login

(http://radsourc.nexcess.net/)
(http://radsource.us)
PROTONPACS (HTTP://RADSOURCE.US/PROTONPACS-PACS/)

MRI INTERPRETATION (HTTP://RADSOURCE.US/MRI-INTERPRETATION/)

MRI WEB CLINIC (HTTP://RADSOURCE.US/CATEGORY/WEB-CLINIC/)

ABOUT (HTTP://RADSOURCE.US/ABOUT/)

RESOURCES (HTTP://RADSOURCE.US/RESOURCES/)

CONTACT US (HTTP://RADSOURCE.US/CONTACT-US/)

MRI Web Clinic May 2005

Little League Elbow
Mark H. Awh, M.D.

Clinical History: A 15 year-old baseball pitcher presents with persistent medial

elbow pain. Fat suppressed proton density-weighted (1a) coronal and (1b) axial
images are provided. What are the findings? What is your diagnosis?

1a
(http://radsource.us/wpcontent/uploads/2005/05/1a.jpg)

1b
(http://radsource.us/wpcontent/uploads/2005/05/1b.jpg)

Figure 1:
Fat suppressed proton density-weighted (1a) coronal and (1b) axial images

Findings

2a
(http://radsource.us/wpcontent/uploads/2005/05/2a.jpg)
Figure 2:

2b
(http://radsource.us/wpcontent/uploads/2005/05/2b.jpg)

view
clinics

Abnormal marrow edema compatible with a stress reaction (arrows) is identified within and deep to
the medial epicondylar apophysis on both the proton density weighted (2a) coronal and (2b) axial
images of the elbow. On the coronal image, the anterior band of the ulnar collateral ligament appears
mildly edematous and demonstrates subtle laxity at its proximal aspect (arrowhead).

Diagnosis
Little League Elbow

Discussion
In 1960, Brogdon and Crow1 described two cases of separation and fragmentation
of the medial epicondylar apophysis in the elbows of little league pitchers, and
coined the term little leaguers elbow. Both pitchers presented with pain and
tenderness over the medial epicondyle in their pitching arms. Since that early
description, the designation of little league elbow has expanded to include a host
of abnormalities that affect the throwing elbow in adolescent pitchers.
In the throwing athlete, the acceleration phase of the overhead throw causes
extreme valgus stress upon the elbow.2 The whipping action of the throw causes
lateral compression and resultant tension on medial supporting structures,
particularly the ulnar collateral ligament. The ulnar collateral ligament is
composed of three bands, the anterior band, the transverse band, and the
posterior band (3a). The anterior band is by far the most important, providing the
major restraint to valgus stress at the elbow. The anterior band arises from the
anteroinferior aspect of the medial epicondyle and inserts upon the sublime
tubercle of the ulna. In adults, the repetitive valgus forces of throwing often result
in chronic degeneration, microtears, or rupture of the ulnar collateral ligament. In
adolescents, the immature apophysis of the medial epicondyle is often the weaker
link, and injuries that affect this ossification center may thus predominate in the
young thrower (4a).
Figure 3:
(3a) The three bands of the ulnar collateral
ligament are depicted in this illustration of the
medial side of the elbow. The posterior band (PB)
and transverse band (PB) are relatively weak. The
anterior band (AB), which inserts near the
coronoid process, is the primary restraint to
valgus force at the elbow through the functional
range of motion.

3a
(http://radsource.us/wpcontent/uploads/2005/05/3a.jpg)

Figure 4:
(4a) In the immature skeleton, traction from the
thick anterior band of the ulnar collateral
ligament may result in a variety of stress-related
injuries at the medial epicondylar apophysis.

