Elbow Pain in Adolescents

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Elbow Pain in Adolescents

• Kevin deWeber, MD, FAAFP
• Director, Tri-Service Sports Medicine Fellowship

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Goals

• Understand the history/mechanism of injury
• Develop a thorough differential diagnosis for a
  painful elbow
• Understand the findings to look for on physical
  exam
• Understand management and return to play criteria
• Know when to refer

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Case Study

• 11 year old Hispanic male complains of right
  elbow pain for the past 2 weeks. He states that
  the pain is present but better with rest, but
  worse when he pitches on his little league
  baseball team. He has been pitching for 2 years
  now, and started in a new league about 1 month
  ago.

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Other questions about his history?
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Other questions about his history?
Hand Dominance
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Other questions about his history?
Hand Dominance
Other sports participation
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Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
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Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Number of pitches/type of pitches
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Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Number of pitches/type of pitches
How many teams?
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Other questions about his history?
Hand Dominance
Other sports participation
Past trauma/injury history
Number of pitches/type of pitches
How many teams?
Side arm or overhead pitcher?
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DDx

• What can cause elbow pain in the young athlete?

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DDx
UCL sprain/tear

• What can cause elbow pain in the young athlete?

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DDx
UCL sprain/tear
Medial epicondyle avulsion fracture

• What can cause elbow pain in the young athlete?

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DDx
UCL sprain/tear
Medial epicondyle avulsion fracture

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
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DDx
UCL sprain/tear
Ulnar neuritis
Medial epicondyle avulsion fracture

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
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DDx
UCL sprain/tear
Ulnar neuritis
Medial epicondyle avulsion fracture

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Osteochondrosis of medial epicondyle
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DDx
UCL sprain/tear
Medial epicondylitis (golfers elbow)
Ulnar neuritis
Medial epicondyle avulsion fracture

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Osteochondrosis of medial epicondyle
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DDx
UCL sprain/tear
Medial epicondylitis (golfers elbow)
Ulnar neuritis
Medial epicondyle avulsion fracture
Muscle strain/tear (flexor/pronator group)

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Osteochondrosis of medial epicondyle
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DDx
UCL sprain/tear
Medial epicondylitis (golfers elbow)
Ulnar neuritis
Medial epicondyle avulsion fracture
Muscle strain/tear (flexor/pronator group)

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Fascial Compartment Syndrome
Osteochondrosis of medial epicondyle
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DDx
UCL sprain/tear
Medial epicondylitis (golfers elbow)
Ulnar neuritis
Medial epicondyle avulsion fracture
Posteromedial olecranon osteophytosis
Muscle strain/tear (flexor/pronator group)

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Fascial Compartment Syndrome
Osteochondrosis of medial epicondyle
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DDx
Septic arthritis
UCL sprain/tear
Medial epicondylitis (golfers elbow)
Ulnar neuritis
Medial epicondyle avulsion fracture
Posteromedial olecranon osteophytosis
Muscle strain/tear (flexor/pronator group)

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Fascial Compartment Syndrome
Osteochondrosis of medial epicondyle
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DDx
Septic arthritis
Tumor
UCL sprain/tear
Medial epicondylitis (golfers elbow)
Ulnar neuritis
Medial epicondyle avulsion fracture
Posteromedial olecranon osteophytosis
Muscle strain/tear (flexor/pronator group)

• What can cause elbow pain in the young athlete?

C8-T1 radiculopathy
Fascial Compartment Syndrome
Osteochondrosis of medial epicondyle
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Physical Exam

• Appearance
• Palpation
• Range of Motion
• Provocative Tests

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• Slight swelling over medial epicondyle and
  tenderness to palpation. The UCL was also tender
  to palpation. There was some slight tenderness
  over the flexor bundle distally. There was no
  evidence of gross atrophy of the muscle.
• Strength was 5/5 with extension and supination,
  4/5 with pronation and flexion, limited by pain.
  Normal distal sensation, pulses. Negative
  Tinels with percussion of ulnar groove.
• Pain with valgus stress at 20 degrees, no laxity
• No neck tenderness, crepitus or step off, no
  gross shoulder pain or instability, nor any
  wrist/hand pathology noted.

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• Are radiology studies necessary for diagnosis?

Insidious onset NO Acute onset YES
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Diagnosis?
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Little Leaguers Elbow

• Catch-all phrase for elbow pain in young throwing
  athletes

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Medial Epicondyle ApophysitisManagement

• Acute control pain
• PRICEMM
• Relative rest
• Modalities
• Ice, compression
• Brief medication

• Long-term Rehabilitation
• Non-painful ROM ex
• Core strength and shoulder strength
• Gradual return to activity
• FROM and ADLs w/o pain
• Easy throwing
• Assess pitching mechanics with professional
• Non-pitching position
• Return to pitching
• 4-8 weeks

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Anatomy Review
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• Throwing creates predictable force loads across
  the elbow
• Medial elbow traction
• Lateral elbow compression
• Translational forces across the humerus and
  olecranon

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Little Leaguers ElbowDifferential Diagnosis

• Anterior Compartment
• Anterior capsular stretchingBicipital
  tendonitisBiceps and/or brachialis muscle
  weaknessOsteochondritis dissecans
• Medial Compartment
• Medial apophysitis
• Ulnar collateral ligament sprainFlexor and/or
  pronator muscle strainAvulsion of the
  apophysisUlnar nerve neuritis

• Posterior Compartment
• Olecranon tip impingementOlecranon
  apophysitisTriceps tendinitis
• Lateral Compartment
• Extensor and/or supinator muscle strain
  Lateral apophysitis Anconeus muscle strain
  Suprachondral fracture

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Clinical Features

• History
• Insidious onset of pain, usually medial
• Decreased accuracy or distance
• Physical
• Tenderness in the medial, lateral or posterior
  elbow
• /- mild flexion contracture, esp w/ avulstion fx
• Assess ulnar collateral ligament stability at 20
  flexn
• Distal neuro exam

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Imaging Indications

• X-rays
• Decreased ROM
• Avulsion suspected (acute onset)
• Side-to-side comparison useful amount of ME
  displacement
• MRI
• Pain vague
• Dx not certain by exam x-ray
• Suspected loose bodies
• Crepitus, locking

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 8
- AUGUST 97
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Medial apophyseal avulsion
Medial physis widened
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Osteochondritis of capitellum and loose bodies
Loose bodies seen arthroscopically
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Sports Medicine ReferralIndications

• Unsure of dx or tx
• No improvement with appropriate, compliant
  therapy
• Lateral lesions

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Ortho ReferralIndications

• Hot Joint
• Increased joint laxity
• Fractures
• Avulsed apophysis gt5mm
• Loose bodies causing ROM deficits

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Prevention

• Educate athlete, coaches, and family
• Sports activity no more than 9 months/year
• No sliders or curve balls lt13 y/o

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Prevention2006 Little League pitching guidelines

• Restriction of pitches per game
• Age 10 or under 75/day
• 11-12 85/day
• 13-16 95/day
• 17-18 105/day
• Mandatory rest days after varying of pitches
• 1-25 pitches 1 rest day
• 26-50 pitches 2 rest days
• 51-75 pitches 3 rest days
• gt75 pitches 4 rest days
• Rest days if soreness develops
• Regular strengthening program

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Take Home Messages

• Know full athletic history
• Bilateral x-rays
• Emphasize compliance
• EDUCATE EDUCATE EDUCATE

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QUESTIONS?