ACC Sports Sciences Main Page

James Bennett, M.D.
University of Miami

Approximately 35 million children and young adults between the ages 6 and 21 participate in sports, including 6-8 million in school programs. Each year, more than 3.5 million sports related injuries in children under age 15 are treated in hospitals, offices, clinics, ambulatory surgery centers, and hospital emergency rooms in the United States, according to the National Electronic Injury Surveillance System of the United States Consumer Product Safety Commission. Of these reported sports related injuries 252,665 involved baseball.

Young athletes have a higher susceptibility to injury due to the fact that their bones, muscles, tendons, and ligaments are still growing. Several studies have found a high incidence of chronic elbow and shoulder injuries in young pitchers. Approximately, 60% of children and adolescents between the ages 11 and 18 experience elbow injuries during or after pitching in organized games. Injuries fall into two basic categories: overuse injuries and acute injuries. Acute injuries are caused by a sudden trauma and can result in sprains, strains, bruises, and fractures. However, the majority of pediatric sports injuries are due to overuse. Overuse injuries can occur from repetitive submaximal loading or stress. The process begins when repetitive activity fatigues a tendon or bone, leading to inflammation and damage to surrounding tissues. Without adequate recovery, this process becomes a relentless cycle and leads to weakness, loss of flexibility, and chronic pain. With appropriate training and time for adequate recovery, the tissue adapts to the demand and is able to undergo further loading without injury.

The repetitive nature of baseball pitching results in a high risk of overuse injuries. A sore elbow is very common in baseball. Elbow pain that is localized on the medial or inner aspect of the elbow in an individual 11 to 18 years of age is referred to as "Little League Elbow". The symptoms include elbow pain, limited motion, locking, clicking and/or the inability to throw. Little League Elbow can become very serious if it is not addressed. The large forces generated in throwing can tear the ligament and tendon from the bone or damage the growth plate disrupting normal bone growth, resulting in a growth deformity. Permanent damage to the elbow may occur.

Whether an injury is acute or due to overuse, a child who has a symptom that persists or affects the ability to perform, should be evaluated by a sports medicine physician. Prompt treatment can oftentimes prevent a minor injury from becoming worse or causing permanent damage. The majority of these injuries can be treated non-operatively using rest, ice, compression, and elevation. Depending on the injury's severity, treatment may range from observation with minor changes in athletic level to a discontinuation of the activity. Physical therapy, a proper throwing program, strengthening exercises, and bracing may also be prescribed. The fundamental goal of treatment is to develop strong, flexible tissue that can absorb the repetitive forces of the sport.

After injury, the initial phase of treatment involves protecting the injured site from a level of loading that perpetuates overuse by reducing the training volume and using alternative activities to maintain aerobic conditioning. Ice should be used throughout the treatment reducing swelling and pain. The ice should be applied lightly over a cloth or bandage for 10 to 20 minutes several times a day for the first 48 to 72 hours after injury and after rehabilitation exercises. Ice massage using water frozen in a paper cup can also be applied in a circular motion over the injury. Topical heat may help reduce stiffness. Other modalities performed by a physical therapist and/or certified athletic trainer such as ultrasound, iontophoresis, and electrical stimulation may also be useful. When rest, ice, and modalities have not relieved pain, a short course of nonsteroidal anti-inflammatory medication may be used.

Once the pain is controlled a formal rehabilitation program may begin. The objectives of rehabilitation are to restore range of motion, strength, flexibility, and proprioception. The athlete must complete all of these endpoints prior to returning to play otherwise there is a higher risk of re-injury. Athletes, parents, and coaches should be educated about training errors that can occur, the importance of scheduled rest periods, and the need to avoid excessive training volumes, especially during the adolescent growth spurt to limit the risk of re-injury.

Operative intervention is rarely indicated in children less than 14 years of age. Unless a fracture is involved, non-operative management is the initial mainstay of treatment followed by operative intervention if the patient remains symptomatic. Surgical intervention may be indicated in cases of elbow instability, cartilage lesions, loose bodies in the elbow, and chronic pain. When considering surgery the patient and the parents must understand the risks involved including nerve damage, stretching or re-rupture of the reconstructed ligaments, elbow stiffness, and infection. The patient, parents, and coaches must also understand the lengthy postoperative rehabilitation that can take 6 months to a year before returning to competitive throwing.

The American College of Sports Medicine estimates that 50% of overuse injuries in children and adolescents are preventable. Prevention has to start within the schools and homes of the adolescent athlete. Sports specific injury risk factors should be identified early with pre-participation screening to assess young peoples' maturity, skill level and motivation for the sport. Parents should ensure that that their children are receiving proper supervision and coaching at school.

Systematic cycling of training loads over set periods of time with well defined rest periods should be implemented to reduce overuse injuries and prevent overtraining. Training should be carefully monitored and modified during the adolescent growth spurt since the adolescent is more prone to injury during this period.

A comprehensive approach involving the athlete, parents, and coaches is necessary to identify early risk factors and to implement preventative measures to minimize injury among this athletic population.

Bibliography
1. Cain EL, Dugas JR, Wolf RS, Andrews JR: Elbow Injuries in Throwing Athletes: A Current Concepts Review. AJSM 2003; 31(4): 621-635.
2. Chen FS, Rokito AS, Jobe FW: Medial Elbow Problems in the Overhead Throwing Athlete. JAAOS 2001; 9(2): 99-113.
3. DiFiori JP: Overuse Injuries in Children and Adolescents. The Physician and Sportsmedicine. 1999; 27(1): 1-10.
4. Landry GL: Sports Injuries in Childhood. Pediatr Ann 1992; 21(3): 165-168.
5. Medical Clinics of North America. 2000 Nov; 84(4):983-1007.
6. Rudzki JR, Paletta GA: Juvenile and adolescent elbow injuries in sports. Clin Sports Med. 2004 Oct;23(4):581-608.
7. Rettig AC, Sherrill C, Snead DS, Mendler JC, Mieling P: Nonoperative Treatment of Ulnar Collateral Ligament Injuries in Throwing Athletes. AJSM 2001; 29: 15-17.
8. Stanitiski CL: Common Injuries in Preadolescent and Adolescent Athletes: Recommendations for Prevention. Sports Med 1989; 7(1):32-41.