4a
(http://radsource.us/wpcontent/uploads/2005/05/4a.jpg)
This months case is actually a relatively mild form of little league elbow, with only
an apophyseal stress reaction and mild sprain of the ulnar collateral ligament
noted. Additional findings that may be present in little league elbow include
overgrowth of the medial epicondylar apophysis, separation and fragmentation of
the apophysis, complete tears or avulsions of the ulnar collateral ligament (5a,6a),
flexor/pronator muscle strains, and proximal ulna stress fractures. Because of the
repetitive valgus forces that occur with this entity, the medial injuries may be seen
in conjunction with compression abnormalities of the lateral compartment
(7a,8a,9a). In some cases, osteochondritis dissecans of the capitellum may
develop(10a,11a).3
Figure 5:
(5a) A fat-suppressed T2 weighted coronal image
in a 15 year old baseball pitcher reveals an
avulsion fracture (arrow) of the medial
epicondylar apophysis, at the proximal
attachment of the ulnar collateral ligament.

5a
(http://radsource.us/wpcontent/uploads/2005/05/5a.jpg)

Figure 6:
The avulsed bony fragment (arrow) is confirmed
on (6a), a proton density-weighted sagittal
image.

6a
(http://radsource.us/wpcontent/uploads/2005/05/6a.jpg)
Multiple fat-suppressed T2-weighted coronal images (7a 9a) reveal combined
elbow injuries in a 12 year-old baseball pitcher.

Figure 7:
On (7a), an anterior image, edema secondary to
chronic lateral compression (arrows) is identified
within the capitellum and the radial head.

7a
(http://radsource.us/wpcontent/uploads/2005/05/7a.jpg)

Figure 8:
(8a) The 2nd coronal image demonstrates a tear
of the anterior band of the ulnar collateral
ligament at the distal attachment (arrow).

8a
(http://radsource.us/wpcontent/uploads/2005/05/8a.jpg)

9a
(http://radsource.us/wpcontent/uploads/2005/05/9a.jpg)

Figure 9:
(9a) On a posterior coronal image, edema
compatible with a stress reaction is noted
throughout the medial epicondylar apophysis
(arrow).

Figure 10:
(10a) A T1-weighted coronal image demonstrates
an osteochondral lesion (arrow) compatible with
osteochondritis dissecans of the capitellum in a
16 year-old baseball pitcher. Note the sclerosis
along the articular surface of the radial head
(arrowhead), also likely secondary to repetitive
lateral impaction stress.

10a
(http://radsource.us/wpcontent/uploads/2005/05/10a.jpg)
Figure 11:
(11a) On the T2-weighted sagittal view, fluid
signal intensity is seen along the base of the
osteochondral lesion (arrow), suggesting lesion
instability.

11a
(http://radsource.us/wpcontent/uploads/2005/05/11a.jpg)
Patients with little league elbow may complain of medial elbow and proximal
forearm pain a few days after pitching. Symptoms abate with rest initially, but with
progression, pain becomes more continuous and the player may report difficulty
loosening up or maintaining throwing accuracy. Parents and coaches must be
particularly vigilant, as young athletes often will not report early symptoms unless
specifically queried.
Plain radiographs in patients with little league elbow may demonstrate widening
of the growth plate or overgrowth of the medial epicondylar apophysis.
Osteochondritis dissecans of the capitellum is typically difficult to diagnose with

plain films until late in the disease. The advent of MRI has dramatically improved
our ability to diagnose the underlying pathologies in little league elbow. Nearidentical patient symptoms may be caused by a wide variety of elbow pathologies,
and MRIs ability to specifically identify and characterize the soft tissue and
osseous abnormalities that may be present is unparalleled.
The treatment approach in patients with little league elbow is often guided by the
MRI findings. Apophyseal stress reactions, ligamentous sprains, muscle strains,
and minimally displaced apophyseal avulsions may be treated conservatively, and
the response to conservative therapy can be followed with MRI. Conservative
treatment includes the immediate cessation of throwing, use of anti-inflammatory
medications, application of ice, and stretching programs.4 If apophyseal avulsions
are displaced by 3-4mm or greater, surgical reattachment is typically indicated.
Full thickness ulnar collateral ligament tears may necessitate reconstruction, often
with a palmaris longus graft, the so-call Tommy John procedure. In patients with
osteochondritis dissecans of the capitellum, the presence of an unstable fragment
or loose bodies within the joint are common indications for surgery.
Following treatment of little league elbow, the return to throwing should be
approached cautiously. A strength and flexibility exercise regimen should be
rigorously adhered to, and pitch counts should be limited to 80 to 100 pitches per
week. Prior to high school, torsional pitches such as curveballs and sliders are to
be avoided. Any recurrence of symptoms necessitates cessation of throwing and a
re-evaluation of the patient.

