Medial Epicondyle Apophysitis

Aka: Medial Epicondyle Apophysitis, Little Leaguer's Elbow, Apophysitis of the Medial Epicondyle, Thrower's Elbow, Pitcher's Elbow

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II. Definitions

  1. Medial Epicondyle Apophysitis (Little Leaguer's Elbow)
    1. Medial Epicondyle Apophysitis in child pitchers

III. Epidemiology

  1. Most common in ages 9 to 13 years
  2. Affects 20-40% of school aged pitchers

IV. Mechanism

  1. High risk injury in child pitchers
  2. Traction injury at medial epicondyle physeal plate due to repetitive valgus load
    1. Frequent throwing puts repetitive stress across medial epicondyle Growth Plate
    2. Side-arm throwing increases the risk

V. Pathophysiology

  1. Medial elbow
    1. Ulnar ligament avulsed
    2. Pulls medial epicondyle from physis
  2. Lateral elbow (secondary to changes at medial elbow)
    1. Capitellum compresses into radial head

VI. Risk Factors

  1. High pitch counts per game
  2. Recently increased innings pitched
  3. Pitching on multiple teams
  4. Coaches encourage harder pitching
  5. Radar gun use to measure pitching speed
  6. Inadequate time off from sport during the year

VII. Symptoms

  1. Medial Elbow Pain in the dominant arm with throwing a ball
  2. May affect pitch speed and accuracy

VIII. Signs

  1. Decreased elbow range of motion
  2. Localized swelling and tenderness over the medial epicondyle
    1. Tenderness increased if there is avulsion Fracture
  3. Provocative maneuvers
    1. Palpation of medial epicondyle
    2. Resisted wrist flexexion and pronation

IX. Imaging: XRay elbow with comparison view of opposite side

  1. Often normal
  2. Findings suggestive of Apophysitis
    1. Medial epicondyl hypertrophy
    2. Widening or avulsion at apophysis
    3. Medial epicondyle fragmentation

X. Differential Diagnosis

  1. Referred pain (esp. Shoulder)
  2. Medial epicondyle avulsion Fracture (Salter Harris IV)

XI. Diagnosis

  1. Clinical diagnosis based on suspicion despite XRay

XII. Management

  1. No throwing for 4-6 weeks (esp. overhead throwing)
  2. Analgesics (Acetaminophen, NSAIDs)
  3. Gradually advance throwing after 4-6 weeks of rest
    1. May return to competitive throwing after 3 months
  4. Muscle Strengthening (Scapular retractors)
  5. Specific thrower rehabilitation programs
    1. Advanced Thrower's Ten
      1. https://www.ortho.ufl.edu/sites/ortho.ufl.edu/files/handouts/Throwers-Ten.pdf
  6. High recurrence rate (avoid repeat repitive injury)
  7. Surgical management is rare but may be considered if avulsion Fracture widely displaced

XIII. Prevention

  1. Allow for adequate recovery between outings
  2. Consider throwing mechanics evaluation
  3. Avoid rotating through pitching and catching for the same team
  4. Allow for 4 months free of throwing per year (including 2 contiguous months)
  5. Limit number of pitches per week and per outing
    1. Guidelines adjusted for age and pitch type
      1. Age 9-12 years: Max of 6 innings, and pitch count <250
      2. Age 13-15 years: Pitch count 300-350
    2. AAP: 200 pitches/week and 90 pitches/outing
    3. USA-BMSAC: 125 pitches/week and 75 pitches/outing
    4. Limitation of curve balls and sliders is most critical (excessive torque)

XIV. Management: Orthopedic referral indications

  1. Elbow Osteochondritis Dissecans
  2. Avulsion Fractures

XV. Complications

  1. Results in chronic injury and decreased function

XVI. References

  1. Achar (2019) Am Fam Physician 99(10): 610-8 [PubMed]
  2. Atanda (2011) Am Fam Physician 83(3): 285-91 [PubMed]
  3. Cain (2003) Am J Sports Med 31(4): 621-35 [PubMed]
  4. Lintner (2023) Am Fam Physician 108(6): 544-553 [PubMed]

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