Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: A variant of Little League elbow

Context:Many studies have explored closed kinetic chain (CKC) shoulder exercises (SEs) with a sling because they are safer and more effective than open-chain exercises, especially in early stages of treatment. However, the application of CKC SE in youth baseball players has rarely been attempted, although teenage baseball players also experience shoulder pain.Objective:To investigate the effects of CKC SE on the peak torque of shoulder internal rotation (IR) and external rotation (ER) in youth baseball players.Design:Single-group pretest, posttest.Setting:Biomechanics laboratory.Participants:23 Little League Baseball players with subacromial impingement syndrome.Interventions:The CKC SE with a sling was CKC shoulder-flexion exercise, extension exercise, IR exercise, and ER exercise. This exercise regimen was conducted 2 or 3 times/wk for 8 wk.Main Outcome Measures:The peak torque of shoulder IR and ER was measured using an isokinetic dynamometer. Concentric shoulder rotation was performed, with 5 repetitions at an angular velocity of 60°/s and 15 at 180°/s.Results:The IR and ER peak torque significantly increased at each angular velocity after the exercise program. In particular, the increase in IR and ER peak torque values was statistically significant at an angular velocity of 180°/s.Conclusions:CKC SE was effective in increasing shoulder IR and ER strength, demonstrating its potential benefits in the prevention and treatment of shoulder injury. In addition, increased IR peak torque appears to improve throwing velocity in baseball players.

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The Influence of Pitch Velocity on Medial Elbow Pain and Medial Epicondyle Abnormality Among Youth Baseball Players

The American Journal of Sports Medicine ◽

10.1177/0363546520914911 ◽

2020 ◽

Vol 48 (7) ◽

pp. 1601-1607 ◽

Cited By ~ 1

Author(s):

Daisuke Kurokawa ◽

Takayuki Muraki ◽

Hiroaki Ishikawa ◽

Kiyotsugu Shinagawa ◽

Hideaki Nagamoto ◽

...

Keyword(s):

Medial Epicondyle ◽

Level Of Evidence ◽

Baseball Players ◽

Elbow Pain ◽

The Past ◽

Youth Baseball ◽

Elbow Injuries ◽

Internal Rotation Angle ◽

Straight Leg Raise ◽

The Relationship

Background: Pitch velocity is associated with elbow injuries among skillful baseball players. However, the relationship between pitch velocity and throwing elbow injuries among youth players has not yet been clarified. Purpose: To investigate the influence of pitch velocity on medial elbow pain and medial epicondyle abnormality among youth baseball players. Study Design: Cohort study; Level of evidence, 3. Methods: The participants consisted of 256 elementary school players (mean age, 11 ± 1 years; range, 9-12 years). The medial aspect of the elbow was evaluated using ultrasound imaging. A questionnaire was used to investigate past or present pain in the elbow, background of the players (age, height, body mass index, and years of baseball experience), and playing environment (number of days of practice in a week, experience as a pitcher, and cryotherapy of the shoulder and elbow after practice). Positioning of the scapula, range of motion in shoulder internal/external rotations and hip internal rotation, angle of the straight-leg raise, and heel-to-buttock distance were measured. The pitch velocity was recorded using a pitch velocity radar gun. The relationship between these variables and the presence of medial epicondyle abnormality, as well as past or present elbow pain, were statistically analyzed. Results: A medial epicondyle abnormality was observed in 130 players (51%), elbow pain in the past in 65 players (25%), and elbow pain during the examination in 14 players (5%). Sixty-nine players (27%) experienced elbow pain either in the past or during examination. Abnormality of the medial epicondyle had a relationship with the pitch velocity (odds ratio [OR], 1.1 for increase of 1 km/h; 95% CI, 1.1-1.2; P < .0001) and the number of practice days in a week (OR, 1.8 for increase of the practice days; 95% CI, 1.4-2.5; P < .0001). Pitch velocity was also significantly related with past pain, present pain, and past and/or present pain of the elbow (OR [km/h], 1.1, 1.1, 1.1; 95% CI, 1.0-1.1, 1.0-1.2, 1.1-1.2; P < .0001, P = .002, P < .0001, respectively). Conclusion: Pitch velocity was significantly associated with abnormality of the medial epicondyle and elbow pain. A 10-km/h increase in pitch velocity would increase the risk of medial epicondyle abnormality and medial elbow pain by 3 times.

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Experience Rate of Elbow Pain and Morphological Abnormality of Humeral Medial Epicondyle among Youth Baseball Players

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967116s00121 ◽

2016 ◽

Vol 4 (7_suppl4) ◽

pp. 2325967116S0012

Author(s):

Yoshihiro Kotoura ◽

Toru Morihara ◽

Yoshikazu Kida ◽

Tsuyoshi Sukenari ◽

Ryuhei Furukawa ◽

...

Keyword(s):

Medial Epicondyle ◽

Morphological Abnormality ◽

Baseball Players ◽

Elbow Pain ◽

Youth Baseball

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Are the Current Little League Pitching Guidelines Adequate? A Single-Season Prospective MRI Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117704851 ◽

2017 ◽

Vol 5 (5) ◽

pp. 232596711770485 ◽

Cited By ~ 15

Author(s):

Andrew V. Pytiak ◽

Phillip Stearns ◽

Tracey P. Bastrom ◽

Jerry Dwek ◽

Peter Kruk ◽

...

