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Valgus Stress Mechanism/Little Leaguer's Elbow
Kirkland W. Davis, MD, FACR; Andrew Sonin, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        TERMINOLOGY

        • Synonyms

          • Thrower's elbow, medial epicondyle apophysitis, medial epicondyle avulsion
        • Definitions

          • Valgus stress mechanism
            • Pattern of injury occurring in elbow due to repetitive valgus elbow stress, including
              • Distraction of medial structures
              • Compression of lateral structures
              • May have "extension overload" at end of throwing mechanism → posteromedial compression
                • Stress injury to olecranon
                • Cartilage loss/OA at posteromedial trochlea, olecranon
                • Intraarticular fragments common
                • May cause ulnar neuritis
          • Injuries differ based on skeletal maturity
            • Skeletally mature: medial ligament ± tendon injury
            • Skeletally immature: Little Leaguer's elbow
          • Little Leaguer's elbow
            • Specific pattern of valgus stress injury to elbow in preadolescent/adolescent thrower's elbow
            • Avulsion of medial humeral epicondyle apophysis
            • ± intraarticular entrapment of epicondyle fragment
            • Often associated with capitellum cartilage/osteochondral injury
            • Apophysitis may be medial injury instead of avulsion
              • More chronic, submaximal stresses

        IMAGING

        • General Features

          • Radiographic Findings

            • CT Findings

              • MR Findings

                • Ultrasonographic Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        • Staging, Grading, & Classification

                          CLINICAL ISSUES

                          • Presentation

                            • Demographics

                              • Natural History & Prognosis

                                • Treatment

                                  DIAGNOSTIC CHECKLIST

                                  • Consider

                                    • Image Interpretation Pearls

                                      • Reporting Tips

                                        Selected References

                                        1. Firth AM et al: Paediatric medial humeral epicondyle fracture management: 2019 approach. Curr Opin Pediatr. 31(1):86-91, 2019
                                        2. Kheterpal AB et al: Overuse injuries of the elbow. Radiol Clin North Am. 57(5):931-42, 2019
                                        3. Beck JJ et al: What's new in pediatric upper extremity sports injuries? J Pediatr Orthop. 38(2):e73-7, 2018
                                        4. Kim HH et al: Pediatric elbow injuries. Semin Ultrasound CT MR. 39(4):384-96, 2018
                                        5. Lin A et al: Clinical applications of ultrasonography in the shoulder and elbow. J Am Acad Orthop Surg. 26(9):303-12, 2018
                                        6. Sconfienza LM et al: Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus. Eur Radiol. 28(12):5338-51, 2018
                                        7. Bruce JR et al: How much valgus instability can be expected with ulnar collateral ligament (UCL) injuries? A review of 273 baseball players with UCL injuries. J Shoulder Elbow Surg. 23(10):1521-6, 2014
                                        8. Ciccotti MG et al: Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med. 42(3):544-51, 2014
                                        9. Makhni EC et al: Pediatric elbow injuries in athletes. Sports Med Arthrosc Rev. 22(3):e16-24, 2014
                                        10. Patel RM et al: The thrower's elbow. Orthop Clin North Am. 45(3):355-76, 2014
                                        11. Bancroft LW et al: Osteochondral lesions of the elbow. Semin Musculoskelet Radiol. 17(5):446-54, 2013
                                        12. Jans LB et al: MR imaging findings and MR criteria for instability in osteochondritis dissecans of the elbow in children. Eur J Radiol. 81(6):1306-10, 2012
                                        13. Smith MV et al: Surgical treatment for osteochondritis dissecans of the capitellum. Sports Health. 4(5):425-32, 2012
                                        14. Hechtman KS et al: Long-term results of ulnar collateral ligament reconstruction in throwing athletes based on a hybrid technique. Am J Sports Med. 39(2):342-7, 2011
                                        15. Sabo MT et al: Osteochondral lesions of the capitellum do not affect elbow kinematics and stability with intact collateral ligaments: an in vitro biomechanical study. J Hand Surg Am. 36(1):74-80, 2011
                                        16. Smith W et al: Utilization of sonography and a stress device in the assessment of partial tears of the ulnar collateral ligament in throwers. Int J Sports Phys Ther. 6(1):45-50, 2011
                                        17. Baker CL 3rd et al: Osteochondritis dissecans of the capitellum. Am J Sports Med. 38(9):1917-28, 2010
                                        18. Dugas JR: Valgus extension overload: diagnosis and treatment. Clin Sports Med. 29(4):645-54, 2010
                                        19. Mihara K et al: Surgical treatment for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg. 19(1):31-7, 2010
                                        20. Ruchelsman DE et al: Osteochondritis dissecans of the capitellum: current concepts. J Am Acad Orthop Surg. 18(9):557-67, 2010
                                        21. Wei AS et al: Clinical and magnetic resonance imaging findings associated with Little League elbow. J Pediatr Orthop. 30(7):715-9, 2010
                                        22. Keeley DW et al: A biomechanical analysis of youth pitching mechanics. J Pediatr Orthop. 28(4):452-9, 2008
                                        23. Lynch JR et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg Am. 33(3):430-7, 2008
                                        24. Magra M et al: A review of epidemiology of paediatric elbow injuries in sports. Sports Med. 37(8):717-35, 2007
                                        25. Creighton RA et al: Evaluation of the medial elbow in the throwing athlete. Am J Orthop. 35(6):266-9, 2006
                                        26. Benjamin HJ et al: Little league elbow. Clin J Sport Med. 15(1):37-40, 2005
                                        27. Lee HH et al: Operative treatment of displaced medial epicondyle fractures in children and adolescents. J Shoulder Elbow Surg. 14(2):178-85, 2005
                                        28. Ahmad CS et al: Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med. 23(4):665-76, x, 2004
                                        29. Hang DW et al: A clinical and roentgenographic study of Little League elbow. Am J Sports Med. 32(1):79-84, 2004
                                        30. Miller TT et al: Sonography of injury of the ulnar collateral ligament of the elbow-initial experience. Skeletal Radiol. 33(7):386-91, 2004
                                        31. Cain EL Jr et al: Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 31(4):621-35, 2003
                                        32. Thornton R et al: Magnetic resonance imaging of sports injuries of the elbow. Top Magn Reson Imaging. 14(1):69-86, 2003
                                        33. Klingele KE et al: Little league elbow: valgus overload injury in the paediatric athlete. Sports Med. 32(15):1005-15, 2002
                                        34. Grana W: Medial epicondylitis and cubital tunnel syndrome in the throwing athlete. Clin Sports Med. 20(3):541-8, 2001
                                        35. Ellenbecker TS et al: Medial elbow joint laxity in professional baseball pitchers. A bilateral comparison using stress radiography. Am J Sports Med. 26(3):420-4, 1998
                                        36. Inoue G et al: Surgical repair of traumatic medial disruption of the elbow in competitive athletes. Br J Sports Med. 29(2):139-42, 1995
                                        37. Mirowitz SA et al: Ulnar collateral ligament injury in baseball pitchers: MR imaging evaluation. Radiology. 185(2):573-6, 1992
                                        Related Anatomy
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                                        Related Differential Diagnoses
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                                        References
                                        Tables

