"Patellofemoral Pain Syndrome"-Issue 12

           Patellofemoral pain syndrome (PFPS) is the most common cause of chronic knee pain affecting young active adolescents.  It is estimated to account for 24-40% of all knee problems presenting to sports medicine clinics.  Symptoms usually consist of pain along the front part of the knee that increases with activities such as running, climbing stairs, squatting, kneeling, and sitting for prolonged periods of time.

            Knowledge of the anatomy of the patellofemoral joint is key to understanding why PFPS occurs. Normally, as the knee bends and straightens, the patella (or kneecap) slides up and down a groove formed in the thighbone.  This motion is controlled by a number of muscles, ligaments and tissue that surround the knee.

The exact cause of PFPS is not well understood.  Most researchers believe it is caused by a breakdown in the structures that control the motion of the kneecap. If the patella moves incorrectly through this groove, it creates the potential for pain and instability in the knee to occur.

Some of the more common reasons that contribute to this breakdown include: muscle tightness, weakness in the hip and an imbalance of the muscles in the front of the thigh.

The quadriceps muscles and ilio tibial band (ITB) tend to be tight in people with PFPS. If the quadriceps muscles are tight, they tend to pull the kneecap much closer to the thigh bone. This increase in tension leads to grinding of the kneecap against the thigh bone which can lead to changes along the surface of the patella causing it to track differently. The ITB has attachments to the outer side of the kneecap.  When it is tight, it pulls the kneecap in an outward direction shifting the kneecap away from its groove.

Recent research also shows PFPS is related to hip muscle weakness. The muscles located in the outer and back portion of our hips contribute tremendously to how our leg lands when we walk and run.  Normally, these muscles help to slow the leg down before it impacts the ground.  Weakness in these muscles can cause the leg to impact the ground with greater force, causing the knee to fall inward and stress the patellofemoral joint.  Repeated landing in this position can result in inflammation and poor tracking of the kneecap.  

Finally, poor tracking of the patella can also result from an imbalance of the muscles in the front of the thigh. The muscle along the inner part of the thigh called the vastus medialis oblique, or VMO can become weak with repeated landing in a poor mechanical position.  When this muscle becomes weak or inflamed, the muscles in the center and outer portion of the thigh begin to overwork causing the kneecap to pull up and out to the side.    

Treatment of patellofemoral pain is complex.  A thorough assessment by a physician or physical therapist to determine the structures involved is key to understanding how to resolve the pain.  Most studies show that physical therapy remains the treatment of choice for the management of PFPS. Surgery is typically indicated in cases where therapy has been ineffective or when changes to the surface of the patella are evident. 

To learn more about this injury and others, contact your local physician or physical therapist.

References:
1. Cowan et al. Physical Therapy Alters Recruitment of the Vasti in Patellofemoral Pain Syndrome. Med Sci Sports Exerci. 2002. 34:12;1879-1885.
2. Eng et al. Evaluation of Soft Foot Orthotics in the Treatment of Patellofemoral Pain Syndrome. Phys Ther. 1993, 73:2, 62-68.
3. Fagan et al. Patellofemoral pain syndrome: a review on the current associated neuromuscular deficits and current treatment opitions. Br J Sports Med. 2008;42:789-795.
4. Harvie et al. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? Journal of Multidsciplinary Healthcare. 2011; 4:383-392.
5. Cerny K. Vastus Medialis Oblique/Vastus Lateralis Muscle Activity Ratios for Selected Exercises in Persons With and Without Patellofemoral Pain Syndrome. Phys Ther. 1995; 75(8):672-682.

"Elbow pain in throwers- UCL injuries"-Issue 11

Elbow pain is the most common complaint in adolescent and pre-adolescent baseball pitchers. Because of the high speed and excessive range of motion involved in pitching, the elbow joint is susceptible to unique and sport specific injuries.

As the arm reaches a fully cocked position and prepares to release the ball, an extreme stress, known as valgus stress, is generated at the elbow. This valgus stress creates a tremendous traction force along the inside of the elbow and a forceful compression on the outside of the elbow. The ligament along the inside of the elbow, known as the UCL, is the primary resistance to this stress and therefore most prone to injury.  

Overhead throwing at high speeds causes this ligament to stretch to its limit with each pitch. Injury to the ligament can occur suddenly with a high-generated force or gradually as it is exposed to repetitive stress and trauma. Both can result in instability or a tear of the UCL. 

