Little League Elbow Syndrome Clinical Presentation

Updated: Aug 30, 2018
  • Author: Holly J Benjamin, MD, FAAP, FACSM; Chief Editor: Craig C Young, MD  more...
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  • Little league elbow syndrome occurs most commonly in pitchers, but it is also seen in infielders, catchers, and outfielders. This condition can also occur in other overhead or throwing sports, such as tennis and football (quarterback position). It is important to identify the player's position on the sports team during history taking, because this makes determining the magnitude of the stress placed on the elbow and the subsequent risk of injury easier.

  • Skeletal age is an indicator of the stage of skeletal maturity and is a major determining factor in regard to these potential types of injuries. Little league elbow injuries during childhood are usually due to repetitive microtrauma to the apophysis and ossification center of the medial epicondyle. During adolescence, increased throwing force and valgus stress result in avulsion, delayed union, or nonunion of the medial epicondyle. In young adulthood, the medial epicondyle is fused, and injuries to the UCL are more common.

  • Throwing history is important. Types of pitches, an accurate pitch count of approximate numbers of competitive pitches per game per week and/or season is necessary information. (See the 2008 USA Baseball Medical & Safety Advisory Committee recommendations for youth pitch counts. [11] )The level of play and time of season should be noted. Recent changes in pitch types, counts, or other alterations in training should be carefully noted. For example, fastballs and change-up pitches result in less medial elbow stress than curveballs and sliders. Curveballs thrown at a young age, regardless of previous pitching experience, are associated with an increased risk of little league elbow syndrome and more serious injuries such as medial epicondylar avulsion fractures due to shear forces over a immature growth plate.

  • It is vital to obtain the location, timing, and duration of symptoms (usually pain). Elbow pain in a thrower is usually a chronic overuse injury. However, an acute inciting event that changes or worsens the symptoms may prompt an athlete to seek an evaluation. Pain is most commonly localized to the medial epicondyle, although patients may also present with lateral or posterior elbow pain. Medial elbow pain during the cocking and/or acceleration phases of throwing is typical. Pain during the deceleration phase is more likely to be associated with posterior elbow injuries. Radiation of symptoms is important to note, because patterns such as radiation of symptoms into the forearm with flexor-pronator tendinitis are common, as are paresthesias into the ring and little fingers with ulnar neuritis.

  • Handedness is important only because symptoms usually manifest in the dominant extremity.

  • Past history of injuries such as shoulder, back, or knee injuries that can easily alter the biomechanics of throwing may place the elbow at increased risk for overuse injuries. A general health assessment is also important.



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  • Inspection is important to note the carrying angle and any flexion contractures that may be present relative to the opposite side. During the initial examination, evaluate for muscle atrophy or hypertrophy, bony deformities, or the presence of swelling and ecchymosis. [1, 20, 21]

  • Palpation of bony structures should include both epicondyles, the olecranon process, the capitellum, and the radial head. Soft-tissue palpation should include the UCL (felt best with the patient's elbow in 50-70° of flexion), the biceps tendon, the triceps tendon, and the flexor-pronator and extensor-supinator muscle complexes.

  • Strength testing of the various muscles should be performed.

  • Neurologic testing should include evaluation of the ulnar nerve. Palpation for tenderness, stability testing, and a Tinel test via percussion over the ulnar groove for paresthesias consistent with ulnar neuritis constitute a thorough examination.

  • Special tests include valgus stress testing to evaluate injury to the UCL. The patient may be prone, supine, or upright. The stress test should be performed with the elbow in 20-30° of flexion with a valgus force exerted on the elbow. Opening up on the injured side, compared with the opposite uninjured side, is most reflective of an injury to the UCL. Pain without instability during valgus stress testing is more commonly seen with little league elbow syndrome.

  • Two special tests to note are the milking maneuver , which is performed with the patient seated, and the valgus extension overload test.

    • For the milking maneuver, the examiner grasps the thrower's thumb with the arm in the cocked position of 90° of shoulder abduction and 90° of elbow flexion. Then the examiner applies a valgus stress by pulling down on the thumb.

    • For the valgus extension overload test, the examiner stabilizes the humerus from the outside and then pronates the forearm during extension while applying valgus stress. Pain is more likely associated with posterior impingement if this test result is positive.

  • Conduct a complete examination of the neck, shoulders, wrist, and hand. A general inspection should include an assessment of height and weight, because a larger body habitus is associated with an increased risk of elbow injury.

  • Perform a complete neurologic and vascular examination of the neck and upper extremity.



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  • Training errors, such as abrupt changes in intensity, duration, or frequency of throwing activity are frequently associated with sports injuries. Poor coaching and lack of preseason conditioning can also contribute to an increased risk of injury.

  • Strength and flexibility imbalances can indirectly cause elbow injuries, as can injuries to other areas of the body (current and/or previous injuries).

  • Anatomic malalignment of the lower extremities can cause little league elbow syndrome.

  • Improper footwear or playing surface can result in an insecure platform for stability in throwing activities.

  • Associated disease states or preexistent injury can be causative.

  • Growth patterns are sometimes implicated as the cause of little league elbow syndrome. Physeal or growth cartilage at the epiphysis or apophysis is less resistant to repetitive trauma than fused adult bone at ligamentous and tendinous insertions; thus, skeletally immature athletes more commonly develop growth plate (apophyseal) injuries. In addition, rapid growth (growth spurts) causes increased muscle and tendon tightness around a joint, resulting in loss of flexibility, biomechanical imbalance, and an increased risk of injury.