Updated: May 5
Little League Elbow Cause
Little League elbow refers to damage of the growth plate along the inside of the elbow. The image below courtesy of sportsmd.com shows the relative location of the injury.
I previously wrote about little league shoulder in a blog post here if you are interested, as it is a similar process. The growth plate refers to an area of cartilage at the end of bones. It is called the growth plate because the bones grow longer from the cartilage, but it is weaker than the surrounding bone. Growth plate injuries including little league elbow are most prevalent from the ages of 8-15 because that is when growth rates peak.
Typically, we worry about the UCL in the elbow and Tommy John surgery as being the worst case outcome for a pitcher. Interestingly, the growth plate in the elbow is actually the weakest point structurally, even more so than the UCL. UCL tears are possible at a young age, but the growth plate is more likely to suffer damage first.
There are many possible causes of little league elbow, but one of the most common is inadequate strength. Before puberty, it can be difficult to gain muscle to support the arm during the throwing motion, which is the fastest movement in all of sports. We often do a poor job of promoting strength training in young baseball players for fear of them getting “too bulky” which is absurd. Any amount of strengthening can provide muscular support to lessen the force on the growth plate during throwing.
Young players are throwing harder than ever. While increased velocity has a huge benefit on the field, it does increase injury risk. Hurd, et al. showed that increased pitching velocity leads to greater force on the inner elbow, putting the growth plate at greater risk. Throwing a ball 70 miles per hour is going to stress your body more than throwing a ball 60 miles per hour in a vast majority of cases. As younger players throw harder than ever before, we will see more injuries that we associated with higher level players.
Throwing year round is also more prevalent than ever before. While there is conflicting evidence about injury risk and performance in older athletes, younger pitchers need time off from throwing. There are many more weak points including growth plates that need to be considered in young pitchers compared to a 30 year old pitcher. Taking time off from throwing can allow for healing as well as a focus on strength and movement quality to improve stress when returning to pitching for the baseball season.
Workload monitoring has come a long way, but there is still a lot that can be improved, particularly for younger athletes. Too often, pitchers play on multiple teams that have different pitch count rules. I have personally seen multiple athletes suffer injuries because they pitch a complete game and then catch the next day, adding hundreds of throws back to the mound. We need to continue monitoring overall throws and stress, not just pitches off of the mound during the game.
Little League Elbow Symptoms
Symptoms of little league elbow can vary depending on the individual and the severity of the injury, but they typically follow common patterns. Pain is usually located on the inside of the throwing elbow. Initially, it may only hurt with hard throws, but gradually the symptoms will include all throwing. Then, the athlete may notice some pain or soreness after throwing before eventually having pain most of the day and with activities other than throwing.
Gripping and twisting such as opening a door or can is a very stressful movement for the elbow and forearm. It is one of the most common painful motions other than throwing. Athletes may notice pain and/or weakness with movements that used to be easy for them. Swinging a bat may also be painful due to the grip and motion at the elbow.
Swelling can occur at the inner elbow if there is severe inflammation of the growth plate. Swelling should never be ignored, particularly in young athletes. Any noticeable inflammation around the pitching elbow warrants an immediate medical evaluation.
X-rays can diagnose a little league elbow based on damage to the growth plate. Repeated x-rays are used for return to sport to ensure that full healing of the growth plate has occurred. MRIs can provide information about the surrounding soft tissue if necessary.
Little League Elbow Treatment
Treatment for little league elbow is lengthy due to the slow healing nature of the growth plate. Commonly, 6 weeks of no throwing is prescribed followed by another x-ray to determine if the growth plate has healed. Physical therapy should be ongoing during this time to address other factors that may have contributed including strength, mobility, and mechanics. It is a good time to address underlying issues with 6 weeks off from throwing to allow for energy to be directed towards strengthening.
A return to throw program can begin once cleared by your medical provider, and it should be slow and gradual. While there may be important tournaments or games that athletes do not want to miss, it is important to understand that health is more important than performance. Setbacks can lead to a re-injury of the growth plate and 6 more weeks of not throwing. Physical therapy should be continuing at this time with all coaches and healthcare providers in communication to ensure the athlete’s health.
Workload is crucial to monitor at this time. As throwing ramps up, it may be necessary to decrease volume in the weight room. Communication between coaches is key to develop a comprehensive plan and react to any setbacks that occur.
Little League Elbow Exercises
While waiting for the injury to heal, elbow exercises are limited to protect the growth plate, but shoulder strengthening can be progressed. If gripping is painful, then utilizing J Bands (shown below on amazon.com) can be beneficial. The loops are perfect for sliding your hands through to allow for shoulder exercises without having to grip the band.
Exercises in a push up position such as the shoulder taps pictured below courtesy of gestrong.fit are also well tolerated. Gripping is not necessary and the elbow can be kept in a straightened position under load.
Once you are cleared to begin forearm exercises, isometrics are a great way to start. Isometric wrist flexion along with supination and pronation can provide blood flow and activation to the muscles without the stress of moving under load. Wrist flexion is pictured below courtesy of schoolwires.net. Isometric wrist supination and pronation would involve a similar set up but the other hand would resist twisting in both directions.
As recovery continues, it is important to introduce movement with strengthening. Simple exercises like tennis ball squeezes can increase forearm strength. Supination and pronation with a hammer as pictured below courtesy of hep2go.com, are excellent exercises to incorporate.
Eventually, you will want to increase weight to allow for actual strengthening of the muscles. Too often, we underload athletes in physical therapy and return them to the field before true strengthening has occurred. Biceps curls are excellent for grip strength as well as support during throwing. Wrist curls with heavy dumbbells can also strengthen the important forearm muscles that prevent stress on the growth plate.
Once strength has been addressed, the focus should shift to power. Plyo balls are a perfect introduction to throwing, as heavier balls are shown to exert less force on the elbow. Starting with a heavier ball for light throws can allow for acclimation to the throwing motion without the stress of throwing a light baseball. This is also an excellent time to work on mechanical changes in conjunction with a pitching coach.
Finally, it will be time to begin a return to throwing program. This should progress slowly to allow for proper recovery between throwing sessions and gradual stress buildup for the young athlete. Throwing programs should lead to long toss at maximal distance and throwing off of a mound at 100% before returning to a game setting. Oftentimes, athletes will throw harder coming out of this period due to relative rest along with strengthening of weak links in their kinetic chain (I discussed the kinetic chain here and the reason that people are stronger after elbow injuries here).
In summary, little league elbow is a complicated and difficult injury. Communication between providers is crucial, along with a long term plan to get back to baseball stronger than before. Fortunately, the time off from throwing can be used for a thorough assessment and to uncover weak links that may have been neglected. Addressing these issues can hasten recovery and hopefully prevent injury from reoccuring in the future.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about little league elbow and its symptoms and treatment. If you have interest in other elbow injuries, check out our elbow page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you want to subscribe so that you don’t miss any other posts, click the sign in button on the top right of this page. Once you have created an account, click the drop-down menu in the top right next to your name and go to your settings page. Click the subscribe button next to “Blog Subscription” and you won’t miss any future posts! If you are in the Northern Virginia area and would like to work with me or you have any questions, please email me at email@example.com or follow me on Instagram or Twitter @drdannydpt.