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1 · SNAPSHOT

Little Leaguer's Elbow (Medial Epicondyle Apophysitis) body chart — Illustrative, not diagnostic. Canva body chart for Little Leaguer's Elbow (Medial Epicondyle Apophysitis).

Who: Skeletally immature throwers. Baseball pitchers and catchers above all; the same logic applies to cricket, javelin and any repeated overhead valgus load.
What: Traction overload of the medial epicondyle apophysis.
How it behaves: Gradual medial elbow pain through late cocking and acceleration. A "pulling" or "tight" ache. Worse with pitching volume. No single traumatic event.

The one thing to take from this page:

Same load, same sport, same position — different failure point. In the immature elbow the apophysis is the weak link; in the mature elbow it's the ligament. Age decides which page you're on.

The safety split

Uncomplicated — yours	Escalate
Gradual onset, no trauma	Acute pop, sudden severe pain
Focal apophyseal tenderness	Medial epicondyle avulsion
Full or near-full range	Loss of range
No neurological symptoms	Ulnar nerve symptoms
Improving on deload	Lateral elbow pain → osteochondritis dissecans

⚠️ No Australian guideline exists — and the pitch-count numbers you'll hear are American governing-body rules, not clinical thresholds. The principle transfers: count the load, mandate rest days, don't play year-round. The specific number should come from the local competition, not from a page.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. The workload history is the diagnosis and the treatment, and you are usually taking it from a child, a parent and — indirectly — a coach.

MAIN PROBLEM

"My elbow pulls when I throw."
"He's lost velocity and he's not getting it over the plate."
"It only hurts when he pitches."

Velocity loss and loss of control are symptoms. They often arrive before the child says the word "pain".

BODY CHART

Mark the medial epicondyle apophysis — focal, not the whole medial elbow.
Mark the lateral side too. Lateral pain is the osteochondritis dissecans question and it changes everything.
Mark any 4th and 5th digit symptoms — the ulnar nerve screen.

BEHAVIOUR

	Fits apophysitis	Points elsewhere
Aggs	Late cocking to acceleration, pitching volume, fatigue	Gripping rather than throwing → flexor tendinopathy
Severity	VAS 0–10 at best / at worst / right now	—
Onset	Gradual	Acute pop → avulsion
Range	Full or near-full	Loss of range → escalate
Symptoms	Load-related pain	Numbness in 4th/5th digits → cubital tunnel

HISTORY — the workload audit

Ask all of it. This is the assessment.

Pitch counts, innings, rest days.
Multiple teams, overlapping seasons, showcases, year-round throwing.
Velocity change, control change, fatigue during outings.
Was he pitching through pain? Ask the child separately if you can.
Recent workload spike.

SPECIAL / SCREENING QUESTIONS

Any single traumatic pop? Avulsion.
Loss of extension or flexion? Escalate.
Lateral elbow pain, catching, locking? Osteochondritis dissecans.
Numbness or tingling in the little and ring fingers?
And note: youth players can develop elbow injury even without prior pain (Matsuura et al. 2013), so absence of a pain history is not reassurance about load.

Assessing this region? Download the Elbow assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Ulnar collateral ligament injury	Skeletally mature thrower. This one is apophyseal — tender medial epicondyle apophysis, widening on radiograph.
Medial elbow flexor tendinopathy	Tendon rather than apophysis; gradual with gripping rather than with throwing volume.
Cubital tunnel syndrome	Numbness and tingling in the 4th and 5th digits rather than load-related medial pain.

The two that outrank the table

Medial epicondyle avulsion — a severe variant of this same problem. Acute worsening, a pop, or functional loss needs imaging [1].

Osteochondritis dissecans of the capitellum — lateral elbow pain, catching, locking, loss of extension. Different side, different consequence, and it is why you palpate laterally in a medial elbow presentation.

And the one that changes how seriously you take persistence

Chronic, non-healed medial epicondylar traction apophysitis has been associated with later ulnar collateral ligament insufficiency [2]. So persistent symptoms are not growing pains — they are a reason to keep the athlete deloaded and reassessed.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Acute pop with severe pain	Medial epicondyle avulsion	Image. Orthopaedic review
Loss of elbow range	Avulsion, loose body, or OCD	Image
Inability to throw at all	Higher-grade injury	Image
Lateral elbow pain, catching or locking	Osteochondritis dissecans of the capitellum	Image. Orthopaedic review
Elbow pain at rest	Capitellar OCD — rest pain predicted it in screened adolescent throwers	Palpate and compress laterally; image if it's there (Yang et al. 2018) [20]
Ulnar nerve symptoms	Nerve involvement	Escalate
Visible swelling or deformity	Structural	Image
Valgus instability	Ligamentous or avulsion injury	Orthopaedic review
Persistent symptoms despite deload	Non-healing apophysitis	Image, and keep them off throwing

The rule: gradual load-related medial pain with full range in a skeletally immature thrower is yours. Acute, stiff, lateral, neurological or unstable is not.

Cross-links: Little leaguer's shoulder · Lateral elbow tendinopathy · Cubital tunnel syndrome

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Guideline anchor

No Australian guideline covers youth throwing elbow injury.