Typically, athletes with UCL injury complain of pain along the inside of the elbow during the acceleration phase of throwing. If the injury is sudden, the athlete will hear an audible pop, followed by immediate pain and inability to continue throwing. Chronic injuries present gradually and often with pain occurring only when throwing 50-75% of maximum effort.

More than 40% of athletes with UCL injury also report symptoms of numbness and tingling in the hand or arm.  These symptoms result from friction or snapping of the ulnar nerve as it stretches across the inside of the elbow as the ball is thrown.

The diagnosis of UCL tears can be difficult to make and should begin by a thorough exam and stress x-rays of the elbow. Often an MRI is recommended to confirm a tear. Once diagnosed, treatment decisions require consideration of the individual athlete’s demands and the extent of the UCL injury.

Non-surgical treatment is attempted with partial tears and sprains of the UCL. If treatment start as symptoms begin, then it may stop the injury from progressing and allow the athlete to return to competition.  Conservative stretching and strengthening can begin once the initial pain and inflammation has been treated. Strengthening exercises focus on the muscles that help to stabilize the elbow during the late cocking and acceleration phases of throwing. If the athlete desires to return to highly competitive throwing, rest with rehabilitation of up to three months is recommended.

If the athlete fails to improve with non-surgical treatment, or the athlete has a complete tear of the UCL, surgical intervention is recommended.

Surgical management for UCL injury consists of two different methods: repair and reconstruction.  The recommendation for a direct repair of the UCL is rare and only considered if the athlete has a sudden or acute injury with no associated nerve symptoms.  In the majority of patients, a reconstruction is performed to restore stability to the inside portion of the elbow.

After surgery, the same type of rehabilitation program is used for both the repair and reconstruction techniques. Physical therapy will include a slow, gradual return to throwing over a period of 12 to 18 months.  Exercises will emphasize strengthening the specific muscles that counteract valgus stress and proper throwing mechanics will be stressed.

Prevention is key in avoiding the pain and time associated with this injury. USA Baseball recommends immediately removing a pitcher from a game when he or she complains or shows signs of arm pain.  Parents should seek medical attention if pain is not relieved within four days or if pain returns immediately the next time the player pitches.

To learn more about this injury and others, contact your local physician or physical therapist.

References:

1. Johnston et al. Elbow Injuries to the Throwing Athlete. Clinics in Sports Medicine. 1996. 307-321.
2. Fry et al. Rehabilitation Guidelines for Elbow Ulnar Collateral Ligament (UCL) Reconstruction. 
www.uwsportsmedcine.org
3. Kerry et al. Elbow medial collateral ligament injuries. Curr Rev Musculoskelet Med. 2008. 1:197-204.
4. Wilk et al. Rehabilitation of thrower's elbow. Clin Sports Med. 2004. 765-801.
5. Azar et al. Operative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Athletes. Amer Sports
Institute. 2000. 16-21.
6. www.usabaseball.com
 

"Idiopathic Toe Walking"-Issue 10

All children will experiment by walking on their “tippy toes” at some point during development.  So when then does this playful experiment become something that should be looked into a little further?  Most experts will recommend that if your child spends >25% of their walking time up on their toes and are over the age of two they should be evaluated by a physician.

Toe walking can occur for many reasons, and a thorough exam should be performed to determine the cause and prescribe the most appropriate treatment. Your physician should first rule out any serious neuromuscular or orthopedic problems such as: cerebral palsy, injuries to the spinal cord, or paralytic muscle diseases including muscular dystrophy, that could be causing this tip toe walking pattern.  

Idiopathic toe walking is only diagnosed when your child demonstrates a persistent tip toe walking pattern, and all potential neurologic, orthopedic and psychiatric causes have been completely ruled out. This term implies that the toe walking occurs in an otherwise healthy child and that there is no disease or dysfunction creating the abnormal walking pattern.  It is estimated that idiopathic toe walking occurs in up to 24% of children, and that there is a family history of toe walking in 30-71% of children diagnosed.

Studies show that occasionally this diagnosis can be tied to language delays and learning disabilities.  If you begin to notice any delays in your child’s ability to learn, communicate, or interact socially, requesting a developmental assessment from your physician may be appropriate.  A child with idiopathic toe walking may also have some form of a sensory processing dysfunction.  This means that your child may walk on his/her toes due to a hyper or hyposensitivity in their feet.  Your child may not like the feeling of different surfaces on their bare feet, causing them to rise up on their toes to decrease the amount of contact their feet have with the floor.  In this case, requesting a sensory profile/assessment may be appropriate.

