Background & Etiology
The elbow joint is a connection point between the humerus (arm bone) and the radius and ulna (forearm bones.) Ligaments are strong, fibrous connective tissues made of collagen that attach bone to bone. These structures are a key component of a strong joint, providing stability and strength that allows the elbow to move with precision.
Ligaments can be stretched by an injury, excess strain on the joint, or through improper stretching techniques that weaken the elbow joint because stretched-out ligaments can cause joint instability. Ligaments can be highly susceptible to injury, and can lead to complications in the function of the joint. These injuries can range from sprains, which are typically mild, to tears that may require interventions like surgery to heal properly.
Little Leaguer’s Elbow
Injuries referred to as Little Leaguer’s Elbow are injuries that occur to the structures of the medial area of the elbow (the medial epicondyle, the medial epicondylar apophysis and the medial collateral ligament.) These conditions are typically the result of overuse and excess stress placed on the elbow joint, particularly by year-round athletic training.
As the name implies, this injury typically occurs in young or adolescent baseball or softball players, most often pitchers. The stress and strain that occurs during the “follow through” (throwing) phase and “cocking” (wind up and hold) phase of throwing a ball can lead to ligament laxity, and sprains or tears of the medial structures of the elbow.
Symptoms of Little Leaguer’s Elbow will vary depending on the severity of the injury, but they may include some or all of the following:
- Moderate to severe pain
- Loss of motion and weakness of the elbow
- Redness, discoloration or bruising over the injured area
- Stiffness
- Acute elbow pain when attempting to throw a ball.
- Possible deformity over the medial epicondyle.
Treatment for elbow ligament injuries may require resting the joint to allow pain and inflammation to subside. For severe injuries, like ligament tears surgery to reattach or repair the ligaments may be needed. How much movement should be restricted following the injury will depend on the severity of the ligament damage. Once cleared by the physician, a physical therapy program should be initiated to reverse the effects of immobilization and restore elbow motion.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the elbow and related muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the upper extremity, improve proximal joint stability and improve movement technique and mechanics (for example: throwing) in use of the involved upper extremity in daily activities especially overhead activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the elbow joint and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Post surgery immobilization can have detrimental effects that can be improved through physical therapy including:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased mobility of the joint and connective tissues
- Decreased circulation
- Loss of active and passive motion
- Progressing to strengthening
- Analysis and correction of poor throwing mechanics
Goals for physical therapy post surgery immobilization are optimal loading and restoration of normal tissue relationships to improve motion, strength and ability to perform functional activities of daily living.
Physical therapy interventions can help improve range of motion, strength, coordination, proprioception and endurance. Formal therapy and compliance with an extensive home program is the mainstay to restoring function of the elbow
The use of pain medications, immobilization, rest and ice are the first line of treatment. A course of physical therapy will help reduce inflammation, pain, and restore motion and strength. In severe case arthroscopic surgery may be indicated.
Prognosis
Rate of recovery and the prognosis for Little Leaguer’s Elbow will depend on a number of factors:
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually their pre-injury tissue integrity is better.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.
Prevention
- Discourage athlete from pitching at home during and after the season
- Restrict or eliminate the throwing of curveballs, sliders, and other breaking balls
- Shorten playing season
- Provide three to four rest days between pitching
- Allow for proper conditioning and warm-up
- Instruct throwing athlete in proper throwing mechanics
- Educate coaches and parents of the risk and prevention of this injury