Keyword(s):

Physical Examination ◽

Significant Loss ◽

Mri Findings ◽

Level Of Evidence ◽

Baseball Players ◽

Guideline Compliance ◽

Arm Pain ◽

Little League ◽

Significant Difference ◽

Youth Baseball

Background: Little League throwing guidelines have recently been implemented in an attempt to lessen the growing number of elbow injuries occurring in youth baseball players. Hypothesis/Purpose: The purpose of this study was to examine pre- and postseason changes seen on magnetic resonance imaging (MRI) in youth baseball players’ elbows in an attempt to identify risk factors for pain and MRI abnormalities, with a particular focus on the current Little League guidelines. We hypothesized that MRI abnormalities would be common in pitchers with high pitch counts and poor guideline compliance. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective study of Little League players aged 10 to 13 years was performed. Players were recruited prior to the start of the season and underwent bilateral elbow MRI as well as a physical examination and completed a questionnaire addressing their playing history and arm pain. At the end of the season, a repeat MRI and physical examination were performed. MRIs were read by blinded radiologists. During the season, player statistics including innings played, pitch counts, and guideline compliance were recorded. Physical examination findings and player statistics were compared between subjects with and without MRI changes utilizing chi-square and analysis of variance techniques. Results: Twenty-six players were enrolled. Despite 100% compliance with pitching guidelines, 12 players (48%) had abnormal MRI findings, and 28% experienced pain during the season. There was a significant difference in distal humeral physeal width measured pre- to postseason (1.54 vs 2.31 mm, P < .001). There was a significant loss of shoulder internal rotation during the season, averaging 11°. While pitch counts, player position, and throwing curveballs/sliders were not significantly associated with changes seen on MRI, year-round play was associated with abnormalities ( P < .05). Much lower compliance (<50%) was observed with nonenforced guidelines, including avoidance of single-sport specialization, year-round play, and throwing curveballs/sliders. Conclusion: Arm pain and MRI abnormalities of the medial elbow are common in Little League baseball players who comply with the Little League throwing guidelines, especially those playing year-round.

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Asymptomatic Medial Elbow Ultrasound Abnormality in Youth Baseball Players Is an Independent Risk Factor for Elbow Injury: A Prospective Cohort Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120986791 ◽

2021 ◽

Vol 9 (4) ◽

pp. 232596712098679

Author(s):

Hitoshi Shitara ◽

Tsuyoshi Tajika ◽

Takuro Kuboi ◽

Tsuyoshi Ichinose ◽

Tsuyoshi Sasaki ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Cohort Study ◽

External Rotation ◽

Medial Epicondyle ◽

Baseball Players ◽

Elbow Pain ◽

Elbow Injury ◽

Youth Baseball ◽

Elbow Injuries

Background: Youth baseball players who experience elbow pain during the season frequently exhibit radiographic elbow abnormalities. However, it is unknown whether asymptomatic elbow abnormalities are risk factors for in-season elbow injuries. Purpose: To determine whether the preseason presence of asymptomatic medial epicondyle apophysitis is a risk factor for in-season elbow injuries in youth baseball players. Study Design: Cohort study; Level of evidence, 2. Methods: Youth baseball players (N = 210; age range, 7-12 years) with no pain or history of injury in their throwing arms underwent preseason evaluations that included shoulder and elbow range of motion measurements, shoulder muscle strength testing, and ultrasound elbow scans with a multifrequency 13-MHz linear array transducer. Over 1 year of play, the players and their parents maintained daily elbow pain diaries. Elbow injuries were defined as medial elbow symptoms that prevented ball throwing for ≥8 days. Results: The preseason ultrasound evaluation revealed medial epicondyle apophysitis in 59 players. In the year following, elbow injuries occurred in 17 (28.8%) players with preseason medial epicondyle apophysitis and 18 (11.9%) players without apophysitis. Independent predictors of elbow injuries were preseason medial epicondyle apophysitis (odds ratio [OR], 2.488; 95% confidence interval [CI], 1.152-5.376; P = .02) and deficits of abduction (ABD) and external rotation of the dominant shoulder (OR, 0.963; 95% CI, 0.936-0.992; P = .012). Conclusion: Asymptomatic medial epicondyle apophysitis and ABD and external rotation deficits in the dominant shoulder were risk factors for elbow injuries in 7- to 12-year-old youth baseball players. These findings may aid in the design of programs to prevent elbow injuries in this population.

