Elbow Pain in Adolescents

Kevin deWeber, MD, FAAFP

Director, Tri-Service Sports Medicine Fellowship

Goals

• Understand the history/mechanism of injury

• Develop a thorough differential diagnosis for a painful elbow

• Understand the findings to look for on physical exam

• Understand management and return to play criteria

• Know when to refer

Case Study

11 year old Hispanic male complains of right elbow pain for the past 2 weeks. He states that the pain is present but better with rest, but worse when he pitches on his little league baseball team. He has been pitching for 2 years now, and started in a new league about 1 month ago.

Other questions about his history?

Other questions about his history?

Hand Dominance

Other questions about his history?

Hand Dominance

Other sports participation

Other questions about his history?

Hand Dominance

Other sports participation

Past trauma/injury history

Other questions about his history?

Hand Dominance

Other sports participation

Past trauma/injury history

Number of pitches/type of pitches

Other questions about his history?

Hand Dominance

Other sports participation

Past trauma/injury history

Number of pitches/type of pitchesHow many teams?

Other questions about his history?

Hand Dominance

Other sports participation

Past trauma/injury history

Number of pitches/type of pitchesHow many teams?

Side arm or overhead pitcher?

DDx

What can cause elbow pain in the young athlete?

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathy

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathy

Ulnar neuritis

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

Medial epicondylitis (“golfer’s elbow”)

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

Medial epicondylitis (“golfer’s elbow”)

Muscle strain/tear (flexor/pronator group)

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

Medial epicondylitis (“golfer’s elbow”)

Muscle strain/tear (flexor/pronator group)

Fascial Compartment Syndrome

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

Medial epicondylitis (“golfer’s elbow”)

Muscle strain/tear (flexor/pronator group)

Fascial Compartment Syndrome

Posteromedial olecranon osteophytosis

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

Medial epicondylitis (“golfer’s elbow”)

Muscle strain/tear (flexor/pronator group)

Fascial Compartment Syndrome

Posteromedial olecranon osteophytosis

Septic arthritis

DDx

What can cause elbow pain in the young athlete?

UCL sprain/tear

Medial epicondyle avulsion fracture

C8-T1 radiculopathyOsteochondrosis of medial epicondyle

Ulnar neuritis

Medial epicondylitis (“golfer’s elbow”)

Muscle strain/tear (flexor/pronator group)

Fascial Compartment Syndrome

Posteromedial olecranon osteophytosis

Septic arthritisTumor

Physical Exam

Appearance

Palpation

Range of Motion

Provocative Tests

• Slight swelling over medial epicondyle and tenderness to palpation. The UCL was also tender to palpation. There was some slight tenderness over the flexor bundle distally. There was no evidence of gross atrophy of the muscle.

• Strength was 5/5 with extension and supination, 4+/5 with pronation and flexion, limited by pain. Normal distal sensation, pulses. Negative Tinel’s with percussion of ulnar groove.

• Pain with valgus stress at 20 degrees, no laxity

• No neck tenderness, crepitus or step off, no gross shoulder pain or instability, nor any wrist/hand pathology noted.

Are radiology studies necessary for diagnosis? Insidious onset: NO

Acute onset: YES

Diagnosis?

Little Leaguer’s Elbow

• Catch-all phrase for elbow pain in young throwing athletes

Medial Epicondyle ApophysitisManagement

• Acute: control pain• “PRICEMM”• Relative rest• Modalities

• Ice, compression

• Brief medication

• Long-term : Rehabilitation• Non-painful ROM ex• Core strength and

shoulder strength• Gradual return to activity

• FROM and ADLs w/o pain• Easy throwing• Assess pitching

mechanics with professional

• Non-pitching position• Return to pitching

• 4-8 weeks

Anatomy Review

•Throwing creates predictable force loads across the elbow

–Medial elbow traction

–Lateral elbow compression

–Translational forces across the humerus and olecranon

Clinical Features

• History• Insidious onset of pain, usually medial• Decreased accuracy or distance

• Physical• Tenderness in the medial, lateral or posterior elbow• +/- mild flexion contracture, esp w/ avulstion fx• Assess ulnar collateral ligament stability at 20° flexn• Distal neuro exam

Medial physis widened

Medial apophyseal avulsion

Osteochondritis of capitellum and

loose bodies

Loose bodies seen arthroscopically

Sports Medicine Referral

Indications

• Unsure of dx or tx

• No improvement with appropriate, compliant therapy

• Lateral lesions

Ortho ReferralIndications

• Hot Joint• Increased joint laxity• Fractures• Avulsed apophysis >5mm• Loose bodies causing ROM

deficits

Prevention• Educate athlete, coaches, and family

• Sports activity no more than 9 months/year

• No sliders or curve balls <13 y/o

Prevention2006 Little League pitching guidelines

• Restriction of pitches per game• Age 10 or under: 75/day• 11-12: 85/day• 13-16: 95/day• 17-18: 105/day

• Mandatory rest days after varying # of pitches• 1-25 pitches: 1 rest day• 26-50 pitches: 2 rest days• 51-75 pitches: 3 rest days• >75 pitches: 4 rest days

• Rest days if soreness develops• Regular strengthening program

Take Home Messages

• Know full athletic history

• Bilateral x-rays

• Emphasize compliance

• EDUCATE EDUCATE EDUCATE

QUESTIONS?