Little League Elbow is a common injury in youth baseball players.
Little League Elbow is a growth plate injury typically seen in baseball pitchers around the age of 13.
At this age, the bone is typically the weak link, not the ligament. This is why we see more bony growth plate injuries than Tommy John injuries in youth athletes.
These often take longer to heal than you think, so we don’t usually rush them.
Here’s how we rehab these injuries.
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#AskMikeReinold Episode 357: Little League Elbow
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Show Notes
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Transcript
Gavin Harden:
All right. So first question. Derrick from Georgia asks, “I’m working with a 13-year-old baseball pitcher who’s been dealing with little league elbow since last season. It’s been going on for six months and it keeps returning when we start throwing. What advice do you have in order to help him pitch this year?”
Mike Reinold:
Good question. I like it. So we deal with this quite a bit. It was an interesting part. Gavin left one part of the question out that was the person… And this is what I really liked about the question… The person wrote, “is a really good pitcher,” because every kid… And good ad lib there, Gav. Every kid that him and his parent come, they’re always like, “Nah, he’s a 13-year-old kid,” like, “He’s a really good pitcher.” It’s like, “Okay. Okay. Sure.” But what that tends to mean when they say a 13-year-old pitcher and he’s really good… Obviously, I’m sure he’s successful, but I feel like I bet you this kid throws hard. That was the first thing that came to my mind, or throws hard for his age compared to those other 13-year-old kids.
So let’s start with this. I think we see this a lot. Maybe Anthony, Len, you guys probably see this more, but I think, Dave, I’d like to hear your thoughts on just the healing of this. Little league elbow, so it’s a growth plate injury, just to be clear. We can jump right to the chase. We don’t have to define it. But a growth plate injury to the elbow in a 13-year-old kid. And again, what happens, just to quickly cover that, in a 13-year-old kid, the bone is the weak link, not the ligament. So in adults, as the bone matures and solidifies a little bit, then the stress goes more on the ligament. That’s why we have so many Tommy John injuries as you get older. But in that 13 range, and that’s probably the highest percentage, the mean, we tend to see it in 13, 14, it can be 12 to 16, but 13, 14 range, they tend to get these.
So why don’t we start a little bit here on this type of kid? Why don’t we start with this? Why do we think after six months he’s still potentially having discomfort? Anthony, Len, anybody want to jump in on this one? I’d be curious to hear your thoughts on six months, why? What do you think?
Lenny Macrina:
Yeah. I mean, we don’t see this. I guess we see it a little, meaning they have continued pain, but I think for us, it’s just establishing guidelines early of you need to shut down… A) educating the family on what’s going on and what potentially led them here and trying to figure out the history, but what could potentially be going on is not giving enough time of bone healing and maybe reassessment. Maybe another MRI is needed or some kind of CAT scan or something is more than we think. Maybe a different study is needed. But it sounds like they need more time. And then what’s the ramp-up process? What are we using for a process to determine return to throwing?
And then what does that return to throwing look like? If this kid is 13 and he’s trying to get back, he’s probably good and he has pressures to get back from wherever. You don’t know what the effort is he’s giving on each throw. So I think reestablishing the diagnosis, making sure it’s accurate, and making sure the areas that were involved are healed… And then what’s the process that you’ve gone through, meaning have you gone through a strengthening program? Have you tested strength? Have you looked at plyometric program to begin a return to throwing program to see if they are ready to push stresses on that area? Then do a slow ramp-up of a throwing program. But I would recommend probably at least three months of no throwing at all. And so hopefully it wasn’t like a six week, “Let’s shut them down for six weeks and then test it out,” because that’s oftentimes what we hear, is this six-week shutdown. I think they need longer, especially these bone issues in young kids. So I think it’s probably going to be they weren’t shut down long enough, I’m going to guess. And if they were, then is the throwing effort and program appropriate for what this kid is doing?
Mike Reinold:
Len, would you shut him down for three months at the beginning the first time? Or are you saying that now just because he’s had some recurrent injuries and it’s not going away?
