TSRHC

Elbow Throwing Injuries

Throwing Injuries in the Elbow

Baseball injuries, particularly in pitchers and heavy throwers, are on the rise. Most of these, with early recognition, proper rest and treatment, will not need surgery. Read on to learn more about each of these unique elbow problems and for tips for preventing elbow injuries.

Throwing athletes perform many throws in practice, games, and tournaments. Overuse elbow problems can occur when the arm does not get proper rest. In some cases, injuries occur with sudden forceful motions. The provider considers the athlete’s stage of bone growth, throwing technique, pitching and rest schedule, and the history of the injury when evaluating a throwing athlete.

Here are some common diagnoses: 


Normal Elbow Anatomy

 

An immature elbow with normal growth areas visible around the elbow. These growth areas are made of cartilage and are weaker then bone or ligament. Therefore, they are susceptible to injuries including overuse injuries.

The elbow joint is a joint made up of three bones: upper arm bone (humerus) and the two bones in the forearm (radius and ulna). Muscles, ligaments, and tendons hold the elbow joint together.

The elbow is a combination hinge and pivot joint. The hinge part of the joint lets the arm bend like the hinge of a door; the pivot part lets the lower arm twist and rotate.

Cartilage is soft tissue that protects the bony surfaces. It is also found in young bones at areas that are still growing. These growth areas are at risk for injury.
 

 

“Little Leaguer’s Elbow” - Medial Epicondyle Apophysitis

This is the most common condition of the throwing child. It is typically caused by excessive throwing. The throwing motion puts stress on the middle side of the elbow because the tendons and ligaments of the forearm are pulling on the growing bone.

Pain typically occurs on the inside “bump” of the elbow during or after activity like throwing or pitching. Repeated pulling can tear ligaments and tendons away from the bone. The tearing may pull tiny bone fragments with it in the same way a plant takes soil with it when it is uprooted. This can disrupt normal bone growth, resulting in deformity and instability with throwing.

Symptoms

  • Elbow pain with throwing or after activity.
  • Pain and tenderness on the inside of the elbow (on the bump).
  • May have soreness for days to weeks.
  • Worsening control with throwing.
  • Inability to throw desired distance.
  • May have difficulty fully straightening or bending the elbow.
  • May have locking of the elbow.

Treatment

  • Rest. Continuing to throw may lead to major complications and jeopardize a child’s ability to remain active in a throwing sport.
  • Common recommendations include 2-4 weeks of complete rest.
  • Apply ice packs to bring down any swelling.
  • Proper stretching and strengthening.
  • May require a cast or splint if the pain does not resolve with rest.
  • Therapy to focus on flexibility, strength and trunk and scapular stabilization.
  • Focused training to improve throwing form is needed.
  • Surgery to stabilize the medial epicondyle is rarely necessary, especially in girls older than 12 years and boys older than 14 years.
     



Avulsion Fracture of the Medial Epicondyle

An avulsion fracture occurs when the muscles and tendons pull off a piece of bone that is connected by cartilage to the main bone. A strong pull of the forearm muscles, during a pitch for example, can cause an avulsion fracture of the medial epicondyle on the inside of the elbow.

With this injury, the athlete will typically hear a pop and will have severe pain, swelling, and bruising. The child may or may not have had elbow pain before the injury.  With operative or non-operative treatment, most kids will return to the same level of sports following treatment.

Symptoms

  • May hear a pop or giving way.
  • Immediate pain on inside of the throwing elbow.
  • Immediate swelling and bruising is seen.
  • May have pain with wrist movement.
  • May have numbness or tingling in the ring finger and small finger.
  • Unable to bend the elbow or pick up heavy objects.

Treatment

  • Ice pack may be helpful to reduce inflammation in early stages.
  • Anti-inflammatory medication may be needed.
  • For fractures that are in good position, a splint is recommended for 2-3 weeks.
  • In all cases, aggressive range of motion early in healing stages (within 2-3 weeks) is recommended.
  • Therapy to focus on flexibility, strength, trunk and scapular stabilization.
  • Strengthening and proper throwing progression is recommended 8-12 weeks following injury.
  • Focused training to improve throwing form is needed.
     



Osteochondritis Dissecans of the Elbow

A less common condition, called osteochondritis dissecans (OCD), is also caused by excessive throwing. Because of the pulling of the muscles on the inside of the elbow, there is pushing, or compression, of the bones on the outside. The pressure on the immature bones can loosen a piece of the bone and cartilage.

 

Capitellar Osteochondritis Dissecans: Repeated activity, such as throwing, causes damage to the cartilage surface of the bone. Compression of the radial head on the capitellum occurs with each throw. This is often a progression of the pulling injury on the other side of the joint. 
 

Symptoms

  • Dull achiness on the outside of the elbow.
  • Pain that is worse with activity and improved with rest.
  • Pain that gradually worsens over time.
  • Unable to completely straighten the arm.
  • Popping and locking can be common.