Idiopathic toe walking first appears when the child learns how to walk.  Often the child can walk flatfooted when asked to do so, but quickly returns to the tip toe pattern as their preferred method of movement.  Over time, walking in this position will result in tightness of the calf muscles and limited motion of the ankle/foot. The longer the child walks in this position, the greater the loss of motion.  This not only places your child at an increased risk for ankle injuries as a child, but is also statistically tied to increased foot pain and pathology as an adult.  If the calf tightness is not addressed early on, it can develop into a “muscle contracture”.  This is when the muscle becomes physically shortened after being too tight for too long and can no longer be stretched out by conservative means.

Early identification and treatment of children with idiopathic toe walking is needed to prevent the development of calf tightness, limited motion of the ankle, and development of permanent abnormalities in how they walk.  Physical therapy is generally recommended to address calf tightness, leg weakness, balance deficits, provide sensory feedback and assess the need for orthotics.  When started early on, therapy has proven to be successful in correcting toe walking.  Older children with idiopathic toe walking may not respond as well to physical therapy and may also require a series of casts or night splints to help correct the problem.  In severe cases, such as the development of contractures, the use of botox injections or surgical intervention to help lengthen the muscle tendons may be recommended. 

For more information about this topic and others, contact your local physician or physical therapist.

Physical Therapy Quick Tips:

·      Daily passive stretching for the calf and hamstring muscles is recommended frequently throughout the day

·      Proper shoes are a must!  Lace up tennis shoes will give your child feedback about where their feet are and provide additional support for their ankles, making it easier to walk with flat feet

o Squeaky shoes may be helpful.  These shoes make a sound only when your child walks with his/her feet flat on the floor providing them with a squeaky sound to encourage correct walking (Caution to parents: you will want to do this in conjunction with the other tips as this sound may get a little too much too handle on a long day)

·      Take time to SLOW DOWN and LOWER DOWN: Your child’s little legs sometimes have a hard time keeping up with your pace, causing them to rise up on their toes.  When this is combined with trying to hold your hand—which may be a big stretch to reach for, it may be difficult to walk flat footed.  Take the time to lower your hand and slow your pace to help encourage a proper walking pattern 

References:

1. Le Cras S, Bouck J, Brausch S, Taylor-Hass A; Cincinnati Children's Hospital Medical Center: Evidence-based clinical care guideline for Management of Idiopathic Toe Walking, Guideline 040, pages 1-17, February 15, 2011.

2.Eiff M, Steimer E; What is the appropriate evaluation and treatment of children who are toe walkers? The Journal of Family Practice. 2205; 55(5):1-3.

3. Englebert R et al. Idiopathic toe-walking in children, adolescents, and young adults: a matter of local or generalized stiffness? BMC Musculoskeletal Disorders. 2001. 12(61):1-8.

4. Zimbler S. Idiopathic Toe Walking: Current Evaluation and Management. Children's Hospital. 2009. 98-100.

"Adolescent Back Pain"-Issue 9

About 80% of the population suffers from low back pain at some point in their lifetime. For obvious reasons, athletes are at a greater risk of low back injuries due to the amount of stress and load the spine endures with high impact, repetitive activity. It is estimated that approximately 10-15% of adolescent sport injuries involve the low back/lumbar spine. This incidence is even higher in sports that involve repetitive hyperextension, or arching, of the spine, such as: gymnastics, football, volleyball and swimming.

            Adolescents may be predisposed to back injuries because of muscle imbalances, inflexibility, and structural differences of the spine. As we have discussed in the past, in the growing athlete, the joints have a soft, cartilaginous growth center that is at a higher risk of injury than adults. The joints of the spine are no different.   

In sports that require repetitive backward bending, there is a greater stress placed across this delicate growth center. This amount of stress can increase even more if the athlete develops decreased flexibility during a growth spurt. For instance, tight hip flexors prevent the hips from rotating properly, creating additional stress on the spine during extension. Over time this extra stress may eventually become what is called spondylolysis. 

            Spondylolysis is a stress fracture of the spine caused by repetitive spinal extension and rotation. It is estimated that nearly 50% of adolescent athletes with low back pain results from spondylolysis. 

When this fracture first occurs, pain is not typically severe. The athlete will experience mild complaints of pain across the low back that tends to worsen with arching of the back. Many athletes will ignore this early sign of pain and continue training and competing in sport.

If the athlete chooses to continue, repeated exposure to stress on the spine can cause the fracture to progress into a more serious condition called spondylolisthesis. This condition occurs when the weak area of the bone begins to cause one vertebrae to slip forward over the one below it. The athlete will begin to experience more intense and more frequent pain that may even start to spread down into the legs.