Lenny Macrina:
Yeah.
Mike Reinold:
Would you immediately go three?
Lenny Macrina:
I kind of do. I think it’s a big thing. It’s kind of like a low back, like a stress fracture. And it depends on… You try to talk to the doc and figure out to what degree the tissue’s involved. Is this a big thing? Is there a separation? How much separation is there? Is surgery needed? Did they separate the area enough that they have to put a pin in and re-approximate it? That’s probably what’s going on. And so depending on time of year and the feel you get from the parents… But I try to stick to my guns and talk about three months, and that usually could be a reason why my kids that have this don’t have recurring issues. We shut it down. We get it done.
13. He has another 10-year career in baseball if he can play through college. Why are we rushing in four weeks or six weeks to get him back quicker when we can get this solved and move on? So I’m a proponent for a longer course of not immobilization, relative rest from throwing, but they’re still doing shoulder, elbow stuff. They’re still strength training. They’re still doing stuff in the process. But yeah. It’s like a back. Backs need three months. Right, Tilley?
Dave Tilley:
Minimum. Minimum.
Mike Reinold:
Minimum. Minimum. Again, it was like a red flag that was in the question to me that he’s a good pitcher. To me, that’s a red flag. The first time a 13-year-old says that or says something like that, you’re just like, “Oh, gosh. That means they’re probably pushing that.” And heck, you never know. The kid could have seen his primary care doctor and not a good youth sports ortho that understands growth plate injuries well, and they could just be like, “Let’s rest until you feel better and then start throwing.” And sometimes we know it lags.
I don’t have this data on elbow, but I know for the shoulder there have been published studies that show it takes two and a half months for symptoms to resolve with little league shoulder, and then most of them don’t start playing catch until about four months with little league shoulder. And I don’t think we have that for elbow as much as the data on that. There’s been more studies published on that, but I just thought that was super interesting, but… I don’t know. Anthony, from your perspective, I know we see a decent amount of youth athletes at Champion and kids coming in here. Any thoughts from you on why this kid’s having some recurring issues or anything you’ve seen differently?
Anthony Videtto:
Yeah. I definitely agree with what Lenny just said, but to go off the “a good pitcher” that we have in the description here, he’s probably throwing more than any other pitcher on his team, I’d guess. So it comes down to a workload issue, I’m sure. Why does he keep getting injured? Like you said, maybe it’s not taking enough time. Maybe he’s just taking six weeks to rest and maybe we’re not doing the adequate things in those six weeks to get him stronger, ready to throw again. I don’t think you’re putting him in a good spot if you’re just saying, “Okay, we’ll see you again in six weeks. Let’s let this calm down and then try to throw again.” We’re just going to keep picking the scab there.
So like Lenny said, let’s give this three months, but in those three months, let’s build him a strength training program. Let’s use an arm care program. Let’s get him ready and then build up from there and see how that goes. But it’s also education. If you’re throwing two, three times a week, which I’m sure he probably is because he’s a, quote unquote, good pitcher, let’s educate them on a proper inning usage, pitch count, whatever it may be to really hone in on this and decrease these symptoms that he keeps having.
Mike Reinold:
Yeah. That’s a good point on the workload stuff. And you’re probably right. A lot of this is going to be education and just understanding this process. Maybe this kid’s rushing it, that sort of thing. I was also thinking back to what Lenny was saying here too, and it is funny. If he’s sore, it’s probably in season, it’s probably spring, summer, something like that. There’s no way we can shut him down and get him back that season, almost any way. It doesn’t make any sense. So you might as well wait longer and get that over with. This kid sounds like he’s having some recurring symptoms that happened… It said six months. So to me, we’ve seen this. We tried to shut it down. We tried to be careful over the summer and ramp back up in the winter, but it’s still there. And that’s what we see. Dave, you tend to work with kids where their bones explode in gymnastics, but any issue… I’m sure you have some issues with people having poor bony healing after these sorts of growth plate things. Thoughts from you?
