Little league elbow

Little League elbow also called medial apophysitis, is an overuse injury to the elbow or growth plate injury to the inner part of the elbow that occurs as a result of repetitive throwing motions. By definition, Little League elbow is a repetitive traction injury to the medial epicondylar apophysis (Figures 1 and 2) ¹⁾. Most cases happen in pitchers, but any young athlete who throws a lot (catchers, infielders, and outfielders) can get the condition. Little League elbow happens to young athletes who are still growing. Most cases are in kids and teens 8–15 years old. They’re still growing, so their bones still have growth plates. Bones that are done growing don’t have growth plates. Elbow pain after this age likely is not Little League elbow.

little league elbow is a growth plate injury to the medial (inner) part of the elbow that occurs as a result of repetitive throwing motions. The growth plate is the attachment site for the group of muscles that flex the wrist and rotate the forearm.

Little league elbow is most often the result of repetitive throwing motions, which can create an overload or overstress injury to the medial elbow. During the throwing motion, a large amount of tension is placed on the medial elbow structures that can cause injury to the growth plate of the medial (inside) of the elbow.

If left untreated, little league elbow can become more severe, causing ligaments and tendons tears. In addition, tearing may cause tiny bone fragments to break off and travel to other areas of the elbow joint, disrupting normal bone growth, resulting in deformity.

Patients suffering from little league elbow often report a gradual increase of medial elbow pain and stiffness, particularly while throwing. As the condition progresses, the child will often experience a decrease in throwing velocity and effectiveness.

Diagnosis of Little League elbow is most often made after reports of persistent arm pain and loss of function in youth baseball pitchers between the ages of 11 and 15 years (Table 1) ²⁾.

Most patients are able to return to their favorite sport pain-free after a period of rest and conservative treatments.

Figure 1. Little League elbow

Figure 2. Little League elbow X-ray

Footnote: Radiograph of a 13-year-old male baseball player with Little League elbow

[Source ³⁾ ]

Little league elbow causes

Little League elbow is an overuse injury also called a repetitive stress injury. Overuse injuries happen because the same motion is repeated over and over again.

In Little League elbow, repeated throwing injures a growth plate in the elbow. A growth plate is a layer of cartilage near the end of a bone where most of the bone’s growth happens. It’s weaker and more at risk for injury than the rest of the bone.

Risk Factors for developing Little League elbow

Adolescent pitchers, and other adolescent players who throw repetitively, have a high risk of developing little league elbow. If left untreated, little league elbow can lead to major complications and jeopardize a child’s ability to remain active in a sport, such as softball. Other factors that contribute to the development of little league elbow and the increased injury rates seen in pediatric athlete include:

• Increased single-sport participation with year-round training
• Participation in higher intensity sports at younger ages
• Longer competitive seasons
• Conditioning and training errors

Little league elbow prevention

The best way to prevent Little Leaguer’s elbow is to limit how much your child throws. Children should not play through pain. If your child’s arm hurts, your child should stop throwing.

Overuse injuries, such as little league elbow, can often be prevented. Prevention techniques include:

• Proper warm-up (including stretching, running, easy and gradual throwing)
• Rotate positions while on the field
• Concentrate on age-appropriate pitching
• Adhere to pitching count guidelines
• Avoid pitching on multiple teams with overlapping seasons
• In the event of elbow pain, do not pitch
• Communicate regularly about how your arm feels
• Emphasize control, accuracy, and good mechanics

To help prevent Little League elbow, young athletes should:

• Take a break from throwing for 3–6 months a year. They can play another sport that doesn’t involve throwing, like soccer or swimming.
• Make sure they throw correctly.

