Little Leaguer’s Elbow

By: Karen Myrick, DNP, APRN, FNP-BC, ANP-BC

Repetitive throwing causes forces across the elbow that are compressive on the lateral side and tensile on the medial joint (Shanley, 2013). Repetitive strain without adequate rest and muscle imbalances may lead to apophysitis (Myrick, 2015).
Younger athletes who engage in more than one overhead sport, or do not get adequate rest are more prone to overuse injuries.

Case Study as an Example:
Patient, A 14-year-old baseball pitcher patient, presents with R elbow pain. Pain is worse with throwing and better with rest. With throwing, pain is described as an 8/10, and at rest, it is a 3-4/10. He has tried ibuprofen, 600 mg once or twice without any relief. He has also tried ice in the evening a couple of times, which helps while it is on. He denies any numbness or tingling and describes his arm as feeling weak. There is no specific traumatic event that he is aware of. His current elbow pain has kept him from participating in sports for the last two weeks.

Social History
This 14-year-old male is an eighth-grader at a local school. Outside of his school obligations, he plays often with friends and is active in multiple baseball leagues. He is a good student who regularly is on the honor roll. Generally quiet in nature, he is a motivated athlete who wishes to return to full activity.

Clinical Pearls
For those participating in overhead sports, regular rest is important to prevent overuse injuries. The ability to add strength training can contribute greatly to a healthy season and enhanced performance.
Pain that is worse throwing activities and better with rest is typical in the history of the present illness for patients with medial epicondyle apophysitis.

Physical Assessment
He is in no acute distress. He is 5’8″, weighing 151 lbs. On inspection, there is no visible swelling or deformity. With palpation on the medial side of the elbow, tenderness is elicited over the Medial Collateral Ligament (MCL). No tenderness is evident on the lateral side of the elbow. The patient does not have full extension of the elbow, which is inhibited by pain, lacking approximately 10 degrees. Passive flexion with a feeling of stiffness and pain is 120 degrees. When flexing the elbow, the endpoint is soft. Strength testing elbow flexion and extension displays good strength with some residual pain. Supination itself with a flexed elbow is sound; however, pronation elicits increased soreness over the MCL. With ligamentous testing of the elbow, both varus and valgus stress testing is normal with slight pain at 0 degrees. However, at 30 degrees of flexion, there is significant pain and an obvious gapping with a valgus force. Neurologically, the patient has no focal deficits.

Diagnostic Evaluations
A radiograph was obtained to look for the presence of any avulsion. Diagnosis is typically made with clinical examination only. However, radiographs can be helpful to demonstrate hypertrophy, widening, and fragmentation of the apophysis, especially with a comparison view of the contralateral side. Figure 2.6.1 demonstrates widening of the medial apophysis.

Diagnosis
Medial epicondyle apophysitis.

Interventions
The patient and family were provided education on this condition, and instructions for resting his arm from aggravating movements to include absolutely no throwing, icing 4-6 times daily were provided. He was also instructed on a regimen of NSAIDs to be taken daily with food, ibuprofen 600 mg TID.

Patient Education
Educate the patient on rest of the arm. This includes throwing of other types of balls, which is oftentimes not thought of, and the patient interprets the communication as avoiding only pitching a baseball. Explicit instructions on no throwing activity should clearly include any throwing movements, including that of snowballs.
Keeping the athlete from all throwing activities until there is no pain typically consists of a 4-6 week initial trial of rest. Upon completion of this rest period, a follow-up appointment is encouraged. Dependent upon the history and physical examination findings at that follow up visit, a strength program focusing on hip, trunk, and back musculature is indicated.

Follow-up Evaluation
At the 6-week visit, the patient was feeling less discomfort at rest, and occasionally a dull ache was reported that was rated a 1/10. He was very anxious to get back to his activities. A slow progression was recommended, and physical therapy was prescribed with a focus on strengthening the musculature both proximal and distal to the elbow joint as well as postural muscles surrounding the shoulder joint. Another visit was made for 6 weeks out, and at that time, the patient was progressing to a throwing program, and returning to activity pain-free.

References:
Myrick, K. M. (2015). Pediatric Overuse Sports Injury and Injury Prevention. Journal For Nurse Practitioners, 11(10), 1023-1031 9p. doi:10.1016/j.nurpra.2015.08.028
Shanley, E., & Thigpen, C. (2013). Throwing Injuries in the Adolescent Athlete. International Journal Of Sports Physical Therapy, 8(5), 630-640.

See Karen Myrick, DNP, APRN, FNP-BC, ANP-BC speak in 2020 at a Skin, Bones, Hearts & Private Parts event in Destin • Myrtle Beach • San Antonio • Orlando