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Little League Elbow

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Other Names

  • Little League Elbow
  • Medial Epicondyle Apophysitis
  • Medical Epicondyle Stress Fracture


  • This page refers to the generic title 'Little League Elbow' which can refer to several medial elbow conditions seen in pediatrics
    • Apophysitis of the medial epicondyle
    • Epyphysiolysis of the medial epicondyle
    • Additionally and less commonly, can see UCL injuries, common flexor tendinopathy


  • Originally described by Brogdon and Crow in 1960[1]


  • Incidence of elbow pain in youth baseball players between 20-40%[2][3]
  • Most commonly seen under the age of 10 (not sure that is true, need citation)


  • By definition occurs in sketally immature pediatric patients
    • In these patients, avulsion or physeal injuries more common than ligamentous or tendon injuries
    • As growth plates fuse, these athletes develop other causes of medial elbow pain
    • Injury pattern depends on developmental stage of the elbow
  • Occurs as a result of overuse or repetitive valgus stress placed upon the elbow
    • Causes a tension-force to overload the medial structures
    • Produces tension along the medial elbow, shearing at the posterior elbow, and compression along the lateral elbow[4]


  • Sports
    • Overhead athletes
    • Throwing athletes
  • Seen during cocking, acceleration phases of pitching
  • Overuse can be classified into 4 stages:[5]
    • Pain in the affected area after physical activity
    • Pain during activity without restricting performance
    • Pain during the activity that restricts performance
    • Chronic unremitting pain even at rest
  • Factors that contribute to overuse
    • Pitching mechanics
    • Pitch volume (>80 per game)
    • Pitch type (especially fastball)
    • Pitch duration (> 8 months per year)
    • Pitching when fatigued
    • Physical conditioning

Associated Conditions


Risk Factors

  • Sports
    • Baseball, especially pitchers

Differential Diagnosis

Clinical Features

  • History
    • Typically in 9-12 year old males
    • Almost universally insidious in nature with no acute trauma
    • Important to clarify sport, position, frequency, etc
    • Will complain of pain in throwing arm and loss of speed, accuracy and/or distance
    • Pain is at medial elbow
    • Sometimes stiffness, swelling, limited elbow extension, mechanical symptoms
  • Physical: Physical Exam Elbow
    • Tenderness to medial elbow
    • Swelling and effusion can be present
  • Special Tests



  • Standard Radiographs Elbow
    • Diagnosis is primarily clinical
    • Often normal early on in disease process
  • Findings
    • Apophysitis: physeal widening, sclerosis, cortical irregularity
    • Epiphysiolysis: fragmentation or avulsion of the medial epicondyle


  • Findings
    • Edema across the medial epicondyle physis
    • If suspected UCL injury, will be best viewed
    • Increased T1 and T2 uptake in UCL can be physiologic


  • Findings unknown (needs to be updated


  • Unknown



  • Indications
    • First line therapy in virtually all cases
  • Relative rest
    • Discontinue offending activity, typically throwing until pain and tenderness resolve
    • Usually about 4-6 weeks
  • Physical Therapy
    • Begin when pain free
    • Strengthen dynamic stabilizers of core, shoulder
    • Eventually throwing program as athlete approaches RTP
  • Medications including
  • Activity modification
    • Pitchers may require biomechanical correction
  • Prevention
    • Follow pitch count guidelines
    • Education of athlete, parents and coaches
    • Correct biomechanics
    • Improve core strength and cardiovascular fitness


  • Indications
    • Failure of conservative measures
  • Technique
    • Avulsion fracture: ORIF of medial epicondyle
    • UCL Injury: UCL reconstruction

Rehab and Return to Play


  • Needs to be updated

Return to Play

  • Non-surgical cases
    • Needs to progress through pain free physical therapy
    • Pain free throwing program
    • Usually about 8 to 12 weeks

Complications & Prognosis


  • Most athletes can return to competitive sports in 8 to 12 weeks


See Also


  1. Brogdon BG and Crow NF. Little leaguer's elbow. Am J Roentgenol 83: 671-675, 1960.
  2. Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med. 2005 Jan;15(1):37-40. Review. PubMed PMID: 15654190.
  3. Adirim T, Cheng T. Overview of injuries in the young athlete. Sports Medicine [serial online]. 2003;33(1):75-81. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 21, 2011.
  4. Klingele KE and Kocher MS. Little league elbow. Sports Med 32: 1005-1015, 2002
  5. Brenner JS. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics 119: 1242-1245, 2007.
Created by:
John Kiel on 30 June 2019 20:29:55
Last edited:
13 October 2022 14:07:11