Spring is not just the time for flowers to bloom, and grass to grow. It is also the start of baseball season. The Yankees, Red Sox, and yes, even the Mets, are gearing up for the dog days of summer. But baseball has also started locally with little league games occupying the fields of every town, and playoffs coming for high school teams. It is no coincidence that I tend to see lots of baseball related injuries in children and adolescents this time of year. One of the most common complaints is that of elbow pain.
Elbow pain is not uncommon to see in throwers. Although mainly seen with pitchers, kids can experience pain regardless of the position that they play. The diagnoses can vary and are dependent on the age of the patient. The elbow has numerous growth plates and each growth plate, or physis, fuses at a different time. This can make diagnosing an injury on X-ray very difficult, and it is often necessary to get a comparison view of the opposite elbow. Elbow injuries in the skeletally immature are frequently seen due to the repetitive motions of throwing.
Throwing is broken down into different phases. In the cocking and acceleration phases, there is increased load on the inside (medial) of the elbow. This force puts tension on the medial structures including the physis, ligament and muscle tendon unit. This force is called a valgus stress. I like to use the analogy of bending a paper clip; if a paper clip is repetitively bent back and forth, eventually it will break.
The knob of bone felt on the inside of the elbow is called the medial epicondyle. Its growth plate can become irritated from repetitive valgus forces. This is usually seen in children younger than 10 years old. Kids typically report pain with throwing, weakness, and decreased velocity. The growth plate itself can become inflamed which is called an apophysitis. Some times the bone itself can be pulled from the physis, resulting in a fracture. Treatment usually consists of a period of rest and immobilization followed by a stretching and strengthening program. Patients may return to throwing when their pain resolves, but this can require missing an entire season. Surgery is considered for fractures of the epicondyle that are malaligned or displaced.
Another structure that can become injured on the medial side of the elbow is the ulnar collateral ligament. This is diagnosed clinically and confirmed on MRI. This injury typically improves with conservative management. Surgery is reserved for elite level athletes with a reconstruction of the ligament. This has become a very common procedure in professional baseball pitchers and is referred to as “Tommy John surgery.” Pitchers typically return to competition one year after surgery.
While valgus loads on the elbow cause stretching of the medial structures, the outside portion of the elbow (lateral) is compressed. This can lead to fragmentation of a particular bone called the capitellum. Kids will have the same complaints of pain with throwing, but their physical exam will show tenderness on the outside of the elbow. The bone appears irregular on plain X-rays. This diagnosis is called Panner’s disease and is usually seen in boys younger than 10 years old. Symptoms typically resolve with rest but may take several months to dissipate.
In the adolescent age group, lateral sided pain is more indicative of an osteochondral lesion. This is a defect of the cartilage and underlying bone. This fragment can become unstable and cause locking sensations of the elbow. The lesion can be seen on X-ray and initial management involves rest, immobilization and anti-inflammatory medication. Occasionally surgery is necessary to remove a loose fragment and to drill the bone which promotes a healing response.
One of the most common baseball related injuries is elbow pain. This typically has an insidious onset and is caused by repetitive stresses to the elbow in the throwing motion. Kids are not only throwing during the spring and summer. Some athletes participate in fall leagues and winter clinics and never have a prolonged period of rest. The incidence of elbow pain can be limited by decreasing the frequency and duration of throwing. Pitch counts are important to consider and vary depending on the age of the child. Current recommendations can be found at the American Academy of Orthopaedic Surgeons (AAOS) website.