Dave Tilley:
Yeah, for sure. So it actually ironically works out because Monday night I evaluated like a 14-year-old level 10 gymnast. It’s the highest level in college. She’s really, really talented. She’s like a phenom, similar to this kid who’s probably throwing a ton because he’s an early developer. And there’s this concept I try to educate parents and coaches with, is all kids this age who are early developers or talented, you’re running at this intersection between their talent and their growth. It’s optimally overlapping in a negative way for their health long-term.
So you have someone who’s probably really strong for their age. They’re like 10 to 14 years old. Their bones are very vulnerable, as you said, because they’re spongy bone. They’re not hard, calloused bone yet. They haven’t gone through puberty to solidify that. But also you got to remember that these people are typically growing rapidly. So they go through peak height velocity and their long bones grow very, very fast compared to how fast their muscles can keep up, so Osgood-Schlatter’s, Sever’s disease, some of the stuff related to thrower’s elbow. In the back, it happens too. Because your arms and legs grow so fast, your muscles can’t keep up and it pulls on local spots that are vulnerable.
So all this is going on, but as Anthony said, you’re doing a very high repetition count because you’re having fun, you’re with your friends, you want to show off, you want to do well. And this girl was the same thing because she’s starting to get into college camp mode where colleges are looking at her when she’s a freshman and they’re thinking about who they’re going to recruit in two years. So you’re excited, lots of reps, lots of volume. And it just makes a situation where it’s almost impossible to keep up with the demands because you don’t have enough time to let things heal before you do another bout of stress on the elbow. So three times a week of throwing. Gymnasts do about 39 days per week of gymnastics. So every single day there’s no bony healing happening and you’re continuing to pick the scab.
So it’s tough because in these situations she was like, “Can I compete for nationals? Can I make nationals this year?” And I was like, “Girl, if you broke your ankle, it’d be in a cast for six to eight weeks and then you’d go through six to eight weeks of PT before we think about doing sports. And that’s the whole season.” And that’s the same thing for this kid. It’s like if your elbow bone is inflamed and not healing well, we have to go through rest and then a proper recovery. But I just think, unfortunately, when you said growth plate, some people are like, “Oh, just work through it. It’s just Osgood-Schlatter’s. You’ll be fine. Just work through it.” But that can become a serious stress fracture and a bigger issue. So yeah, I think a lot of it goes, and the environment is not conducive for a 14-year-old who’s going through a hurricane of growth to play at a high volume.
Mike Reinold:
Yeah. Very good point. And I think that’s part of the education process that Anthony talked about a little bit, and even alluding back to what Lenny said, I think we have to educate them here. It’s like, “Look, if we don’t take care of this right now and this thing gets worse and you have a fracture and you need surgery, you’re done for a year.” And then that’s huge at that kid’s level. But also patient education wise, I think when you first tell them, “Hey. We have to shut you down for two, three months,” whatever it may be, let’s say three months, that’s pretty daunting for a kid. Remember that’s a large percentage of his life so far. He’s only 13 years old, so half a year is a large percentage of his life. So that seems like eternity for him.
The patient education needs to be like, “Look, but we’re going to make lemonade out of this here and there’s tons we can do. We just can’t throw. But let’s get your body in shape. Let’s get your lower half going. Let’s get your mechanics cleaned up as we go through this. This is going to be a win for you in the long run,” and motivate them that way. I think that buys them in. So… Oh. Sorry, Dave. Go ahead.
Dave Tilley:
Just one more thing I think because again, these people are 14. They want to compete with their friends and that’s all they care about. You have to reframe why waiting is good for their goals, because on the other side of growth and puberty is all the big skills. You can throw a lot harder. You can play a lot more. And that’s what gets them their goal. Just telling them to rest because it’s an injury thing, it usually goes in one ear out the other with kids that are really excited to play. So just reframe it as what they care about, what their goals are, to get more buy-in.