Treatment

  • Rest. Continuing to throw with this problem may lead to major complications and jeopardize a child’s ability to remain active in a throwing sport.
  • Strict activity restrictions to protect the elbow from further injury with throwing.
  • Immobilization may be necessary in severe cases, or if restrictions are not followed.
  • Surgical treatment may be indicated if it does not heal or the tissue becomes unstable or loose.
  • Therapy to focus on flexibility, strength, trunk and scapular stabilization.
  • Resume throwing at a minimum of 6-12 months.
  • Focused training to improve throwing form is needed.
     

Olecranon Apophysitis

With repeated throwing, inflammation of the cartilage on the back of the elbow can occur. When this occurs, a growing athlete may have pain during follow through or when straightening the elbow.  In the older adolescent, bone spurs and stress fractures can also occur in this area.  Without proper rest and treatment, pieces of cartilage can tear away; these loose pieces may need to be surgically removed.

Symptoms

  • Pain in the back of the elbow during follow through and when straightening arm
  • Pain in the back of the elbow that becomes gradually worse over time
  • Unable to completely straighten the arm
  • Locking and popping may be present, but this is rare

Treatment

  • Rest. Continuing to throw may lead to major complications and jeopardize a child’s ability to remain active in a throwing sport.
  • Common recommendations include 2-4 weeks of complete rest.
  • Ice pack may be helpful to reduce inflammation.
  • Anti-inflammatory medication may be needed.
  • Therapy to focus on flexibility, strength, trunk and scapular stabilization.
  • Focused training to improve throwing technique form is necessary needed.
  • Surgery is rarely needed and only in severe cases.

Ulnar Collateral Ligament (UCL) Injury

Injuries to the UCL are more commonly seen in the older adolescent but may occur in the younger athletes as well. Elbow stability is crucial for a throwing athlete. The UCL is the most important stabilizer for the inside of the elbow. With repetitive throwing, the UCL becomes stretched and has small tears. This is painful and ultimately leads to instability in the elbow. These injuries rarely occur with a single event or throw.

Typically, the pain is on the inside of the elbow a just below the bony bump where medial epicondyle apophysitis can occur. X-rays are often normal. An MRI, with contrast injected in the joint, gives the best view of a tear.

The surgical reconstruction of the UCL is named after Tommy John.  He was a baseball player who returned to major league pitching after having this procedure. There is a misperception that having this surgery will lead to improved performance. Though many athletes do return to play after this procedure, preventing the injury is ideal.

Symptoms

  • Pain over the inside of the elbow with throwing.
  • Gradually increasing pain.
  • May feel unstable or “give way.”
  • Rarely popping.

Treatment

  • Rest for at least 6-12 weeks. Continuing to throw may lead to major complications and jeopardize a child’s ability to remain active in a throwing sport.
  • Immobilization for 4-6 weeks followed by a hinged elbow brace.
  • Anti-inflammatory medication may be needed.
  • Therapy to focus on flexibility, strength, trunk and scapular stabilization.
  • Surgery is typically needed for complete tears, or if the elbow is unstable.
  • Focused training to improve throwing form is needed.


Elbow Injury Prevention in Young Athletes

Throwing elbow injuries in our youth are PREVENTABLE. Parents and coaches are advocates for their young athletes.

Tips to avoid throwing related injuries:

  • Follow pitch count guidelines.
  • Perform proper warm-up and stretching.
  • Learn and maintain proper form.
  • Stop pitching when tired and form becomes worse.
  • Never pitch with pain.
  • Never pitch on consecutive days.
  • Avoid year-round play.
  • Avoid playing on multiple teams during a single season.
  • Never use a radar gun.
  • Serious pitchers should consider using a pitching coach.
  • Do not focus on a single sport until at least 14 years old
  • Cross train and perform exercises to help with trunk and scapular stabilization.

An exact number of pitches per game may not the problem. However, the cumulative effects of excessive pitching are problematic. Monitoring and limiting pitches per game, innings per game and ensuring proper rest breaks are believed to reduce the risk of injury to the growth plates. Here are some current guidelines in place to help parents and coaches.
 

MAXIMUM PITCH COUNTS 

Little League Age (years)

Maximum pitches per day

7 - 8

50

9 -10

75

11 - 12

85

13 - 16

95

17 - 18

105

Source: Little League™ Baseball

REST PERIODS REQUIRED BETWEEN PITCHES

Ages 14 and under

Ages 15 - 18

Required # of Rest Pitches

66+

76+

4 calendar days

51-65

61-75

3 calendar days

36-50

46-60

2 calendar days

21-35

31-45

1 calendar day

1-20

1-30

None

Source: Little League™ Baseball

 

AGE RECOMMENDED FOR
LEARNING VARIOUS PITCHES 

Pitch

Age

Fastball

8

Change-up

10

Curveball

14

Knuckleball

15

Slider

16

Forkball

16

Screwball

17

Source: USA Baseball Medical and Safety Advisory Committee Pitching Guidelines

 

 

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