Elbow Pain in Adolescents Kevin deWeber, MD, FAAFP Director, Tri-Service Sports Medicine Fellowship

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

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

Other questions about his history?

Hand Dominance

Other questions about his history? Hand Dominance Other sports participation

Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history

Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history Number of pitches/type of pitches

Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history Number of pitches/type of pitches How many teams?

Other questions about his history? Hand Dominance Other sports participation Past trauma/injury history Number of pitches/type of pitches How many teams? Side arm or overhead pitcher?

DDx What can cause elbow pain in the young athlete?

DDx What can cause elbow pain in the young athlete? UCL sprain/tear

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Ulnar neuritis

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis Medial epicondylitis (“golfer’s elbow”)

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis Medial epicondylitis (“golfer’s elbow”) Muscle strain/tear (flexor/pronator group)

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis Medial epicondylitis (“golfer’s elbow”) Muscle strain/tear (flexor/pronator group) Fascial Compartment Syndrome

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis Medial epicondylitis (“golfer’s elbow”) Muscle strain/tear (flexor/pronator group) Fascial Compartment Syndrome Posteromedial olecranon osteophytosis

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis Medial epicondylitis (“golfer’s elbow”) Muscle strain/tear (flexor/pronator group) Fascial Compartment Syndrome Posteromedial olecranon osteophytosis Septic arthritis

DDx What can cause elbow pain in the young athlete? UCL sprain/tear Medial epicondyle avulsion fracture C8-T1 radiculopathy Osteochondrosis of medial epicondyle Ulnar neuritis Medial epicondylitis (“golfer’s elbow”) Muscle strain/tear (flexor/pronator group) Fascial Compartment Syndrome Posteromedial olecranon osteophytosis Septic arthritis Tumor

Physical Exam Appearance Palpation Range of Motion Provocative Tests

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.

Are radiology studies necessary for diagnosis? Insidious onset: NO Acute onset: YES

Diagnosis?

Little Leaguer’s Elbow Catch-all phrase for elbow pain in young throwing athletes

Medial Epicondyle Apophysitis Management Acute: control pain “PRICEMM” Relative rest Modalities Ice, compression Brief medication Long-term : Rehabilitation Non-painful ROM ex Core strength and shoulder strength Gradual return to activity FROM and ADLs w/o pain Easy throwing Assess pitching mechanics with professional Non-pitching position Return to pitching 4-8 weeks

Anatomy Review

Throwing creates predictable force loads across the elbow –Medial elbow traction –Lateral elbow compression –Translational forces across the humerus and olecranon

Anterior Compartment Anterior capsular stretching Bicipital tendonitis Biceps and/or brachialis muscle weakness Osteochondritis dissecans Medial Compartment Medial apophysitis Ulnar collateral ligament sprain Flexor and/or pronator muscle strain Avulsion of the apophysis Ulnar nerve neuritis Little Leaguer’s Elbow Differential Diagnosis Posterior Compartment Olecranon tip impingement Olecranon apophysitis Triceps tendinitis Lateral Compartment Extensor and/or supinator muscle strain Lateral apophysitis Anconeus muscle strain Suprachondral fracture

Clinical Features History Insidious onset of pain, usually medial Decreased accuracy or distance Physical Tenderness in the medial, lateral or posterior elbow +/- mild flexion contracture, esp w/ avulstion fx Assess ulnar collateral ligament stability at 20° flexn Distal neuro exam

X-rays: Decreased ROM Avulsion suspected (acute onset) Side-to-side comparison useful; amount of ME displacement MRI Pain vague Dx not certain by exam & x-ray Suspected loose bodies Crepitus, locking THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 8 - AUGUST 97 Imaging Indications

Medial physis widened Medial apophyseal avulsion

Osteochondritis of capitellum and loose bodies Loose bodies seen arthroscopically

Sports Medicine Referral Indications Unsure of dx or tx No improvement with appropriate, compliant therapy Lateral lesions

Ortho Referral Indications Hot Joint Increased joint laxity Fractures Avulsed apophysis >5mm Loose bodies causing ROM deficits

Prevention Educate athlete, coaches, and family Sports activity no more than 9 months/year No sliders or curve balls <13 y/o

Prevention 2006 Little League pitching guidelines Restriction of pitches per game Age 10 or under: 75/day 11-12: 85/day 13-16: 95/day 17-18: 105/day Mandatory rest days after varying # of pitches 1-25 pitches: 1 rest day pitches: 2 rest days pitches: 3 rest days >75 pitches: 4 rest days Rest days if soreness develops Regular strengthening program

Take Home Messages Know full athletic history Bilateral x-rays Emphasize compliance EDUCATE EDUCATE EDUCATE

QUESTIONS?