            Both conditions are difficult to diagnose, as they do not always appear on x-rays. This can result in misdiagnosis early on, resulting in improper treatment and potential for the injury to worsen. More extensive imaging such as a bone scan, MRI or CT scan is often required to discover the break/fracture in the spine.

            Once diagnosed, treatment will vary depending on how far the injury has progressed. The primary method of treatment includes rest from sport or activity, allowing time for the fracture to heal. During that time, physical therapy may be recommended to strengthen the abdominal muscles, stretch the muscles of the legs and increase mobility in the low back.

Bracing may also be recommended to relieve pain and prevent further slippage of the vertebrae.  These braces work to flatten out the normal curve of the low back, preventing the athlete from moving into painful extension.  These braces are often worn for several months as the athlete works back toward normal training.

Complete return to sport for these athletes can take time.  Returning to sport with even mild complaints of pain can result in a rapid return to the same injury.  An athlete is considered safe for return if they are pain free and non-reliant on a brace. 

For more information about this injury and others like it, contact your local physician or physical therapist.

References:
1. Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin N Am. 2002; 49:643-53.
2. www.childrenshospital.org
3. Purcell L. Causes and prevention of low back pain in young athletes. Pediatr Child Health. 2009; 14(8):533-535.
4.www.seattlechildrens.org
5.Gerbino PG. Back injuries in the young athlete. Clinics In Sports Medicine. 1995; 14(3):571-596.
6. Nittoli V. Back pain in young athletes. Technique. 2008;14-18.

"ACL tears in the growing athlete"-Issue 8

The anterior cruciate ligament, or ACL, is one of four ligaments that keep the knee from wobbling or giving way when we move. To fully understand the impact of an ACL tear, it helps to know a little about how the knee works. As you can see in the diagram to the left, the knee is a large joint where the tibia meets the femur. The ACL connects the front of the tibia to the back of the femur. Its job is to make sure that the tibia does not slide in front of the femur, helping to maintain the stability of the joint.

In active children, ACL tears are among the most severe and most frequent sport and play related injuries. This year, in the United States alone, an estimated 250,000 people will tear their ACL. The vast majority will be among women ages 15 to 25, as females are five to eight times more likely to injure their ACL than boys of the same age.

           When the knee is forced into an unusual position, the ACL can tear. Typically, when the ACL is torn, the child will feel his/her knee “give way”, often associated with an audible popping sound. Over the next several hours the child will begin to experience pain, swelling and instability in the knee. To help protect your child from further injury, it is important to get a thorough evaluation from your physician for accurate diagnosis and proper treatment. ACL tears are typically managed with a combination of surgical repair and physical therapy. Your child’s age will be a determining factor for when surgery is most appropriate.

The bones and joints of children are very different from adults, because the child’s bones are still “growing”. This can make caring for children with an ACL tear a bit more complicated. If you can recall from our previous blogs, bones grow from the “growth plate”, which in the knee are located in the ends of the femur and the tibia bones.

 Most modern surgical techniques for ACL repair involve drilling tunnels in the bone through the area of the growth plate. This does not create problems in adults, because the growth plate closes at the time of skeletal maturity. Drilling through these regions while the growth plate remains open, places the child at risk for growth disturbances.

Often, surgeons will recommend delaying surgical repair until skeletal maturity is reached.  During that time, physical therapy is typically initiated for injury management.

In some cases, ACL injuries in children can create enough instability in the knee that return to sport/activity without immediate surgical repair places the athlete at high risk of further injury.

Being faced with the decision of whether or not to have surgery performed on your child is a very difficult situation to be in. Many parents are faced with questions and anxiety about what will happen if they do not have surgery right away. Each decision about ACL surgery in children is unique. You will need to have a discussion with your physician about all potential options and how to make a decision that you and your child will be most comfortable with.

Recovery from an ACL surgery is a lengthy process that can take up to 6 to 12 months, but 90% of kids return to activity/sport without knee instability. As always, prevention is KEY! Seek out ACL prevention programs to help protect your child from future injury. For more information about this topic and others, contact your local physician or physical therapist. 