                                        Tables

                                        KEY FACTS

                                        • Terminology

                                          • Imaging

                                            • Clinical Issues

                                              TERMINOLOGY

                                              • Synonyms

                                                • Thrower's elbow, medial epicondyle apophysitis, medial epicondyle avulsion
                                              • Definitions

                                                • Valgus stress mechanism
                                                  • Pattern of injury occurring in elbow due to repetitive valgus elbow stress, including
                                                    • Distraction of medial structures
                                                    • Compression of lateral structures
                                                    • May have "extension overload" at end of throwing mechanism → posteromedial compression
                                                      • Stress injury to olecranon
                                                      • Cartilage loss/OA at posteromedial trochlea, olecranon
                                                      • Intraarticular fragments common
                                                      • May cause ulnar neuritis
                                                • Injuries differ based on skeletal maturity
                                                  • Skeletally mature: medial ligament ± tendon injury
                                                  • Skeletally immature: Little Leaguer's elbow
                                                • Little Leaguer's elbow
                                                  • Specific pattern of valgus stress injury to elbow in preadolescent/adolescent thrower's elbow
                                                  • Avulsion of medial humeral epicondyle apophysis
                                                  • ± intraarticular entrapment of epicondyle fragment
                                                  • Often associated with capitellum cartilage/osteochondral injury
                                                  • Apophysitis may be medial injury instead of avulsion
                                                    • More chronic, submaximal stresses