Mike Reinold:
Yeah, and assuming this isn’t terrible… If it’s terrible, they’re probably going down the surgery route if they have avulsion fracture or something like that. But assuming this is a lower grade, they’ll heal up in a few weeks, enough to start doing stuff. Diwesh, from your perspective, when we have kids like this and they’re training in the gym, I mean, throwing is the thing that bugs them. There’s really not a lot of things we do in the gym that torque the medial elbow like that, right? From your perspective, what’s a good way to focus on them in the gym and really take advantage of this time?
Diwesh Poudyal:
Yeah. I think it starts first with just a good general strength training program, but maybe a little bit more bias towards the lower body and core. We know that as far as proper sequencing specifically for throwing and honestly for most power-based exercises, our power generators are the lower half, our legs. And then our core is responsible for dissipating that energy or, sorry, transferring that energy so that the arm can dissipate it. So a good lower body strength training program or good lower body power production program, that’s where I would start. And that’s not to say that we’re going to just go ahead and neglect the upper body because it doesn’t matter because it certainly does. Hopefully, this kid is going to get on a good specific arm care program that’s meant for throwers, but that also we’re doing good general upper body preparation, doing your upper body pushes, upper body pulls, maybe adding a little bit of mass on the body. It’s a growing kid that’s probably starting to approach puberty, so now we can probably start to think about adding some muscle mass now that we have some testosterone flowing in the system.
So that’s where I would round it up, a little bit of a lower body emphasis, but make sure that we’re taking care of core, upper body. A good holistic program because we know the arm’s going to be put under stress no matter what you do. You say this all the time: throwing a baseball is bad for you. It’s bad for your arm. We’re not going to change that. But if we can have the stress go a little bit more to your power generators, it should ideally be a little bit less stress on the elbow if you’re really weak with the lower half.
Mike Reinold:
Yeah. And most kids are, right?
Diwesh Poudyal:
Yeah.
Mike Reinold:
Most 13 year olds are. And they haven’t been to the gym yet. If you look at biomechanical comparisons of adults and kids, adults throw with their… Sorry… Kids throw with their arm more and adults throw with their body more. And that’s what it comes down to. So this is a kid that just got lucky probably. He’s probably really loose. He’s tall. He’s big for his age, so he had that mobility. When he threw with his arm, it came out faster than the other kids. But now teaching him lower half stuff and actually transferring it, that’s probably what’s going to really put this kid over the top.
Lenny Macrina:
I think one more thing is… And these kids, they don’t hurt unless they throw a baseball… So when you’re trying to figure out how are they ready to go, oftentimes you need time and just maybe another image and all that, but they don’t hurt daily stuff. They don’t hurt to weight train. It’s literally throwing a baseball. You can try to do a little valgus torque on them and see what their baseline pain was at the time initially and then monitor as they go forward, but they’re not going to hurt. And so you have to keep that in mind too, that it’s literally like a UCL. They hurt when they do something usually. And so it’s tough to just say, “Oh, just slowly get them back when they’re feeling better.” You can’t because they’re always feeling better. It only hurts really when they throw. So that’s another point I think the audience should be aware of as well.
Mike Reinold:
And that’s probably what’s happening in this case too. So I like when our doctors… Sometimes we’ll have our doctors just immediately say, “It’s three months. We’re going to get repeat imaging at three months.” And you know what? That closes the door. There’s nothing happening for three months and you have to get repeat imaging to get clear to throw. It just gives the kid now a three-month runway that he can just follow and just say, “All right. I’m going to put my head down for three months and let’s get over this.”
So awesome. Great stuff. Good question, Derrick. I think that’s probably something a lot of people deal with, especially with mild growth plate injuries, like the lesser extent ones here. It’s not about how fast you can get them back. It’s about planning for the future. So, great question. If you have anything like that, head to the website and click on the podcast link. You can ask away. And please, please, please subscribe, rate, review, Spotify, Apple, whatever. We’ll see you on the next episode. Thank you.