They also should follow pitching guidelines that specify:

• how many pitches are OK for each age
• what kind of pitches are OK for each age
• how much rest is needed between practices and games

You can find information online about pitching guidelines at:

• American Sports Medicine Institute (http://www.asmi.org/research.php?page=research&section=positionStatement)
• Little League Baseball and Softball (https://www.littleleague.org/playing-rules/pitch-count)

If your child is a baseball pitcher, be sure to follow the guidelines for how many pitches or innings a child can throw in a week. In general:

• A child 9 through 12 years old should pitch no more than 6 innings a week and should throw no more than 250 pitches.
• A child 13 through 15 years old should pitch no more than 9 innings a week and should throw no more than 350 pitches.

When your child is not pitching, he or she needs to be sure they are not throwing hard while playing another position (like shortstop), practicing, or playing other sports. It’s also very important for your child to learn proper pitching technique.

Regular Season Pitching Rules

The eligibility of a player to pitch in a Little League® Baseball game is governed by a tiered pitch count that is tied to the number of pitches throw in a game (https://www.littleleague.org/playing-rules/pitch-count). The pitch count determines how many days of rest are required before said player may pitch again in a Little League game. Below you will find a break down of the regular season pitching rules for Baseball and Softball.

Regular Season Pitching Rules – Baseball

VI – PITCHERS

(a) Any player on a regular season team may pitch. (NOTE: There is no limit to the number of pitchers a team may use in a game.) Exception: Any player who has played the position of catcher in four (4) or more innings in a game is not eligible to pitch on that calendar day.

(b) A pitcher once removed from the mound cannot return as a pitcher. Intermediate (50-70), Junior, and Senior League Divisions only: A pitcher remaining in the game, but moving to a different position, can return as a pitcher anytime in the remainder of the game, but only once per game.

A player who played the position of catcher for three (3) innings or less, moves to the pitcher position, and delivers 21 pitches or more (15- and 16-year-olds: 31 pitches or more) in the same day, may not return to the catcher position on that calendar day. EXCEPTION: If the pitcher reaches the 20-pitch limit (15- and 16-year-olds: 30-pitch limit) while facing a batter, the pitcher may continue to pitch, and maintain their eligibility to return to the catcher position, until any one of the following conditions occur:

1. that batter reaches base;
2. that batter is retired; or
3. the third out is made to complete the half-inning or the game.

(c) The manager must remove the pitcher when said pitcher reaches the limit for his/her age group as noted below, but the pitcher may remain in the game at another position:

League Age:

• 13 to 16 years of age – 95 pitches per day
• 11 to 12 years of age– 85 pitches per day
• 9 to 10 years of age– 75 pitches per day
• 7 to 8 years of age– 50 pitches per day

Exception: If a pitcher reaches the limit imposed in Regulation VI (c) for his/her league age while facing a batter, the pitcher may continue to pitch until any one of the following conditions occurs:

1. That batter reaches base;
2. That batter is put out;
3. The third out is made to complete the half-inning.

NOTE: If a pitcher reaches 40 pitches while facing a batter, the pitcher may continue to pitch, and maintain their eligibility to play the position of catcher for the remainder of that day, until any one of the following conditions occurs:

1. that batter reaches base;
2. that batter is retired; or
3. the third out is made to complete the half-inning or the game.

The pitcher would be allowed to play the catcher position provided that pitcher is moved, removed, or the game is completed before delivering a pitch to another batter. If a player delivers 41 or more pitches, and is not covered under the threshold exception, the player may not play the position of catcher for the remainder of that day.

(d) Pitchers league age 14 and under must adhere to the following rest requirements:

• If a player pitches 66 or more pitches in a day, four (4) calendar days of rest must be observed.
• If a player pitches 51-65 pitches in a day, three (3) calendar days of rest must be observed.
• If a player pitches 36-50 pitches in a day, two (2) calendar days of rest must be observed.
• If a player pitches 21-35 pitches in a day, one (1) calendar days of rest must be observed.
• If a player pitches 1-20 pitches in a day, no (0) calendar day of rest is required.

