Little League Elbow (Care of the Young Athlete)

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Little League elbow is a common overuse injury
associated with throwing. This injury is most common in pitchers but also occurs
in catchers, infielders, and outfielders.

Little League elbow is the result of repetitive
stress to the growth plate on the inside of the elbow. The greatest stress
occurs during the acceleration phase of throwing a baseball.

Growing bones are easily injured because the growth
plate is much weaker than the ligaments and muscles that attach to it. Once the
growth plates fuse, athletes are more likely to injure ligaments and tendons

The phases of pitching include windup,
stride, arm cocking, arm acceleration, release, arm deceleration, and
follow-through. This illustration shows arm acceleration, release, and
arm deceleration.


Little League elbow usually begins gradually
without a specific injury, but a distinct painful pop may occasionally be felt.
Young athletes often try to minimize their symptoms so they can continue playing
the sport.

Athletes may experience aching, sharp pain, and
swelling on the inside of the elbow. These symptoms may occur only with
pitching, but may progress to the point when any throwing causes pain. Advanced
stages of the disorder may include small fractures of the growth plate, loose
bodies or bone chips, or early arthritis and bone spurs.

Who gets Little League elbow?

Little League elbow is most common between the
ages of 8 to 15 years but can occur up to age 17 years if the growth plate has
not fused. This condition is seen most often in pitchers. Athletes who play
other high-volume throwing positions, such as catcher, shortstop, or outfielder,
are also susceptible.

There is a direct link between elbow pain and
the number of pitches (pitch counts) and the number of games in which a young
player throws. Most leagues have rules in place about this but they may not be
followed, so it is very important that someone (usually the parent) keeps count.
This includes counting the extra throwing done outside of practice. This problem
is seen much more commonly in baseball players who play year-round and pitch for
more than one team.

Fastballs are the most common pitches thrown in
baseball and are thrown hard, usually with backspin. Changeups are thrown with
the same arm action as a fastball, but the ball moves slower because the pitcher
holds the ball with a different grip. Breaking pitches (curveballs/sliders) are
thrown with topspin that causes them to “break” or drop down as
they reach the plate. Breaking pitches appear to cause the most stress to the
shoulder and elbow and so they are not recommended until age 14 for a curveball
and age 16 for a slider.


X-rays of the elbow can help determine if the
growth plate is still open and if it is widened. They can also show other bone
problems, loose bone chips, and early arthritis. X-rays in patients with Little
League elbow may show nothing abnormal, but the athlete may still have pain.


Treatment of Little League elbow involves 3
stages: rest, rehab, and return to pitching.

  • Rest. At first, complete
    rest from all throwing activities is important. Ice can be helpful to
    relieve pain and swelling. Nonsteroidal anti-inflammatory drugs can be
    used but are not usually necessary if the athlete is not throwing.

  • Rehab. Individualized
    physical therapy programs are the most useful for these young baseball
    players. The program should include elbow range of motion and strength
    exercises and should progress to include strengthening of the forearm,
    upper arm, shoulder, back, and core.

  • Return to pitching. Players
    can return to throwing when they are pain-free and have full range of
    motion and strength. They should progress gradually from non- throwing
    positions (like designated hitter), through less throwing positions
    (like first and second base), to full- effort throwing positions. A
    return to pitching program, which outlines a progression of the number
    and the distance of throws, should be discussed and instituted for these
    young pitchers.

Most cases of Little League elbow clear up with
rest and conservative management as described previously. However, the timeline
for recovery, as with most overuse injuries, is different for every athlete. Not
following the treatment plan may lead to long-term disability or deformity,
including such conditions as osteoarthritis.


  • Year-round fitness. Players
    need to recognize the benefits of year-round physical fitness and
    conditioning. Resistance training is important and useful for all
    baseball players and should include arm, shoulder, back, trunk, and hip
    strengthening, and aerobic conditioning.

  • Active rest. Baseball
    players need a period of “active rest” where they do not
    throw but are able to play other sports. This rest period should be at
    least 3 to 6 months long to give the body time to rest and recover.

  • Pitching guidelines. Pitch
    counts are necessary at all levels of baseball. Guidelines have been
    updated, researched, and summarized in a publication titled
    “Protecting Young Pitching Arms.” These guidelines are
    important for all young pitchers, parents, and coaches to be familiar
    with. Guidelines can be found at http://www.littleague.org or http://www.asmi.org/asmiweb/usabaseball.htm.

  • Control, command, and
    Young pitchers need to work first on control (getting
    the ball in the strike zone). After gaining control they should work on
    command (being able to place the pitch in certain areas of the strike
    zone). Finally, after they master control and command they can work on
    increasing pitch speed. Pitchers younger than 14 years should only throw
    fast balls and changeups. Curveballs can be added after age 14 and
    sliders after age 16.

  • Avoiding maximum effort
    Young pitchers need to avoid other high-demand
    throwing positions (catcher, short-stop, third base) on days they have
    pitched. They should also rest from pitching for 24 to 48 hours after an
    outing, including backyard practice.

  • Avoiding further injury.
    Athletes need to listen to their bodies carefully and avoid pitching
    through pain. An athlete who complains of pain around the elbow or
    shoulder, popping, or discomfort with throwing should not be allowed to
    throw anymore that day until pain-free. After that, a careful plan for
    gradual return to throwing would include

    • Warm-up and throws that are less
      than maximum effort

    • Pitching with less than maximum

    • Maximum effort pitches

  • Proper mechanics. Correct
    pitching and throwing mechanics should be stressed at a young age. Poor
    mechanics can lead to injury. Biomechanic evaluation can be obtained
    from a qualified pitching coach or in a biomechanics laboratory.

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by the American Academy of Pediatrics (AAP). The AAP is not responsible for the
content of the resources mentioned in this publication. Web site addresses are
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