What is Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)?
Medial epicondyle apophysitis (MEA), also known as ‘little league elbow’, is a common injury from overuse often found in young athletes who frequently use overhead throwing, play with rackets, or perform other overhead arm motions in their sport. The medial epicondyle is a small, bony bump on the inside of your elbow, and it has its own growth center, separate from the end of the upper arm bone. This growth center, which is called an apophysis, starts to develop around the age of 6-7 and typically joins with the rest of the bone by age 15. The inner side of the elbow joint is supported and stabilized by a ligament (the UCL) and muscle groups that start at this point.
MEA happens due to excessive and repetitive sideways stress on this growth center before it fully fuses with the bone. Over time, this repetitive strain can lead to an injury similar to when muscles or tendons are pulled too hard, and can cause harmful swelling and stretching of the growth center or even a small bone fracture. MEA can cause significant discomfort in young athletes, who then need to take time off from their sport until the pain eases and the healing process has finished. Properly preventing, identifying, and promptly treating MEA can help young adolescents to keep participating in the sports they love without long breaks in their activity.
What Causes Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)?
Performing overhead throws or serves in sports, such as baseball, volleyball, or tennis, can put a lot of stress on your elbow. This repeated motion can lead to a condition known as medial epicondyle apophysitis. This is a type of inflammation or irritation of a specific part of your elbow. It’s most commonly associated with baseball pitching.
Several factors increase the risk of developing this condition among baseball players. These include throwing a large number of pitches per game, pitching at high speeds, continuing to pitch even when your arm is tired, and playing on multiple baseball teams. Being a catcher or pitching for many innings and months per year can also potentially lead to medial epicondyle apophysitis. However, more research is needed on these specific factors.
Risk Factors and Frequency for Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
Medial epicondyle apophysitis, a condition affecting the elbow, specifically occurs in children between 6 and 15 years old. This is because around the age of 15, a part of the elbow known as the apophyseal ossification center fuses together. Interestingly, about 50% of all youth sports injuries are due to overuse.
Reports suggest that from 2011 to 2016, overall sports-related injuries in high school increased by 15%, whereas elbow-related injuries linked to baseball nearly doubled within the same period. Potential factors for this increase could be more kids participating in organized sports, young children facing high levels of competition, kids playing on multiple teams at the same time, and an early focus on a specific sport, often played all year round.
- In baseball, the likelihood of experiencing elbow pain tends to rise with age.
- The highest rate of medial epicondyle apophysitis usually occurs when a child is around 11 to 12 years old, affecting approximately 30% in this age group.
- For instance, observations from Little League Baseball championships revealed that 57% of participants displayed signs of potential displacement in the medial epicondyle region of the elbow.
- While females generally experience more overuse injuries from sports, medial epicondyle apophysitis appears to be more common in boys since more boys play baseball.
- However, it is unclear whether boys are physiologically more prone to this condition, or if it is simply that they are more exposed to activities that could trigger the condition.
Signs and Symptoms of Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
Medial epicondyle apophysitis, or irritation of the elbow joint, is a condition commonly found in young athletes between the ages of 6 and 15 who engage in sports that require repetitive overhead motions. Those affected may complain of gradual, increasing pain in the inner elbow, particularly when engaging in overhead throwing activities. This condition can negatively impact sports performance and physical endurance. In some cases, patients may also experience a sudden, intense pain accompanied by a “pop” – this could indicate a more serious injury like an avulsion fracture.
- Typical in young athletes aged 6-15 years
- Associated with sports requiring repetitive overhead motions
- Gradual escalation of inner elbow pain
- Deterioration in performance and physical endurance.
- Sudden severe pain with “pop” sound could indicate avulsion fracture
A physical examination is key to correctly identifying this condition. Symptoms could include tenderness in the inner elbow, experiencing pain when the elbow is bent outwards, and minor elbow stiffness. There are special diagnostic tests, such as the moving valgus stress test, which can help evaluate the condition. This involves the physician applying force to a fully bent elbow as it’s straightened out. If this recreates the inner elbow pain, the test is positive. An accompanying test, the “milking maneuver”, assesses the pain response when the elbow is bent at 90 degrees, while rotating the wrist outwards.
