The Young Throwing Athlete

Every year when spring sports season rolls around, doctors see an increase in certain sports-related injuries in young athletes.

"Young athletes are skeletally immature," says Peter Kriz, MD, a sports medicine physician at The Center For Sports Medicine."Their growth plates have not yet closed. This unique quality makes them susceptible to a variety of elbow injuries that are not encountered in older throwing athletes."

Among the elbow injuries potentially seen in school-age and adolescent throwers:

• Medial epicondylar apophysitis (Little League Elbow)
• Medial epicondyle avulsion fractures
• Osteochondritis dissecans (OCD)

Prevention and Rehabilitation of Throwing Injuries

The Center For Sports Medicine is collaborating with Rhode Island Hospital/Hasbro Rehabilitation Services to provide dedicated throwing programs for young athletes recovering from throwing-related injuries. The programs focus on improving throwing mechanics, flexibility, core strength, while teaching how the entire kinetic chain — from the toes to the fingertips and transmits energy from the lower body to the upper body (including arm, hand, and fingers), and eventually to the ball.

In an era of year-round single sport participation, multi-league seasons and showcases for the adolescent athlete, the sheer volume of throwing the developing athlete may perform is staggering. Strong evidence suggests that programs which limit pitch counts among young throwers are effective in reducing overuse syndromes. The table below provides a program endorsed by USA Baseball’s Medical and Safety Advisory Committee; it also addresses commonly-asked questions by parents of young throwers.

Pitch Counts	Game	Week	Season	Year
9-10 years old	50	75	1000	2000
11 - 12 years old	75	100	1000	3000
13 - 14 years old	75	125	1000	3000
Pitch Type	Youth pitchers should avoid throwing breaking pitches (curves, sliders) until they reach physical maturity.
Multiple Appearances	Once a pitcher has been removed from a game, do NOT return him/her to the mound.
Showcases	Participation typically occurs at end/after season, increasing risk of serious arm injury due to fatigue/deconditioning. This should be discouraged unless proper rest/recovery can be provided.
Multiple Leagues	Pitching in multiple leagues is discouraged given the likelihood of exceeding pitch counts.
Year-Round Baseball (leagues, training)	Pitchers need a period of “active rest” after their season ends and before the next preseason begins. For at least 3 months per year, baseball pitchers should NOT play any baseball, participate in throwing drills, or other stressful overhead activities (football quarterback, competitive swimming, javelin throwing).
Technique/Conditioning	Proper mechanics should be taught as early as possible. Year-round physical conditioning (including core strengthening) can be started as the young athlete’s body develops.

Medial epicondylar apophysitis (Little League Elbow)

Medial epicondylar apophysitis, commonly referred to as Little League Elbow (LLE), is a condition that frequently presents in young throwers, usually 9 to 14 years old.

LLE is often encountered in pitchers. Many athletes suffering from LLE typically pitch in addition to playing shortstop or other infield positions such as catcher or third base. This injury results from repetitive stresses on the medial epicondyle (inner elbow) encountered with throwing activities. Ultimately, the weak link — the growth plate — becomes inflamed, resulting in a spectrum of injuries, ranging from irritation to stress fracture and separation of the medial epicondyle from the rest of the upper arm. X-rays may demonstrate a subtle widening of the growth plate.

Symptoms:

• Gradual onset of worsening medial (inner) elbow pain during throwing activities
• Elbow pain combined with loss of speed and/or accuracy when throwing
• Tenderness over the medial epicondyle
• Swelling over the inner elbow
• Difficulty extending the elbow completely

Treatment:

• Restriction of all throwing activities for a minimum of six weeks
• Ice
• Non-steroidal anti-inflammatory drugs
• Short (7-14 day) course of elbow immobilization (for severe cases)
• Proper throwing mechanics, through participation in a dedicated throwing program, is an integral component of the rehabilitative process

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Medial epicondyle avulsion fractures

Medial epicondyle avulsion fractures are seen in children and adolescent throwers. These injuries occur suddenly. X-rays typically reveal the fracture and subtle widening of the growth plate.

Symptoms:

• Immediate pain over the inner elbow after an especially hard pitch or throw, usually accompanied by an audible pop or crack
• Inability to continue playing
• Tenderness over the medial epicondyle, the attachment site for the forearm muscles used in throwing

Treatment:

• Rest from throwing to give the fracture and growth plate injury time to heal
• A brief course of immobilization in a sling; activity restriction
• Physical therapy emphasizing range of motion following diagnosis
• A hinged elbow brace is often used during the rehabilitative phase to protect the elbow and provide some restraint to forces which can be generated on the elbow joint
• Review pitch counts and proper throwing mechanics

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Osteochondritis dissecans (OCD)

Osteochondritis dissecans (OCD) of the capitellum, a bone and cartilage-containing part of the developing elbow, is a cause of lateral (outside) elbow pain in throwing athletes typically between 11 and 16 years old. This injury results from repetitive forces to the radiocapitellar joint during certain phases of throwing. These forces are believed to affect the blood supply to the capitellum.

Symptoms:

• Several months (3-12) of elbow pain which is progressive and typically relieved by rest.
• The radiocapitellar joint of the elbow, which can be examined best when the elbow is bent, is tender.

Treatment:

• Plain x-rays may identify this condition.
• An MRI may be necessary to help determine whether lesions are stable or unstable, an important distinction that determines which injuries require surgery and which can be watched closely.
• Non-surgical treatment typically involves elbow rest for six months, with physical therapy for stretching/strengthening starting once pain has decreased.
• X-rays are obtained at selected intervals to assess for healing.
• Repeat MRI is typically performed after six months of conservative management. If MRI shows lesion healing, a dedicated throwing program under close supervision is begun.