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Prevalence and Consequences of Sport Specialization Among Little League Baseball Players

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120970956 ◽

2021 ◽

pp. 194173812097095

Author(s):

Eric G. Post ◽

Michael D. Rosenthal ◽

Andrew T. Pennock ◽

Mitchell J. Rauh

Keyword(s):

Cross Sectional Study ◽

Patient Reported Outcome ◽

Online Questionnaire ◽

Level Of Evidence ◽

Cross Sectional ◽

Baseball Players ◽

Little League ◽

Patient Reported ◽

Youth Baseball ◽

Level 3

Background: Baseball is one of the most popular boy’s youth sports, and there has been a rise in the rates of certain overuse injuries among players. Specialization has been identified as a risk factor for overuse injury in high school athlete populations, but there is little understanding of the prevalence or consequences of sport specialization in Little League baseball players. Hypothesis: Sport specialization will be highly prevalent among Little League baseball players and specialization will be associated with worse throwing arm health. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: A total of 246 Little League baseball players (male; N = 241; age, 9.5 ± 1.6 years) between 7 and 12 years old completed an anonymous, online questionnaire with their parent’s assistance. The questionnaire consisted of participant demographics and baseball participation information, including sport specialization status and the Youth Throwing Score (YTS), a valid and reliable patient-reported outcome measure for youth baseball players. Results: Only 29 (11.8%) players met the criteria for high specialization. Approximately one-third of all players (n = 77; 31.3%) reported participating in baseball year-round or receiving private coaching outside of their league (n = 81; 32.9%). Highly specialized athletes demonstrated worse scores on the YTS on average compared with low-specialization athletes (mean [SE]: 56.9 [1.6] vs 61.1 [1.2]; P = 0.01). Similarly, pitching in the previous year ( P < 0.01) or traveling overnight regularly for showcases ( P = 0.01) were associated with a worse score on the YTS. Conclusion: While the prevalence of high sport specialization was low among Little League baseball players, other behaviors associated with specialization such as year-round play and the receiving of private coaching were more common. Highly specialized Little League players demonstrated worse throwing arm health compared with low-specialization players. Clinical Relevance: Little League players and their parents may represent a potential target audience for dissemination campaigns regarding sport specialization.

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Medial Epicondyle Apophyseal Avulsion Fractures in Youth Throwers: A Severe Variant of Little League Elbow (132)

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00275 ◽

2021 ◽

Vol 9 (10_suppl5) ◽

pp. 2325967121S0027

Author(s):

Evan Zheng ◽

Donald Bae ◽

Carley Vuillermin ◽

Yi-Meng Yen ◽

Patricia Miller ◽

...

Keyword(s):

Tertiary Care ◽

Medial Epicondyle ◽

Implant Removal ◽

Acute Injury ◽

Control Group ◽

Elbow Fracture ◽

Elbow Pain ◽

Avulsion Fractures ◽

Little League ◽

Significant Difference

Objectives: Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The current study sought to characterize presenting features, treatment options, and clinical results of a large cohort of pre-adolescent and adolescent patients who presented with these fractures. Methods: Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were fractures sustained during non-throwing activity or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently by fellowship-trained pediatric orthopaedic surgeons or sports medicine physicians on a case-by-case basis. Patients treated with open reduction and internal fixation (ORIF) were compared to those treated non-operatively, and all fracture patients were compared to a larger control group of patients diagnosed with medial epicondyle apophysitis/Little League elbow with no fracture. Results: During the study period, a total of 317 patients were diagnosed with Little League elbow due to medial epicondyle apophyseal overuse injury, 50 of whom (16%) sustained a discreet, radiographically confirmed epicondyle fracture sustained during a single throw. Median age of the fracture cohort at presentation was 13.1 years (range 8 years – 16 years). Forty-nine fracture patients (98%) were male baseball pitchers and one (2%) was a male football quarterback. Fracture patients had significantly higher median BMI (21.3 kg/m2 vs. 19.2kg/m2, p=0.004) than the apophysitis control group, but there was no significant difference in age. Of the 37 patients with documentation regarding pre-injury symptoms, 31 patients (84%) described pre-existing medical elbow pain prior to their acute injury, while 6 (16%) denied pain prior to the inciting throw. Of the 12 patients (24%) with documented shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Twenty-three patients (46%) were treated with ORIF (22 single screw fixation; 1 suture anchor fixation), while 27 (54%) were treated non-operatively. Median fracture displacement was significantly greater in operative patients than non-operative patients (5.0mm vs. 3.0mm, p=<.001), with all ‘minimally displaced’ (<4mm) fractures undergoing non-operative treatment (Figure 1). Multivariable analysis determined that for each additional mm of displacement, the odds of surgical intervention increased by 6.4 times (OR=6.36; 95% CI=1.83-22.07; p=.004), when controlling for age and BMI. All patients returned to their throwing sport (RTS) at a median of 12.8 weeks post-diagnosis, but 13 (26%) developed recurrent elbow pain, with no significant difference in in RTS time or recurrence rate between treatment cohorts. Nine of twenty-two (41%) screw ORIF patients underwent secondary implant removal, with no significant difference in this rate between those with or without a washer. Conclusions: Medial epicondyle apophyseal avulsion fractures in youth throwers represent a severe variant of Little League elbow, constituting approximately 16% of cases within the condition’s spectrum. These fractures may be effectively treated with either non-operative measures, particularly minimally displaced fractures <4mm, or ORIF, though >40% of operative patients may require implant removal. A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable.

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