Anchored to the clinical review of adolescent overhead elbow injuries (Looney et al. 2021, PMID 33996078) for the differential, the systematic review of risk factors in adolescent baseball (Norton et al. 2019, PMID 29630388) for prevention, and the pitch-count limitation cohort (Matsuura et al. 2021, PMID 33796588) for the workload intervention that has actual outcome data behind it.

PubMed Source

None of these is an Australian document and none is a formal guideline. The pitch-count rules that exist are American youth baseball governing-body rules, not clinical guidelines, and they do not transfer directly to Australian club structures or to cricket. The principle — count the load, mandate rest days, don't play year-round — does.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 19

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2025Zheng et al. (2025). Medial Epicondylar Apophyseal Avulsion Fractures in Youth Throwers: A Severe Variant of Little League Elbow. Orthopaedic journal of sports medicine, 13(9), 23259671251365974. https://doi.org/10.1177/23259671251365974
2022Otoshi et al. (2022). The influence of chronic medial epicondylar apophysitis on medial ulnar collateral ligament insufficiency-: a retrospective cohort study. JSES international, 6(3), 539-544. https://doi.org/10.1016/j.jseint.2021.12.014
2021Shitara et al. (2021). Asymptomatic Medial Elbow Ultrasound Abnormality in Youth Baseball Players Is an Independent Risk Factor for Elbow Injury: A Prospective Cohort Study. Orthopaedic journal of sports medicine, 9(4), 2325967120986791. https://doi.org/10.1177/2325967120986791
2006Olsen SJ 2nd et al. (2006). Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. The American journal of sports medicine, 34(6), 905-12. https://doi.org/10.1177/0363546505284188
2021Matsuura et al. (2021). Limiting the Pitch Count in Youth Baseball Pitchers Decreases Elbow Pain. Orthopaedic journal of sports medicine, 9(3), 2325967121989108. https://doi.org/10.1177/2325967121989108
2002Lyman et al. (2002). Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. The American journal of sports medicine, 30(4), 463-8. https://doi.org/10.1177/03635465020300040201
2010Harada et al. (2010). Risk factors for elbow injuries among young baseball players. Journal of shoulder and elbow surgery, 19(4), 502-7. https://doi.org/10.1016/j.jse.2009.10.022
2012Fleisig & Andrews (2012). Prevention of elbow injuries in youth baseball pitchers. Sports health, 4(5), 419-24. https://doi.org/10.1177/1941738112454828
2013Gregory & Nyland (2013). Medial elbow injury in young throwing athletes. Muscles, ligaments and tendons journal, 3(2), 91-100. https://doi.org/10.11138/mltj/2013.3.2.91
2013Matsuura et al. (2013). Elbow Injuries in Youth Baseball Players Without Prior Elbow Pain: A 1-Year Prospective Study. Orthopaedic journal of sports medicine, 1(5), 2325967113509948. https://doi.org/10.1177/2325967113509948
2019Norton et al. (2019). Risk Factors for Elbow and Shoulder Injuries in Adolescent Baseball Players: A Systematic Review. The American journal of sports medicine, 47(4), 982-990. https://doi.org/10.1177/0363546518760573
2021Looney et al. (2021). Evaluation and management of elbow injuries in the adolescent overhead athlete. SAGE open medicine, 9, 20503121211003362. https://doi.org/10.1177/20503121211003362
2021Tajika et al. (2021). Risk Factors for Throwing-Related Shoulder and Elbow Pain in Adolescent Baseball Players: A Prospective Study of Physical and Developmental Factors. Orthopaedic journal of sports medicine, 9(9), 23259671211017129. https://doi.org/10.1177/23259671211017129
2021Watanabe et al. (2021). Increased medial laxity of the elbow in preadolescent baseball players with or without medial elbow apophysitis. JSES international, 5(6), 1119-1124. https://doi.org/10.1016/j.jseint.2021.07.010
2021Mine et al. (2021). Risk Factors of Shoulder and Elbow Injuries in Baseball: A Scoping Review of 3 Types of Evidence. Orthopaedic journal of sports medicine, 9(12), 23259671211064645. https://doi.org/10.1177/23259671211064645
2024Koseki et al. (2024). Characteristics and Clinical Assessment of Elbow Pain in Youth Baseball Players. Sports (Basel, Switzerland), 12(6). https://doi.org/10.3390/sports12060161
2024Sgroi et al. (2024). Throwing Injuries and Prevention Strategies in Youth Baseball. HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 20(3), 341-345. https://doi.org/10.1177/15563316241249139
2026Kriz et al. (2026). Do Pitching Restriction Policies Reduce Shoulder and Elbow Injuries in High School Baseball Players?. Orthopaedic journal of sports medicine, 14(2), 23259671251412404. https://doi.org/10.1177/23259671251412404
2026Saito et al. (2026). Age-Related Medial Elbow Laxity in Youth Baseball Players: Ultrasonographic Evaluation. Orthopaedic journal of sports medicine, 14(2), 23259671261420424. https://doi.org/10.1177/23259671261420424

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