Sorting out Causes of Elbow Pain in Young Throwers

Any type of elbow discomfort in a young thrower is not a good thing, and while the easiest kids to worry about are those who will openly report elbow pain or limited motion, other more subtle signs of a potential elbow issue might be:

• "shaking" of the arm between throws
•  less interest in throwing
•  throws going higher than usual
•  not being as accurate with the location of throws.

I get particularly concerned about kids who can use a fingertip to identify the exact location of pain and those throwers who have swelling around the elbow joint. I'm also particularly careful with any case of limited ability to straighten the elbow compared to the non-throwing arm; while this might be more acceptable in an adult thrower, it definitely is not normal in a child or early teenage thrower.

Likely culprits leading to elbow pain can include excessive throwing both in one game and over the course of season(s), poor shoulder internal rotation, lack of strength in the legs and back, and trying to snap the wrist or straighten the elbow with too  much force after releasing the ball.

I'll list several common causes  by organizing them according to location within the elbow. Of course, this post is not intended to diagnose or treat any form of pain and should not be considered formal medical advice, but rather should be used as a guide to seek care from a qualified pediatric sports medicine specialist.

A few definitions:  INSIDE OF THE ELBOW is above the pinky side of the hand, and the OUTSIDE OF THE ELBOW is above the thumb side of the hand.

Keeping in mind the following visual about the unique forces that throwing places on the elbow can greatly simplify thinking about potential elbow injuries:

source: http://radsource.us/ulnar-collateral-ligament-tears-of-the-elbow/

• Structures on the INSIDE OF THE ELBOW (BLUE ARROWS) are stretched when a ball is thrown
• Structures on the OUTSIDE OF THE ELBOW (RED ARROWS) are compressed or pushed together when a ball is thrown

Inside (Medial) Elbow Pain (again, most often caused by that stretching motion)

• Irritation of growth plate (aka: medial apophysitis or "throwers's elbow")
  • he medial apophysis is a growth center separate from the rest of the humerus bone (upper part of elbow). Both ligaments (connect bones together) and tendons (connect muscle to bone) have attachment sites to the medial apophysis, so any stretch of these attachments can pull on the growth center and cause a range of injury from more simple irritation to a frank fracture and increased separation of the growth plate
• Irritation or strain of flexor/pronator  muscles
  • These muscles start on the inside of the elbow and allow snapping and/or rolling over of the wrist. Often can be injured after learning new breaking pitches or throwing too many breaking pitches with improper form
• Stretching of Ulnar Nerve
  • The ulnar nerve runs along the inside of the elbow and repetitive stretching can lead to damage with numbness and tingling sensations that travel down into the ring and pinky fingers.
• Ulnar Collateral Ligament (UCL) Tears
  • opularly known as the "Tommy John ligament", the typical story of a UCL tear is immediate pain after one throw with inability to continue throwing. Less common in throwers who haven't completed growth- the apophysis tends to be the weaker link. In more mature throwers (high school and above), the UCL is at greater risk of injury. 

Outside of the Elbow Pain (caused by compression)

• Capitellum Injury
  • ocated at the end of the humerus bone, the capitellum can be damaged by repetitive compression leading to either damage of the entire bone (usually in throwers age 5-10) or more local areas of bone and overlying soft tissue cartilage injury (usually in thrower over the age of 13).
• adial Head Injury
  • Also caused by repetitive compression, injuries to the radial head can involve damage to the growth plate that could affect long-term growth
• xtensor-supinator muscle injury
  • These muscles control straightening and rolling of the wrist. requently known as "tennis elbow", injuries to these muscles are much more common in adults and if suspected in a younger thrower, damage to the capitellum or radial head must first be excluded before making diagnosis of extensor-supinator muscle injury.

Back of the Elbow Pain

• Olecrenon impaction syndrome
  • Repetitive straightening (extension) of elbow can cause irritation of triceps muscle insertion into the olecranon, or even bone spur formation in the olecranon region. Often caused by trying to whip the arm into the straightened position with too much force.

No matter the location of pain, any possible elbow injury in a young thrower deserve urgent and specialized evaluation to determine exact cause, review contributing factors, and provide appropriate recommendations for treatment and recovery. Trying to throw through pain may lead to more damage and ultimately reduce future ability to return to throwing activities.

Do Colder Climates Foster More Sensible Development of Pitchers?

For years, I have heard claims that some Major League Teams favor drafting pitchers who grew up in colder climates.

The reason?

Fewer months able to be spent outside likely means fewer competitive pitches thrown, fewer innings pitched, and perhaps less risk of cumulative stress to shoulders and elbows. Practicing pediatric sports medicine in almost too sunny Southern California (yes indeed, we desperately need rain) I commonly encounter young throwers who pitch most if not almost all months of the year.

Now, thanks to the recent study Is Tommy John Surgery Performed More Frequently in Major League Baseball Pitchers From Warm Weather Areas?, there might actually be some scientific confirmation to these concerns.

Based on rates of elbow medial ulnar collateral ligament (UCL) reconstruction (commonly known as Tommy John Surgery) in Major League pitchers who played high school baseball in warmer vs. colder climates (defined by latitude on map and mean average temperatures), those who grew up in the warmth were found to have a more frequent and earlier UCL reconstructions than players who grew up in the colder environments.

I also found another interesting finding that almost 2/3 of the Major League pitchers in the study pool from 1974 to June 1, 2014 were from colder climates, while by the definitions utilized of warmer vs. colder climates, almost 2/3 of the 73 total studied areas were in colder climates while only 23 of 73 areas were defined as warmer. This correlation does make sense from a general statistical model, but when considering that the warmer areas contain purported baseball hotbeds such as California, Florida, Texas and countries in the Caribbean, Central and South America, the 2/3 proportion coming from colder climates again might support the higher risk cumulative stress and injury in warmer, more possible year-round baseball climates. Perhaps hibernating from too much pitching is ultimately a protective and positive thing and not just another reason to complain about bad weather in certain regions.

The published results on Major League pitchers should not be directly correlated with injury risk to pitchers at the pre-high school, high school and even collegiate or minor league levels. However, if similar studies were conducted at those levels with comparison of UCL reconstruction rates between  climates, I wouldn't be too surprised if the surgical frequencies were higher in warmer climates and possibly starting at younger ages as well.

The upshot of this post is not an endorsement or call for relocation to colder climates to foster a potential Major League Pitching career, but rather a cautionary tale that even in those fortunate and talented enough to pitch in the Major Leagues, the potential blessings to have year-round chances to competitively pitch must be tempered with the need for adequate rest and recovery. I think this need to not take undue advantage of virtually unlimited pitching opportunities does definitely correlate down to school-age and collegiate/minor league pitchers.

Once again, we are getting the message that more is not often better, especially in the long-term development of young athletes.