                                              IMAGING

                                              • General Features

                                                • Radiographic Findings

                                                  • CT Findings

                                                    • MR Findings

                                                      • Ultrasonographic Findings

                                                        • Imaging Recommendations

                                                          DIFFERENTIAL DIAGNOSIS

                                                            PATHOLOGY

                                                            • General Features

                                                              • Staging, Grading, & Classification

                                                                CLINICAL ISSUES

                                                                • Presentation

                                                                  • Demographics

                                                                    • Natural History & Prognosis

                                                                      • Treatment

                                                                        DIAGNOSTIC CHECKLIST

                                                                        • Consider

                                                                          • Image Interpretation Pearls

                                                                            • Reporting Tips

                                                                              Selected References

                                                                              1. Firth AM et al: Paediatric medial humeral epicondyle fracture management: 2019 approach. Curr Opin Pediatr. 31(1):86-91, 2019
                                                                              2. Kheterpal AB et al: Overuse injuries of the elbow. Radiol Clin North Am. 57(5):931-42, 2019
                                                                              3. Beck JJ et al: What's new in pediatric upper extremity sports injuries? J Pediatr Orthop. 38(2):e73-7, 2018
                                                                              4. Kim HH et al: Pediatric elbow injuries. Semin Ultrasound CT MR. 39(4):384-96, 2018
                                                                              5. Lin A et al: Clinical applications of ultrasonography in the shoulder and elbow. J Am Acad Orthop Surg. 26(9):303-12, 2018
                                                                              6. Sconfienza LM et al: Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus. Eur Radiol. 28(12):5338-51, 2018
                                                                              7. Bruce JR et al: How much valgus instability can be expected with ulnar collateral ligament (UCL) injuries? A review of 273 baseball players with UCL injuries. J Shoulder Elbow Surg. 23(10):1521-6, 2014
                                                                              8. Ciccotti MG et al: Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med. 42(3):544-51, 2014
                                                                              9. Makhni EC et al: Pediatric elbow injuries in athletes. Sports Med Arthrosc Rev. 22(3):e16-24, 2014
                                                                              10. Patel RM et al: The thrower's elbow. Orthop Clin North Am. 45(3):355-76, 2014
                                                                              11. Bancroft LW et al: Osteochondral lesions of the elbow. Semin Musculoskelet Radiol. 17(5):446-54, 2013
                                                                              12. Jans LB et al: MR imaging findings and MR criteria for instability in osteochondritis dissecans of the elbow in children. Eur J Radiol. 81(6):1306-10, 2012
                                                                              13. Smith MV et al: Surgical treatment for osteochondritis dissecans of the capitellum. Sports Health. 4(5):425-32, 2012
                                                                              14. Hechtman KS et al: Long-term results of ulnar collateral ligament reconstruction in throwing athletes based on a hybrid technique. Am J Sports Med. 39(2):342-7, 2011
                                                                              15. Sabo MT et al: Osteochondral lesions of the capitellum do not affect elbow kinematics and stability with intact collateral ligaments: an in vitro biomechanical study. J Hand Surg Am. 36(1):74-80, 2011
                                                                              16. Smith W et al: Utilization of sonography and a stress device in the assessment of partial tears of the ulnar collateral ligament in throwers. Int J Sports Phys Ther. 6(1):45-50, 2011
                                                                              17. Baker CL 3rd et al: Osteochondritis dissecans of the capitellum. Am J Sports Med. 38(9):1917-28, 2010
                                                                              18. Dugas JR: Valgus extension overload: diagnosis and treatment. Clin Sports Med. 29(4):645-54, 2010
                                                                              19. Mihara K et al: Surgical treatment for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg. 19(1):31-7, 2010
                                                                              20. Ruchelsman DE et al: Osteochondritis dissecans of the capitellum: current concepts. J Am Acad Orthop Surg. 18(9):557-67, 2010
                                                                              21. Wei AS et al: Clinical and magnetic resonance imaging findings associated with Little League elbow. J Pediatr Orthop. 30(7):715-9, 2010
                                                                              22. Keeley DW et al: A biomechanical analysis of youth pitching mechanics. J Pediatr Orthop. 28(4):452-9, 2008
                                                                              23. Lynch JR et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg Am. 33(3):430-7, 2008
                                                                              24. Magra M et al: A review of epidemiology of paediatric elbow injuries in sports. Sports Med. 37(8):717-35, 2007
                                                                              25. Creighton RA et al: Evaluation of the medial elbow in the throwing athlete. Am J Orthop. 35(6):266-9, 2006
                                                                              26. Benjamin HJ et al: Little league elbow. Clin J Sport Med. 15(1):37-40, 2005
                                                                              27. Lee HH et al: Operative treatment of displaced medial epicondyle fractures in children and adolescents. J Shoulder Elbow Surg. 14(2):178-85, 2005
                                                                              28. Ahmad CS et al: Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med. 23(4):665-76, x, 2004
                                                                              29. Hang DW et al: A clinical and roentgenographic study of Little League elbow. Am J Sports Med. 32(1):79-84, 2004
                                                                              30. Miller TT et al: Sonography of injury of the ulnar collateral ligament of the elbow-initial experience. Skeletal Radiol. 33(7):386-91, 2004
                                                                              31. Cain EL Jr et al: Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 31(4):621-35, 2003
                                                                              32. Thornton R et al: Magnetic resonance imaging of sports injuries of the elbow. Top Magn Reson Imaging. 14(1):69-86, 2003
                                                                              33. Klingele KE et al: Little league elbow: valgus overload injury in the paediatric athlete. Sports Med. 32(15):1005-15, 2002
                                                                              34. Grana W: Medial epicondylitis and cubital tunnel syndrome in the throwing athlete. Clin Sports Med. 20(3):541-8, 2001
                                                                              35. Ellenbecker TS et al: Medial elbow joint laxity in professional baseball pitchers. A bilateral comparison using stress radiography. Am J Sports Med. 26(3):420-4, 1998
                                                                              36. Inoue G et al: Surgical repair of traumatic medial disruption of the elbow in competitive athletes. Br J Sports Med. 29(2):139-42, 1995
                                                                              37. Mirowitz SA et al: Ulnar collateral ligament injury in baseball pitchers: MR imaging evaluation. Radiology. 185(2):573-6, 1992