Medial Epicondyle Apophysitis

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

1. Definition
   1. Medial Epicondyle Apophysitis in child pitchers
2. Epidemiology
   1. Most common in ages 9 to 12
3. Mechanism
   1. High risk injury in child pitchers
   2. Frequent throwing puts repetitive stress across medial epicondyle Growth Plate
   3. Side-arm throwing increases the risk
4. 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
5. Symptoms
   1. Medial Elbow Pain with throwing a ball
   2. May effect pitch speed and accuracy
6. Signs
   1. Decreased elbow range of motion
   2. Localized swelling and tenderness over the medial epicondyle
      1. Tenderness increased if there is avulsion Fracture
7. 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
8. Differential Diagnosis
   1. Referred pain from Shoulder
9. Diagnosis
   1. Clinical diagnosis based on suspicion despite XRay
10. Management
    1. No throwing for 4-6 weeks
    2. Gradually advance throwing after 4-6 weeks of rest
    3. Surgical management is rare but may be considered if avulsion Fracture widely displaced
11. Prevention
    1. Allow for adequate recovery between outings
    2. Consider throwing mechanics evaluation
    3. Limit number of pitches per week and per outing
       1. Guidelines adjusted for age and pitch type
       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)
12. Management: Orthopedic referral indications
    1. Elbow Osteochondritis Dissecans
    2. Avulsion Fractures
13. Complications
    1. Results in chronic injury and decreased function
14. References
    1. Atanda (2011) Am Fam Physician 83(3): 285-91 [PubMed]
    2. Cain (2003) Am J Sports Med 31(4): 621-35 [PubMed]