References:
1. Moksnes H. et al. Management of Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals. Journal of Orthopedic and Sports Physical Therapy. 2012;3:172-195
2. Wilk K. et al. The Challenge of Return to Sports for Patients Post-ACL Reconstruction. Journal of Orthopedic and Sports Physical Therapy. 2012; 4:300-301.
3.www.childrenshospital.org
4.www.seattlechildrens.org 

"Shoulder Impingement in the throwing athlete"-Issue 7

     Throwing a baseball is one of the fastest and most violent maneuvers to which the shoulder joint can be exposed.  Each pitch requires generating high levels of force through the trunk and legs in order to accelerate the ball, followed by extreme control from the shoulder to slow this force as the ball is released.
     Repetitive throwing at this high speed increases the stress and strain on the arm of the young athlete, often resulting in injury.  These injuries typically affect the rotator cuff muscles, labrum, and/or joint capsule.  The athlete will initially report decreased pitching speed and control, require a longer warm up period, and experience shoulder pain during the latter part of their throwing motion. 
     Impingement syndrome involves a mechanical compression of the rotator cuff tendons and/or bursa underneath the acromion. As the athlete raises his/her arm overhead to throw, the muscles crossing the shoulder joint are pinched inside of the joint resulting in sharp pain and irritation along the shoulder.  See the diagram above for a better visual understanding of where this occurs.
     Impingement sydrome can occur for a variety of reasons.  A thorough evaluation by a medical physician or physical therapist to determine the source behind the pain is key. The two most common causes are poor mechanics and overuse.  The risk of injury increases tremendously when these two factors are combined.
     When a pitcher has poor mechanics, the shoulder joint is not as effective at slowing the high levels of force generated through the legs.  This creates undue stress for the muscles and capsular structures of the shoulder joint.  A common break down in throwing mechanics is a lack of follow through.
     To achieve the speed required to pitch effectively, seasoned throwers will develop an excess amount of shoulder external rotation.  The greater the arm is able to externally rotate, the more time it has to pick up speed before the ball releases.  Without adequate follow through, the arm is forced to decelerate too quickly, placing extreme stress across the shoulder joint. 
     When this is combined with repetitive throwing without sufficient rest periods, the problem amplifies.  Mild cases of impingement syndrome could quickly progress into a more serious issue if the young athlete ignores early signs of pain and continues to overuse the arm.
     Throwing injuries to the shoulder can be extremely complex.  Prevention is key in avoiding injury.  Studies show that in pitchers ages 9-14: curveball pitches were associated with a 52% increased risk of shoulder injury, sliding pitches were associated with an 86% increased risk of elbow pain, and change up pitches were associated with a 29% increased risk of shoulder pain.  Studies also show that in pitchers ages 14-20: there is a 5x greater risk of shoulder surgery for players who participate in sport >8 months/year; and that risk of injury increases with pitching speeds >84mph, >80pitches/game, and participation in showcases.
     Parents and players should become familiar with the pitching guidelines established by Little League Baseball (http://www.littleleague.org/).  To learn more about this specific throwing injury and others, contact your local physician or physical therapist.


References:
1. Scolaro et al. The Thrower's Shoulder. University of Pennsylvania Orthopedic Journal. 2011 May; 20:53-57.
2. Mahaffey et al.  Shoulder Instability in Young Athletes. Am Fam Physician. 1999 May; 59(10):2773-2782.
3. Seroyer et al. Shoulder Pain in the Overhead Throwing Athlete. American Orthopedic Society for Sports Medicine. 2009; 108-120.
4. Lyman et al. Effect of pitch type, pitch count and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. The American Journal of Sports Medicine. 30(4):463-468,2002.
5. Andrews et al. Kinematic and kinetic comparision of baseball pitching among various levels of development. Journal of Biomechanics. 32(12):1371-1375, 1999.

"Torticollis in Infants"-Issue 6

     Eighty percent of torticollis in infancy is determined to be muscular in origin and is correctly termed congenital muscular torticollis.  In the remaining twenty percent, the torticollis posture  may indicated signs of a more serious underlying condition.  Accurate identification of a muscular cause is important in diagnosing congenital muscular torticollis. 
    Congenital muscular torticollis typically results from tightness in a specific muscle in the neck.  This muscular tightness causes a child's head to tilt toward one shulder while causing his or her face to turn toward the opposite shoulder. 
     Torticollis limits a child's ability to turn the head in order to see, hear and interact freely with his or her environment.  Because of these limitations, torticollis may lead to: delayed learning, poor body awareness, decreased muscle strength and poor balance.  Babies with torticollis are also very likley to develop a flattening of the back of the head or side of the face.  This is called plagiocephaly,  which can also lead to dealys in development.  Studies show that children with torticollis and plagiocephaly can decrease their risk of delayed development by spending supervised time on their tummies.  This playing position helps promote head and neck control.

