PRACTICE RECOMMENDATIONS
• Administer the valgus stress test, the “milking maneuver,” and the moving valgus stress test to athletes suspected of having ulnar collateral ligament injury. C
• Treat Little League elbow with nonsteroidal anti-inflammatory drugs, ice, brief immobilization, and a 4- to 6-week “break” from throwing. A
• Advise young baseball players (and their parents) to avoid pitching year-round, and to get 3 months of rest per year. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The growing popularity of club teams and year-round participation in sports has spawned an epidemic of elbow injuries in primary and secondary school students and young adults alike. The incidence of elbow pain in children engaged in sports that require overhead throwing, such as baseball, football, volleyball, tennis, and javelin, ranges from 45% to 78%.1
Fortunately, acute traumatic elbow injury, with pain severe enough to force the athlete to cease participation entirely, is relatively rare, accounting for only 1% to 5% of cases.1,2 Far more often, elbow pain is associated with overuse, resulting in a gradual onset of medial elbow soreness that does not prevent the athlete from playing.
When an athlete seeks care for elbow pain, there are a number of things to consider, including the patient’s age, skeletal maturity, and type and frequency of throwing. Younger “throwers” typically incur injuries related to the physes, while adolescents and adults are more likely to sustain injuries to the ligaments and tendons.3 In both cases, repetitive valgus stress is the mechanism of injury. This review—of elbow anatomy (see the box),4-6 injury, differential diagnosis, and treatment—will make it easier for you to get injured athletes back in the game.
Elbow anatomy and biomechanics
The elbow has 3 articulations—ulnohumeral, radiocapitellar, and proximal radioulnar—that provide primary stability to valgus stress. The elbow’s soft tissue restraints include 2 ligament complexes (medial and lateral collateral), 4 muscle groups (flexors, extensors, pronators, supinators), and 3 major nerves (radial, median, ulnar) and their branches.
The ulnar collateral ligament (UCL) complex—which consists of the anterior and posterior bundles and the transverse ligament—is the main source of medial elbow stability. 4 Mechanical stability for overhead throwing is provided by both bony and soft tissue restraints. During the pitching motion, the forces generated exceed the UCL’s tensile strength, and protective flexor muscles are activated.5,6
And the pitch…There are 6 stages of throwing: windup, early cocking, late cocking, acceleration, deceleration, and follow-through. Elbow pain is most likely during the late-cocking or early acceleration phase of a throw, the point of ball/javelin release, or the moment the racquet hits the ball.4
Is it Little League elbow? Start with a targeted history
In skeletally immature athletes, open physes result in the epicondylar apophysis being the weakest structure on the medial aspect of the elbow. Thus, repetitive valgus stress and tension overload often lead to “Little League elbow”—an umbrella term with a differential diagnosis that encompasses medial epicondylar fragmentation, delayed or accelerated growth of the medial epicondyle, and delayed closure of its growth plate, among other conditions (TABLE 1).3,7,8
In more mature athletes, repetitive microtrauma to the ulnar collateral ligament (UCL) leads to its gradual attenuation or complete failure.7 This increases the stress on the radiocapitellar joint and olecranon, and can lead to edema, scarring, calcification, osteophyte formation, medial epicondylitis, ulnar nerve neurapraxia, or radiocapitellar chondral damage.9 Extended practices and tournaments, with no substantial rest period throughout the year, put adolescents at increased risk for UCL injuries.10
Regardless of age, the medical history of an athlete with elbow pain should elicit information about the mechanism of injury; the location, duration, and quality of the pain; factors that alleviate or exacerbate the pain; the presence of weakness or paresthesias; and the extent to which the pain has affected the patient’s ability to throw. Patients with chronic UCL injuries, for example, often report a loss of arm control and decrease in throwing speed. It is also important to address hand dominance, level of participation, the position played, changes in technique or training regimen, prior injuries, and the effects of any previous treatment.11
TABLE 1
Differential diagnosis of elbow injuries
| Location | Differential diagnosis |
|---|---|
| Medial | Little League elbow
|
| Anterior | Anterior capsule strain Biceps tendon rupture Biceps tendonitis Dislocation Median nerve compression (pronator) syndrome |
| Posterior | Olecranon bursitis Olecranon process or tip stress fracture Triceps rupture/olecranon avulsion Triceps tendonitis Trochlear rupture Valgus overload syndrome (posterior olecranon impingement syndrome) |
| Lateral | Capitellum fracture Lateral epicondylitis Lateral ulnar collateral ligament injury Osteochondritis dissecans Posterior interosseous nerve syndrome Posterolateral rotary instability Radial head fracture Radiocapitellar chondromalacia |
| Adapted from: McKeag DB, Moeller JL. ACSM’s Primary Care Sports Medicine. 2nd ed.3 | |