Elbow

Little League Elbow

Little League elbow is a medial apophysitis of the skeletally immature throwing athlete. The repetitive valgus stress of overhead pitching applies tensile load across the medial growth plate (apophysis), causing pain, swelling, and, if ignored, potential avulsion fracture. Early recognition and appropriate rest are essential to protect the developing elbow.

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What is little league elbow?

During the overhead throw, the elbow undergoes rapid valgus stress at the medial side. In adult athletes, this stress is borne by the ulnar collateral ligament (UCL). In youth throwers, the medial epicondyle apophysis (an open growth plate) is the weakest link in the medial column.

During the overhead throw, the elbow undergoes rapid valgus stress at the medial side. In adult athletes, this stress is borne by the ulnar collateral ligament (UCL). In youth throwers, the medial epicondyle apophysis (an open growth plate) is the weakest link in the medial column. Repetitive microtrauma to this cartilaginous growth plate causes medial apophysitis or, in severe cases, partial or complete avulsion of the medial epicondyle.

This is distinctly different from a UCL tear, which occurs in mature athletes with fused apophyses. In a youth pitcher with medial elbow pain, Little League elbow is the primary diagnosis until proven otherwise.

Peak incidence is between ages 9 and 12 in baseball pitchers, but also seen in youth gymnasts and overhead throwers in other sports. Overuse (pitching too many innings without adequate rest) is the single most modifiable risk factor.

Plain radiographs classically demonstrate widening of the medial apophysis compared to the contralateral side. Fragmentation or displacement of the apophysis indicates more severe injury. MRI can detect growth plate edema and any ligamentous involvement.

Symptoms — do you recognize these?

Medial elbow pain during or after throwing
Tenderness directly over the medial epicondyle
Swelling at the medial elbow
Decreased throwing velocity or accuracy
Occasional locking (suggests loose fragment)
In severe cases: inability to fully extend the elbow

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.

How we diagnose it

Clinical examination reveals medial epicondyle tenderness. Valgus stress test at 30° may be mildly painful but true instability suggests UCL involvement. Plain radiographs are the first-line study. Medial apophyseal widening or fragmentation is diagnostic. Comparison views of the contralateral elbow are helpful. MRI is reserved for cases with suspected UCL injury, loose bodies, or OCD of the capitellum.

Treatment options

Complete rest from throwing is the cornerstone of treatment.

Rest

Complete rest from throwing is the cornerstone of treatment. "Throwing through" the pain risks avulsion fracture with displacement, which may require surgical fixation. Rest from throwing for 4–6 weeks, followed by a graduated return-to-throw (RTT) protocol supervised by a physical therapist. Ice, NSAIDs for short-term pain management. Pitch count guidelines (USA Baseball / Little League Baseball): Ages 7–8: ≤ 50 pitches/day - Ages 9–10: ≤ 75 pitches/day - Ages 11–12: ≤ 85 pitches/day - Ages 13–16: ≤ 95 pitches/day. Mandatory rest periods based on pitch counts and consecutive days pitched. Compliance with these guidelines is strongly associated with reduced injury risk. We counsel both athletes and parents on safe workload management.

Physical Therapy

Physical therapy addresses the underlying contributors to Little Leaguer's Shoulder (including posterior shoulder tightness, scapular dyskinesis, and hip and core weakness) that increase stress on the proximal humeral physis during the throwing motion. A structured program corrects these deficiencies so that when the athlete returns to throwing, mechanics are optimized and the likelihood of recurrence is significantly reduced.

Recovery & rehabilitation

With complete rest and structured rehabilitation, most athletes recover fully in 4–8 weeks and return to pitching via a supervised RTT protocol over 6–8 additional weeks. Recurrence is common if pitch counts are exceeded or rest is insufficient. Athletes with displaced fractures requiring surgery face a longer recovery of 3–6 months before return to throwing.

Frequently Asked Questions

How is Little League elbow different from Tommy John injury?

Little League elbow is an injury to the growth plate (apophysis) in a still-developing skeleton. Tommy John (UCL tear) occurs in athletes with mature bones where the growth plate has closed. Most youth pitchers with medial elbow pain have apophysitis, not a UCL tear.

Can my child ever pitch again after Little League elbow?

Yes. With appropriate rest and a proper return-to-throw program, the vast majority of athletes return to full pitching without lasting problems.

How important are pitch counts?

Very. Population studies show a direct dose-response relationship between pitch counts and elbow injury risk in youth throwers. Adhering to evidence-based guidelines is the most effective injury prevention strategy available.

How long does my child need to rest before returning to pitching?

The required rest period depends on the severity of the injury to the medial apophysis (the growth plate on the inner elbow). Mild cases with no displacement typically require 4–6 weeks of complete rest from throwing, followed by a gradual interval throwing program. More significant stress reactions or small avulsion fractures may require 2–3 months before a controlled return-to-throw program begins. At MOS, we use serial imaging to confirm healing before your child advances through each stage of the return-to-sport protocol.

Will my child need surgery for Little League elbow?

Most cases of Little League elbow heal with rest and activity modification alone, without any surgery. Surgery is reserved for situations where the medial apophysis has been significantly displaced (typically more than 5 mm) or where a loose bone fragment is causing persistent symptoms. In those cases, your MOS surgeon may recommend arthroscopic removal of the fragment or internal fixation of the displaced growth plate. The vast majority of young athletes recover fully with conservative management when caught early.

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Peter G. Fitzgibbons, MD

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Related conditions

UCL Injury (Tommy John)Little Leaguer's Shoulder

Medically reviewed by Peter G. Fitzgibbons, MD

Last reviewed May 1, 2026

References

Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. American Journal of Sports Medicine (AJSM). 2011;39(2):253–257. https://doi.org/10.1177/0363546510384224
Hang DW, Chao CM, Hang YS. A clinical and roentgenographic study of Little League elbow. American Journal of Sports Medicine (AJSM). 2004;32(1):79–84. https://doi.org/10.1177/0363546503258786
American Academy of Orthopaedic Surgeons. Little Leaguer's Elbow. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/little-leaguers-elbow (accessed May 2026).
Dun S, Loftice J, Fleisig GS, Kingsley D, Andrews JR. A biomechanical comparison of youth baseball pitches: is the curveball potentially harmful? American Journal of Sports Medicine (AJSM). 2008;36(4):686–692. https://doi.org/10.1177/0363546507312408