     Torticollis and plagiocephaly should be thoroughly evaluated by a physician to determine the cause and whether treatment is necessary.  Your child should be screened for: motion and end feel of the head/neck, visual function, head shape, hip symmetry, and age appropriate reflexes.  If torticollis is diagnosed, physical therapy is typically recommended.  

     Studies show that ninety percent (90%) of children achieve a good to excellent outcome with physical therapy.  The best results occur if therapy begins as early as possible. Physical therapy will include: stretching for the head and neck, strengthening activities for the head and trunk, and parent education to promote optimal development for the child.  For more information contact your local physcian or physical therapist.

References:

1.  Burch C et al; Cincinnati Children's Hospital Medical Center: Evidence-based clinical care guidelines for Therapy Management of Congenital Muscular Torticollis, www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/otpt.htm, Guideline 33, pages 1-13,11-19-09.

2. http://www.childrensmemorail.org/

3. http://www.seattlechildrens.org/

4. Vimmeren et al; Torticollis and Plagiocephaly in Infancy: Therapeutic Strategies; A Review; Pediatric Rehabiliation; 9:40-46, 2006.

5. Schertz et al; Motor and Cognitive Development: A one-year follow up in infants with torticollis;  Early Human Development. 84:9-14, 2008.

6. Ohman et al, Are infants with Torticollis at risk for a delay in early motor milestones compared with a control group of healthy infants; Developmental Medicine and Child Neurology. 51:545-650, 2009.

"Little Leauge Elbow"- Issue 5

             Little League Elbow, also known as medial epicondyle apophysitis, is the irritation and inflammation of the growth plate along the inner side of the elbow.

          In a pitcher who is not finished growing, the soft, cartilaginous growth plate of the elbow is the weak link during the throwing motion.  During an overhand throw, the inside of the elbow has traction pressure while the outside of the elbow has compression influences.  Frequent and excessive throwing results in repeated traction on the inside of the elbow. This repetition creates a pulling action on the growth plate causing it to become irritated and inflamed over time.

          In Adults, whose growth plates are closed, the ligament along the inside of the elbow is the weak link in the throwing motion, which can result in the common injury: Tommy John Syndrome.

         Little League elbow most frequently affects pitchers between 9 and 14 years of age, but it can also impact other players in high throwing positions such as shortstop and third base.  It can even be seen in other overhead sports such as water polo, volleyball and football (quarterbacks). The young athlete will typically complain of pain along the inside of the elbow that occurs with throwing and worsens with each additional throw or inning.  This start of pain can often be tied to a recent increase in the number of innings thrown or the number of games pitched by the athlete.

         Upon exam, there will be tenderness along the medial epicondyle and there may be some swelling and loss of elbow motion. X-rays are typically normal, but may show irritation or widening of the growth plate.

The most important step in the treatment of little league elbow is rest.  Ideally, the child should undergo a period of complete rest from throwing for a minimum of 4 to 6 weeks until pain is eliminated.

         During this period of rest, the athlete should focus on overall core/abdominal strength while allowing the arm to rest. Using this time to develop sufficient core strength and body control can help correct throwing mechanics and prevent injury.

         Once the athlete is pain free, a structured throwing program should be initiated over the next 4 to 6 weeks, with special attention to the athlete’s throwing mechanics.  Any pain during this rehab period should result in rest from the program until the pain goes away.

         Typically, it takes about 8 to 12 weeks for an injured athlete to return to competitive throwing. The goal is to return to throwing as quickly and as safely as possible, but if the athlete returns to throwing too soon or throws with pain, the injury may worsen and could lead to permanent elbow pain and difficulty with sports. 

         The best ways to prevent little league elbow are: avoid throwing with pain, do not initiate breaking pitches before the age of 14, and follow the guidelines for pitch count and pitch age recommended by USA Baseball Medical Safety and Advisory Committee-Click here to see guidelines!.  For more specific information contact your local physician or physical therapist. 

REFERENCES:

1. USA Baseball Medical and Safety Advisory Committee Guidelines: May 2006.

2. "Preventing Little Leauge Shoulder and Elbow"; Contemporary Pediatrics; 2004; 21:9.

3. www.childrensmemorial.com

4. Adams, Joel. "Little League Elbow"; California Medicine-The Journal of Western Medicine; 1993:118(3).

5. Benjamin, Holly. "Little Leauge Elbow Syndrome". EMedicine-Medscape. April 19, 2011.