of more than 15 degrees, that has gone undetected and are surprisingly common.

Elbow Examination

Elbow is held in flexion when there is intra-articular effusion or bleeding. Maladaptive changes caused by throwing may result in an increase in the carrying angle (Figure 23-2) of the elbow. Observe asymmetry of elbows and the normal bony configuration between medial epicondyle, lateral epicondyle, and the olecranon. Note any swelling or fullness and its extent.

Assess active and passive elbow range of motions, including forearm supination and pronation. Note loss of motion, especially full extension caused by elbow contracture. The elbow is a compound synovial joint composed of three articulations, namely, radiohumeral (between radial head and the capitellum), ulnohumeral or trochlear (between the trochlea and the trochlear notch), and the proximal or superior radioulnar (between the proximal radius and the ulna). Forearm supination and pronation occur at the radiohumeral and proximal (and distal) radioulnar joints, whereas elbow flexion and extension occur at the trochlear joint. Normal range of flexion–extension is from 0 to 140 degrees and supination–pronation is 80 to 90 degrees.7

During passive flexion the end feel is normally soft. A bony end feel is suggestive of an intra-articular loose body or osteophytes. During passive extension the normal end feel is bony. Because flexion contracture is common in throwing athletes, hyperextension should be considered abnormal.

Localize bony or soft tissue tenderness by systematic palpation. Localization of tenderness will suggest the anatomic etiology of elbow pain. The two major ligaments are the medial (ulnar) and lateral (radial) collateral ligaments. The medial or ulnar collateral ligament is the major stabilizer of the elbow during throwing motion.

Palpate the medial or ulnar collateral ligament with elbow at 50 degree of flexion. Valgus stress test is performed with elbow at approximately 20 to 30 degrees flexion (Figure 23-3) to assess ligament and elbow joint stability. Next perform valgus extension overload test in which the elbow is repeatedly extended from slight flexion while applying a valgus stress at the same time (Figure 23-4).

Palpate the ulnar nerve as it courses posterior to the medial epicondyle. Tenderness is elicited in neuritis. In compressive neuropathy of the ulnar nerve at elbow Tinel sign will be positive with paresthesia felt in the ulnar nerve distribution. Assess pin-prick sensation in the upper extremity, palpate brachial and radial arterial pulses. Strength of entire upper extremity muscles should be assessed and compared to the asymptomatic side.

A number of conditions associated with chronic or recurrent activity-related elbow pain should be considered in the differential diagnosis (Table 23-4).8–11

Diagnostic Imaging

AP, lateral, oblique, and axial view x-rays with comparative views of the opposite side should be obtained in a young athlete with chronic or recurrent episodes of elbow pain. The x-rays are normal early in the course. The findings depend on the major underlying pathology and include hypertrophy and fragmentation of the medial epicondyle, widening of the medial epicondyle physis, olecranon osteophytes, or osteochondritis dissecans of the capitellum. More advanced imaging such as CT scan or MRI scan should be considered in consultation with the radiologist.

Treatment

With early recognition and rest from throwing, the clinical syndrome of medial elbow pain in throwing young athletes generally resolves completely. Nonsteroidal anti-inflammatory medications and local application of ice help alleviate inflammation and pain. With improvement of pain, the athlete can do progressive strengthening exercises for the upper extremity and gradually return to increasing levels of activity. Depending upon the severity, it may take from 6 weeks to 6 months for the athlete to return to full level of activity.

Measures to prevent throwing-related injuries in young athletes include proper preseason conditioning and limitation of the overall pitching or throwing activity. The age of the player and the type and velocity of the throwing techniques are also important factors to be addressed in an effective prevention program. If not recognized and treated early, further complications can occur. These include osteochondritis dissecans of the radial head or the capitellum, ulnar neuropathy, intra-articular loose bodies, flexion contracture at elbow, and early arthritis.

Definition and Epidemiology

Medial epicondyle is affected by repetitive stress during throwing and other overhead activities. This results in inflammation and painful apophysitis. Medial epiconyle apophysitis and avulsion are the most common injuries reported in young baseball pitchers. Similar lesions have also been reported in tennis, softball, football, and track and field, in which overhead arm movements are required.

Mechanism

The etiology is repeated tension stress over the attachment of the ulnar (medial) collateral ligament of the elbow on the medial epicondyle, from valgus movements and repetitive forceful contractions of the flexor-pronator muscle mass, which is attached to the epicondyle. Repetitive valgus stresses may lead to ultimate stress failure of the medial epicondylar apophysis and avulsion.

Clinical Presentation

Medial epicondyle apophysitis is characterized by the insidious onset of medial elbow pain with throwing. There is diminished ability to throw, medial elbow pain, and loss of pitch velocity or distance. Pain is usually most severe in late cocking and early acceleration. Examination often demonstrates pain with valgus stress of the elbow, point tenderness over the medial epicondyle, and a flexion contracture of the elbow may be present.

Diagnostic Imaging

AP and lateral x-rays of the elbow with comparison views of the uninvolved elbow are indicated. In the early stage, x-ray may be normal, later, a widening of the apophysis is seen. Avulsion of the medial epicondyle apophysis can be confirmed on the basis of x-ray. X-rays may show subtle widening of the aphophysis, and this is confirmed by comparison views of the opposite elbow. Hypertrophy and fragmentation of the epicondyle may be present.

Treatment

Treatment is to stop throwing for a minimum of 6 weeks, initial ice and NSAIDs, and a short course of 1 to 2 weeks of immobilization in a sling. If there is a flexion contracture present, rehabilitation to regain motion is instituted, and a course of stretching and strengthening is started. A graduated course of throwing on a strict schedule is begun once the athlete is completely asymptomatic and nontender. Medial apophysitis responds well to nonsurgical treatment without long-term functional deficits. Athletes with medial epicondyle avulsion should be referred to orthopedics (Box 23-1).

Acute sprains of the ulnar collateral ligament of the elbow are rare in young children and adolescents who are more likely to sustain medial epicondylar injury. Ligament sprains are more common in skeletally mature or near mature athletes and are reviewed in Chapter 22.

Definition

Ulnar neuritis is characterized by painful inflammation of the ulnar nerve as passes along the medial side of the elbow.

Mechanism

Traction owing to repetitive valgus stress, compression of the nerve from flexor muscle hypertrophy or osteophytes, or friction owing to subluxation, can also lead to ulnar neuritis in the throwing athletes. Elbow valgus instability is found in many throwing athletes who develop ulnar neuritis.

Clinical Presentation