What is “Little Leaguer’s Elbow”?

The term “Little Leaguer’s Elbow” refers to a stress response that happens to the inside part of the elbow from increased stress from throwing. The clinical term ‘medial apophysitis’ refers to the inflammation or swelling and irritation of the growth plate (apophysis) on the inside part of the elbow.  The elbow gets irritated when young throwing athletes stress their arm repeatedly in the cocking phase (reaching back) of a throw.   As an athlete reaches back to throw, there is a force on the inside of the elbow (valgus stress) which puts added strain on the growth plate and can cause inflammation.  At the same time, there can be a compressive force that occurs on the outside of the elbow as well.  This is different from a UCL (ulnar collateral ligament) injury that most baseball players associate with ‘Tommy John’ injuries, since no ligaments are torn in LL elbow.  In general, younger pitchers tend to injure growth plates while older and more developmentally  mature pitchers tend to be more likely to tear their ligaments requiring a UCL reconstruction (Tommy John surgery). 
General causes of elbow pain in youth baseball players include poor throwing mechanics (overusing the arm while underusing the lower body), lack of proper time away from throwing (3-4 months is recommended), poor posture, and a lack of strength in the legs or trunk.  While there are not specific exercises to avoid LL elbow, addressing the above risk factors are the key to preventing elbow injuries.  If a player complains of pain on the inside of the elbow while throwing, they should be taken out and allowed to rest until the pain is no longer present with throwing.  A simple and effective test to do is called the milking valgus stress test pictured below.  When pulling the hand out to the side, pain in the inside part of the elbow indicates inflamed and irritated tissues and a player should not throw through this pain.  If a player continues to throw through elbow pain, there is a much higher risk of sustaining more serious arm injuries.  
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For this edition of the injury prevention blog, I wanted to address one of the most common questions that I hear when I speak with coaches, players, and parents.  I am often asked:
“What do you think about weighted ball throwing programs?”  “Will throwing a weighted ball help to increase throwing velocity?”
This is a topic that has been debated by physical therapists, athletic trainers, strength trainers, and pitching coaches for years.  There have been several research articles written about the topic, the most recent of which, the “Effect of a 6-week weighted baseball throwing program on pitch velocity, pitching arm biomechanics, passive range of motion, and injury rates”, written by Mike Reinold, PT, DPT and Dr James Andrews sheds some interesting light on the subject.
Since all players are desperately trying to throw harder, there are many programs, web sites, and theories out there that have tried to find the secret.  One such theory is that throwing a heavier ball will strengthen the arm and then allow the player to throw a standard weight baseball even harder.  The research on this has been mixed at best.  This recent study cited above compared 2 groups of teenager baseball players that threw weighted balls in addition to strengthening and routine baseball activities with another that threw only standard weight baseballs. 
The key results were that the weighted ball group had:

• 80% of those in the weighted ball group increased their velocity by 3%, while 8% showed no change, and 12% actually decreased their velocity.
• 67% in the control group showed an increase in velocity with 19% showing no change, and 14% showing a decrease.
• The increased velocity is likely attributed to an increase in shoulder mobility (4’) into external rotation (cocked position) which allowed for improved wind up. 
• The weighted ball group actually showed a decrease in shoulder strength compared to the control group that showed an increase in strength throughout the 6 weeks.
• Of most significance was that the 24% of those in the weighted ball group sustained elbow injuries either during the study or in the season immediately following.

So what does this all mean? The percent of players that increased their velocity with weighted balls over the control group (13%) was less than the number of players who were injured with the weighted ball program. 
So how does a player throw harder?  The answer is to learn to better use the entire body.  The legs produce the force, the trunk transfers the force, and the arm just delivers the ball.  Therefore, the stronger the lower half and the more stable the trunk and core, the harder that a player will throw.  There is no secret weapon out there that substitutes for a stronger kinetic chain and proper throwing mechanics.  In addition, some of the tools that players use may actually lead to an increased risk of injury. 
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1. What is a SLAP tear and why is it so common in baseball?

A SLAP tear stands for superior labrum anterior to posterior and is a tear of the labrum of the shoulder. That means there is a tear that goes from the front of the labrum to the back. If you visualize the shoulder as a ball in a socket, the ball is much bigger than the socket, so the labrum lines the socket to make it deeper. Another analogy is like a cup on a saucer and the labrum is like a ridge that makes the part that the cup sit in deeper so that it does not slide off. The bicep tendon attaches to the top of the labrum and when the shoulder continues to get pulled forward in the socket, the bicep tendon can create a peel back injury where the top of the labrum gets torn.
So, what should be done to prevent a SLAP tear?  There are many factors that contribute to tears of throwing shoulders including taking ample time off, having efficient mechanics and good use of the lower body and core, etc.  The most important muscles to keep strong and healthy are the posterior rotator cuff muscles.  The stronger that the cuff is, the better that the ball of the shoulder (humeral head) will be held in the socket and the less likely that it will peel back the top of the labrum.  Two important exercises to include are external rotations (“W”) and reverse throws.  In both cases, the emphasis should be on slow control of the exercises, especially in the return to starting position (eccentric strengthening).
“W” exercise: Holding a band at shoulder height, pull the bands back into external rotation without arching your back.  Slowly return to the starting position. 
Reverse throws: starting in a lunge position, pull back into a wind-up position (can vary based on normal arm slot) and then slowly return to starting position.  The return should be done in slow motion and should be about 1/3rd the speed of the pull back.