In instances where there’s a fracture involving the medial epicondyle, patients may display additional symptoms like a shaky elbow, limited motion range, and nerve-related issues affecting the nearby ulnar nerve. It’s also important for health professionals to carry out a comprehensive neurological exam to rule out any other potential causes of arm pain and weakness, which could originate from the wrist, shoulder, or neck.
Testing for Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
Imaging plays a key role in evaluating young athletes who display signs of a condition called medial epicondyle apophysitis (an inflammation of the inner elbow joint). This evaluation often begins with simple X-ray images taken from the front, back, and side of both elbows. Another image is taken of the elbow bent at 90 degrees while a gentle force is applied to it.
In these X-rays, medial epicondyle apophysitis can be seen as a widened inner elbow joint, with an irregular, hardened border around the growth area of the bone. One typically sees this condition in the right elbow, whereas the left elbow looks normal. If the joint on the X-ray shows more than 3 millimeters of separation, it suggests that the elbow may be unstable.
Besides X-rays, ultrasound can also be used in a clinical setting as a tool for identifying this condition. An experienced doctor can use ultrasound to detect medial epicondyle apophysitis with 88% accuracy. However, the implications of a negative ultrasound result (i.e., one that doesn’t show the condition) in a patient with symptoms haven’t been fully researched. Therefore, even if ultrasound is used, an X-ray evaluation is still recommended for confirmation.
It’s crucial to diagnose medial epicondyle apophysitis accurately by comparing X-rays of both elbows. This comparison helps to determine if there’s a pull-away fracture and to understand the person’s unique bone structure as one’s growing areas, called growth plates, close at different ages during adolescence. If the growth area in the elbow bone is missing on one side, or if the medical epicondyle growth area is missing but other growth areas in the elbow are present, this might suggest a pull-away fracture.
Advanced imaging techniques, such as CT scans and MRIs, are reserved for more severe cases like pull-away fractures or if the inflammation isn’t responding to treatment. These scans provide more precise information about the extent of the elbow injury and help doctors decide whether surgery or non-surgical treatment is required.
For older athletes nearing the end of their growth period, an MRI might be necessary to check for tears in the ulnar collateral ligament (a prominent ligament in the elbow).
Treatment Options for Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
Medial epicondyle apophysitis is a condition that comes from repetitive overhead arm motion, often seen in athletes. The primary treatment for this condition is to rest the affected arm and avoid the movements that caused the pain for 4 to 6 weeks. Pain can be managed with cold treatment (ice) and pain relievers like acetaminophen or non-steroidal anti-inflammatory medications.
Physical therapy to strengthen the elbow and shoulder can start after 6 weeks if the athlete is pain-free. The patient can also start to gradually return to their sport, with some limitations, over the following 6 weeks. However, the risk of the condition coming back is quite high, which could require more careful recovery management. If pain persists even after these breaks, the patient might need to stop participating in the sport for the rest of the season or consider a less demanding position.
A common complication related to this condition is when the small bump on the inside of the elbow (medial epicondyle) gets pulled away from the upper arm bone. This is known as an avulsion fracture. Thankfully, this usually heals well with non-surgical treatment. At first, a long arm cast is worn for 2 to 4 weeks, followed by a splint with some light exercises to keep the joint flexible. Once the tenderness is gone, the patient will wear a special elbow brace for another 6 to 8 weeks. After removing the brace, the patient can begin physical therapy to further strengthen the muscles around the elbow once the doctor confirms the bone is healing well.
If the elbow becomes loose, unstable, or if the fracture is severely out of place, the patient might need surgery to put the pieces back together. After surgery, the patient will follow a similar recovery plan to those who were treated without surgery. Some studies suggest that for fractures with less displacement, there’s no significant difference in outcomes between surgical treatment and non-surgical treatment.
What else can Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow) be?
