Medial Epicondyle Apophysitis

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

1. See Also
   1. Apophysitis
2. Definitions
   1. Medial Epicondyle Apophysitis (Little Leaguer's Elbow)
      1. Medial Epicondyle Apophysitis in child pitchers
3. Epidemiology
   1. Most common in ages 9 to 12
   2. Affects 20-40% of school aged pitchers
4. Mechanism
   1. High risk injury in child pitchers
   2. Traction injury at medial epicondyle physeal plate
      1. Frequent throwing puts repetitive stress across medial epicondyle Growth Plate
      2. Side-arm throwing increases the risk
5. 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
6. Risk Factors
   1. High pitch counts per game
   2. Pitching on multiple teams
   3. Coaches encourage harder pitching
   4. Radar gun use to measure pitching speed
   5. Inadequate time off from sport during the year
7. Symptoms
   1. Medial Elbow Pain with throwing a ball
   2. May effect pitch speed and accuracy
8. 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
9. 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
10. Differential Diagnosis
    1. Referred pain (esp. Shoulder)
    2. Medial epicondyle avulsion Fracture (Salter Harris IV)
11. Diagnosis
    1. Clinical diagnosis based on suspicion despite XRay
12. 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
    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
13. 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. 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)
14. Management: Orthopedic referral indications
    1. Elbow Osteochondritis Dissecans
    2. Avulsion Fractures
15. Complications
    1. Results in chronic injury and decreased function
16. 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]