Exception: If a pitcher reaches a day(s) of rest threshold while facing a batter, the pitcher may continue to pitch until any one of the following conditions occurs: (1) that batter reaches base; (2) that batter is retired; or (3) the third out is made to complete the half-inning or the game. The pitcher will only be required to observe the calendar day(s) of rest for the threshold he/she reached during that at-bat, provided that pitcher is removed or the game is completed before delivering a pitch to another batter.”

NOTE: If a pitcher reaches 30 pitches while facing a batter in the first game, the pitcher may continue to pitch, and maintain their eligibility to pitch in the second game on that day, until any one of the following conditions occurs: (1) that batter reaches base; (2) that batter is retired; or (3) the third out is made to complete the half-inning or the game. The pitcher would be allowed to pitch in a second game provided that pitcher is moved, removed, or the game is completed before delivering a pitch to another batter. If a player delivers 31 or more pitches in the first game, and is not covered under the threshold exception, the player may not pitch in the second game that day);

(d) Pitchers league age 15-16 must adhere to the following rest requirements:

• If a player pitches 76 or more pitches in a day, four (4) calendar days of rest must be observed.
• If a player pitches 61-75 pitches in a day, three (3) calendar days of rest must be observed.
• If a player pitches 46-60 pitches in a day, two (2) calendar days of rest must be observed.
• If a player pitches 31-45 pitches in a day, one (1) calendar days of rest must be observed.
• If a player pitches 1-30 pitches in a day, no (0) calendar day of rest is required.

Exception: If a pitcher reaches a day(s) of rest threshold while facing a batter, the pitcher may continue to pitch until any one of the following conditions occurs: (1) that batter reaches base; (2) that batter is retired; or (3) the third out is made to complete the half-inning or the game. The pitcher will only be required to observe the calendar day(s) of rest for the threshold he/she reached during that at-bat, provided that pitcher is removed or the game is completed before delivering a pitch to another batter.

(e) Each league must designate the scorekeeper or another game official as the official pitch count recorder.

(f) The pitch count recorder must provide the current pitch count for any pitcher when requested by either manager or any umpire. However, the manager is responsible for knowing when his/her pitcher must be removed.

(g) The official pitch count recorder should inform the umpire-in-chief when a pitcher has delivered his/her maximum limit of pitches for the game, as noted in Regulation VI (c). The umpire-in-chief will inform the pitcher’s manager that the pitcher must be removed in accordance with Regulation VI (c). However, the failure by the pitch count recorder to notify the umpire-in-chief, and/or the failure of the umpire-in- chief to notify the manager, does not relieve the manager of his/her responsibility to remove a pitcher when that pitcher is no longer eligible.

(h) Violation of any section of this regulation can result in protest of the game in which it occurs. Protest shall be made in accordance with Playing Rule 4.19.

(j) A player who has attained the league age of twelve (12) is not eligible to pitch in the Minor League. (See Regulation V – Selection of Players)

(k) A player may not pitch in more than one game in a day.

NOTES:

1. The withdrawal of an ineligible pitcher after that pitcher is announced, or after a warm-up pitch is delivered, but before that player has pitched a ball to a batter, shall not be considered a violation. Little League officials are urged to take precautions to prevent protests. When a protest situation is imminent, the potential offender should be notified immediately.
2. Pitches delivered in games declared “Regulation Tie Games” or “Suspended Games” shall be charged against pitcher’s eligibility.
3. In suspended games resumed on another day, the pitchers of record at the time the game was halted may continue to pitch to the extent of their eligibility for that day, provided said pitcher has observed the required days of rest.

Example 1: A league age 12 pitcher delivers 70 pitches in a game on Monday when the game is suspended. The game resumes on the following Thursday. The pitcher is not eligible to pitch in the resumption of the game because he/she has not observed the required days of rest.

Example 2: A league age 12 pitcher delivers 70 pitches in a game on Monday when the game is suspended. The game resumes on Saturday. The pitcher is eligible to pitch up to 85 more pitches in the resumption of the game because he/she has observed the required days of rest.