When dealing with pain on the inside part of the elbow, doctors usually consider a few specific causes due to the unique anatomy involved. They typically look for a tear in a ligament called the ulnar collateral ligament, issues with the inner part of the elbow (medial epicondylopathy), problems with the ulnar nerve, or a nearby muscle injury.
- A tear in the ulnar collateral ligament can seem similar to an inflammation of the growth plate in the elbow (medial epicondyle apophysitis), but this typically happens in patients who are over 15 years old.
- Problems with the medial epicondyle can also seem like inflammation of the growth plate in the elbow but are usually seen in people who have reached skeletal maturity. X-rays can help tell these conditions apart.
- Ulnar neuropathy, which is a condition involving the ulnar nerve, should be considered if there is associated numbness or tingling in a pattern of the ulnar nerve.
- An injury to the muscle group that helps bend the wrist and elbow can cause muscle weakness and increased pain with wrist bending.
- A condition called valgus extension overload syndrome can occur in athletes who do a lot of throwing. The pain is located at the back of the elbow and gets worse at the end of a throw. It can be associated with the elbow locking up and crunching or crackling sounds.
As with any issues relating to the muscles and bones, the examining doctor needs to check the muscles, tendons, ligaments, and nerves for signs of injury. They should also do a comprehensive exam of the entire arm.
What to expect with Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
The outlook for people with medial epicondyle apophysitis, a condition commonly affecting the inner elbow, is typically excellent. Most cases get better with rest, or once a certain part of the elbow bone (called the apophysis) finishes growing.
About one-third of athletes with this condition are able to return to their sport. However, it’s common for the symptoms to come back.
In rare instances, the apophysis doesn’t join properly with the rest of the bone, even after it stops growing. This can result in leftover pieces of bone (ossicles), which can cause ongoing pain.
Failures in the joining process (nonunion) and sudden, forceful bone injuries (avulsion fractures) are more common in athletes who don’t have enough rest and don’t follow proper rehabilitation steps.
Possible Complications When Diagnosed with Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
One potential complication of a medical condition known as medial epicondyle apophysitis is an avulsion fracture of the medial epicondyle, which is common. There are, however, less common complications such as the broken piece of bone getting trapped inside the elbow joint, compression of the ulnar nerve, small remaining bone fragments, and ongoing pain. If the avulsed, or detached, epicondyle doesn’t heal correctly, these leftover bone pieces can stay in the joint. This may cause the joint to lock, ongoing pain, or compression of the ulnar nerve. These complications may require surgical treatment.
Athletes who had medial epicondyle apophysitis during their development may continue to experience pain even after their bone structure has fully matured, due to these leftover bone fragments. Surgical removal of these fragments or procedure known as tubercleplasty may help relieve these symptoms.
Possible Complications Include:
- Medial epicondyle avulsion fracture
- Trapped bone fragments in the elbow joint
- Ulnar nerve compression
- Persistence of small bone fragments
- Persistent pain
- Elbow joint locking
- Potential need for surgical treatment
- Persistent pain in mature athletes
Preventing Medial Epicondyle Apophysitis (Little League Elbow) ( Little League Elbow)
Preventing injuries mainly involves taking breaks and not overusing certain body parts, especially during high-risk activities. For young athletes, proper training in the correct posture and body movements could theoretically lessen the strain on their elbow and reduce injuries.
Organizations like Major League Baseball (MLB), the USA Baseball Medical and Safety Advisory Committee, and others have recommended guidelines around the number of pitches and breaks between games and seasons for young players. This is in an effort to lower the occurrence of injuries due to overuse of the elbow while throwing.
These guidelines have been shown to be effective — there’s been a clear connection between following these rules and fewer elbow injuries in young athletes. However, a 2012 survey found that only about 73% of youth baseball coaches were actually using these pitching recommendations. There’s a higher risk of overuse injuries in highly talented players who are often on the field. Parents, athletes, and coaches may be wary of taking time off for rest because of how much they contribute to the team.
Health professionals can play a big role in improving their patient’s health and making sure rest guidelines are followed. They do this by educating the coaches, parents, and athletes.
