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The Little League Elbow

The Little League Elbow. Thad Barkdull, MD Fellow, NCC Tri-Service Primary Care Sports Medicine Fellowship MAJ, MC, USA. Goals. Understand the history/mechanism of injury Develop a thorough differential diagnosis for a painful elbow Understand the findings to look for on physical exam

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The Little League Elbow

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  1. The Little League Elbow Thad Barkdull, MD Fellow, NCC Tri-Service Primary Care Sports Medicine Fellowship MAJ, MC, USA

  2. Goals • Understand the history/mechanism of injury • Develop a thorough differential diagnosis for a painful elbow • Understand the findings to look for on physical exam • Understand management and return to play criteria • Know when to refer

  3. History 11 year old Hispanic male complains of right elbow pain for the past 2 weeks. He states that the pain is better with rest, but worse when he pitches with his little league baseball team. He has been pitching for 2 years now, and started in a new league about 1 month.

  4. Other questions about his history?

  5. Important History • Hand dominance • Other sports participation • Past trauma/injury history • Number of pitches/type of pitches • How many teams • Side arm or overhead pitcher

  6. DDx What can cause elbow pain in the young athlete?

  7. UCL sprain/tear • Medial epicondyle avulsion fracture • C8-T1 radiculopathy • Ulnar neuritis • Osteochondrosis of medial epicondyle • Medial epicondylitis (“golfer’s elbow”) • Muscle strain/tear (flexor/pronator group) • Fascial Compartment Syndrome • Posteromedial olecranon osteophytosis • Septic arthritis • Tumor

  8. Physical Exam Appearance Palpation Range of Motion Provocative Tests

  9. Slight swelling over medial epicondyle and tenderness to palpation. The UCL was also tender to palpation. There was some slight tenderness over the flexor bundle distally. There was no evidence of gross atrophy of the muscle. • Strength was 5/5 with extension and supination, 4+/5 with pronation and flexion, limited by pain. Normal distal sensation, pulses. Negative tinel’s with percussion of ulnar groove. • Pain with valgus stress at 20 degrees, no laxity • No neck tenderness, crepitus or step off, no gross shoulder pain or instability, nor any wrist/hand pathology noted.

  10. What studies will assist with this diagnosis?

  11. Final Diagnosis?

  12. Management • Acute • PRICEMM • Encourage especially rest and ROM • Rehabilitation • Non-painful ROM • ADLs without pain • Usually 4-8 weeks • Assess pitching mechanics with professional

  13. Return to Play • When able to perform sport specific activity without pain • Educate athlete, coaches, and family • Sports activity no more than 9 months/year • No more than about 100 pitches per game or in practice, including outside of practice • No more than six innings per week; 3 innings in a game = no pitch next day; 4+ innings = 3 days of rest No sliders or curve balls for the young athlete

  14. RED FLAGS • Hot Joint • Increased laxity • Exam doesn’t match history • No improvement with appropriate, compliant therapy • Fracture on radiograph

  15. Conclusion • Ensure full history of arm usage in sport • Usually good history, exam, radiographs are sufficient • Consider further modalities only with failure to improve with rest (also consider compliance) • EDUCATE EDUCATE EDUCATE

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