Conclusion
Little league elbow refers to a multitude of soft-tissue and osseous abnormalities
that may affect the adolescent throwing athlete. Though common in todays
society, many of these injuries were virtually unheard of in children prior to the
advent of organized baseball. MRI is invaluable in these patients, as it allows
differentiation of the many causes of elbow pain in the young thrower. Treatment
options and the post-treatment assessment are often guided by the MRI findings
in these patients.

References
1

Brogdon BG, Crow NE: Little Leaguers elbow. Am J Radiol 83: 671?675, 1960

Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF: Kinetics of baseball pitching
with implications about injury mechanisms. Am J Sports Med 1995 Mar-Apr; 23(2):
233-9
3

Slocum DB: Classification of elbow injuries from baseball pitching. Tex Med
1968; 64(3): 48-53
4

Andrews JR, Arrigo CA, Chmielewski T, et al: Preventive and Rehabilitative

Exercises for the Shoulder & Elbow. Birmingham, AL, American Sports Medicine
Institute, 1997

Search

search

view all web clinics (/category/web-clinic/)

Web clinics by this radiologist

Posterior Glenohumeral Instability
(http://radsource.us/posteriorglenohumeral-instability/)
Hypermobile Lateral Meniscus
(http://radsource.us/hypermobile-lateralmeniscus/)
Lipoma and Liposarcoma
(http://radsource.us/lipoma-andliposarcoma/)
Rotator Cuff Pitfalls
(http://radsource.us/rotator-cuff-pitfalls/)
Turf Toe (http://radsource.us/clinic-turftoe/)

More on this topic

Distal Biceps Tendon Rupture Elbow
(http://radsource.us/distal-biceps-tendonrupture-elbow/)
Osteochondral Injury of the Elbow
(http://radsource.us/osteochondral-injuryof-the-elbow/)
Snapping Triceps
(http://radsource.us/snapping-triceps/)
Median Nerve Entrapment
(http://radsource.us/median-nerveentrapment/)
Distal Triceps Injuries
(http://radsource.us/distal-tricepsinjuries/)

Be the first to read our web clinics

Sign up for our monthly e-mails.

* Email

submit

Ready to see ProtonPACS for yourself? Our demo is free with no obligations.

clear

schedule a demo (/contact-us

Resources

Helpful Links

Get in Touch

White Papers (/resources/whitepapers/)

ProtonPACS
(http://radsource.us/protonpacs-pacs/)
MRI Interpretation
(http://radsource.us/mriinterpretation/)
Resources
(http://radsource.us/resources/)
MRI Web Clinic
(http://radsource.us/category/webclinic/)
Contact Us
(http://radsource.us/contact-us/)
Webmail Login
(https://owa.uspi.com/owa)

Radsource, LLC

Evaluate the TCO of your PACS

download >
(http://radsource.us/whitepapers/pacshow-to-reduce-the-total-cost-ofownership/)

Case Studies (/resources/casestudies/)

Tippah County Hospital
read more > (http://radsource.us/wpcontent/uploads/2014/10/Case-StudyTippah-County-Hospital.pdf)

(/protonpacs-pacs/)

8 Cadillac Drive, Suite 200

Brentwood, TN 37207
ph 615.376.7502
info@radsource.us
(mailto:info@radsource.us)