Example 3: A league age 12 pitcher delivers 70 pitches in a game on Monday when the game is suspended. The game resumes two weeks later. The pitcher is eligible to pitch up to 85 more pitches in the resumption of the game, provided he/she is eligible based on his/her pitching record during the previous four days.

(EXCEPTION: Junior and Senior League: If a pitcher reaches 30 pitches while facing a batter in the first game, the pitcher may continue to pitch, and maintain their eligibility to pitch in the second game on that day, until any one of the following conditions occurs: (1) that batter reaches base; (2) that batter is retired; or (3) the third out is made to complete the half-inning or the game. The pitcher would be allowed to pitch in a second game provided that pitcher is moved, removed, or the game is completed before delivering a pitch to another batter. If a player delivers 31 or more pitches in the first game, and is not covered under the threshold exception, the player may not pitch in the second game that day).

Note: The use of this regulation negates the concept of the “calendar week” with regard to pitching eligibility

Regular Season Pitching Rules – Softball

Regulation VI – PITCHERS

• (a) Any player on the team roster may pitch. EXCEPTION: A player who has attained a league age of twelve (12) is not eligible to pitch in the Minor League.
• (b) Minors/Little League (Majors): A player may pitch in a maximum of twelve (12) innings in a day. If a player pitches in seven (7) or more innings in a day, one calendar day of rest is mandatory. Delivery of a single pitch constitutes having pitched in an inning.

Little League (Majors) and Minor League example

If a player pitched in seven (7) or more innings on (Column A), that player can pitch again on (Column B):

Column A	Column B
Sunday	Tuesday
Monday	Wednesday
Tuesday	Thursday
Wednesday	Friday
Thursday	Saturday
Friday	Sunday
Saturday	Monday

Junior/Senior League: No pitching restrictions apply.

NOTE: The local league Board of Directors or District may impose additional pitching limitations during the Regular Season and interleague.

Pitching Restrictions for 12 year olds participating in Majors and Junior League

For a 12-year-old participating in the Major and Junior League Divisions as permitted under Regulation IV(a), the pitching rules and regulations regarding days of rest that are pertinent to the division in which the pitcher is used will apply to that game. Innings pitched previously in both divisions are taken into account when determining the eligibility of the pitcher for a particular game, with respect to days of rest and number of innings available.

Example 1 – A player pitches seven innings in a Junior Division game on Sunday. On Monday, she has a scheduled game in the Major Division. She would not be eligible to pitch in that game because the Major Division regulations require her to have one calendar day of rest, as a result of pitching in more than six innings on the previous day.

Example 2 – A player pitches nine innings in a Major Division game on Sunday. On Monday, she has a scheduled game in the Junior Division, and she would be eligible to pitch in that game because the Junior Division has no pitching restrictions.

Example 3 – A player pitches in seven innings in a Junior Division game played on Sunday and has a Major Division game later that same day. The player would be limited to five more innings for the Major Division game (for a total of 12 innings in a day in the Major Division).

• (c) Minor/Major: A pitcher remaining in the game, but moving to a different position, can return as a pitcher anytime in the remainder of the game but only once in the same inning as he/she was removed. A pitcher, withdrawn from the game offensively or defensively for a substitute, may not re-enter the game as a pitcher. Exception: See Rule 3.03(c). Junior/Senior League: A pitcher may be withdrawn from the game, offensively or defensively, and return as pitcher only once per inning provided the return does not violate the substitution, visits per pitcher, or mandatory play rule(s).
• (d) Little League (Major) Division/Junior/Senior League: Not more than five (5) pitchers per team shall be used in one game.
• (e) Violation of any section of this regulation can result in protest of the game in which it occurs. Protest shall be made in accordance with Playing Rule 4.19.

NOTES:

1. The withdrawal of an ineligible pitcher after that pitcher is announced, or after a warm-up pitch is delivered, but before that player has pitched a ball to a batter, shall not be considered a violation. Little League officials are urged to take precautions to prevent protests. When a protest situation is imminent, the potential offender should be notified immediately.
2. Innings pitched in games declared “Regulation Tie Games” or “Suspended Games” shall be charged against pitcher’s eligibility. NOTE 1: In suspended games resumed on a subsequent day, the pitchers of record at the time the game was halted may continue to pitch to the extent of their remaining eligibility for that day.
3. Minors/Little League (Majors): If doubleheaders are played, the limitation of twelve (12) innings in a calendar day would apply to each pitcher. A pitcher who pitches in the first game may pitch in the second game provided that pitcher has eligibility remaining.
4. There is no limit to the number of pitchers of a particular league age group on a team that can be used. EXCEPTION: A player who has attained a league age of twelve (12) is not eligible to pitch in the Minor League.

Little league elbow symptoms

Kids with Little League elbow have pain on the inner part of their elbow. At first, the elbow may hurt only during or right after throwing. But without treatment, the elbow can start hurting all the time. The pain usually starts gradually, but can happen after one throw if the athlete has been making the same motions often.

Little league elbow diagnosis

Doctors diagnose Little League elbow by:

• asking about sports and activities
• doing an exam of the elbow, observing range of motion and doing strength tests
• getting X-rays (X-rays can be normal in Little League elbow but can show other problems in the elbow)
• comparing the affected elbow with the unaffected elbow

Little league elbow treatment

If caught early enough and treated properly by a pediatric orthopaedic physician, Little League elbow will heal completely and not cause any permanent elbow damage. To ensure a proper diagnosis, the orthopedic physician will review the patient’s symptoms, clinical examination results, and x-rays.

Little league elbow treatment options are dependent on the extent of the growth plate injury. Left untreated, throwing injuries in the elbow can be very complex. However, younger children tend to respond better to non-surgical treatments.

Kids with Little League elbow must take a break from all throwing for about 6 weeks. For pain and swelling, they can:

• Put ice or a cold pack on the elbow every 1–2 hours for 20 minutes at a time to bring down any swelling. Put a thin towel between the ice and the skin to protect it from the cold.
• Take non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Advil, Motrin, or store brand) or naproxen (Aleve, Naprosyn, or store brand) if the health care provider says it’s OK. Follow the package directions for how much to give and how often to give it. Kids should always take the medicines with food.

When pain and swelling ease, health care providers usually recommend physical therapy or another exercise program. Before returning to play, it might help some kids to work on how they throw with a pitching coach or physical therapist.

If pain persists after a few days of complete rest of the affected arm, or if pain recurs when throwing is resumed, it is recommended that the child stop the activity until cleared by a pediatric orthopaedic physician. Based on the severity of the injury, a 6-week period of rest may be recommended. Upon approval from the physician, a slow progressive throwing program may be instituted over the next 6-8 weeks. While rare, surgery or casting is occasionally necessary to relieve pain symptoms.

How can parents help a child with Little league elbow

To help kids with Little League elbow:

• Make sure they follow the health care provider’s recommendations for rest and exercises.
• Make sure they don’t go back to throwing until the doctor says it’s OK. Throwing too soon can cause permanent elbow damage.
• When they’re back to throwing, be sure the pitching guidelines are followed. Someone from the team should keep track of pitches. If no one does, you may need to do it yourself.
• Teach your child that if something hurts during training or a game, they should stop playing right away. If the pain continues, your child needs to get checked by a coach, trainer, and health care provider before returning to play.

Little league elbow recovery time

After a rest period and physical therapy or another exercise program, athletes with Little League elbow can slowly return to pitching if they:

• do not have any elbow pain
• have full strength in their arm
• can bend and straighten their elbow fully

Athletes with Little League elbow need to work with their health care provider and coach to create a return to pitching program. The program should:

• slowly increase the number, distance, and intensity of pitches over 6–8 weeks
• say how many pitches can be thrown a day
• say what distance it is OK to throw

They shouldn’t go back to throwing until their health care provider says it’s OK. Going back too early can permanently damage the elbow.