LL/travel ball pitcher & competitive swimmer diagnosed with little league elbow

Please forgive the long post. I stumbled upon this forum while reading/researching after my son was recently diagnosed with medial epicondyle apophysitis (aka little league elbow) and there seems to be knowledgeable members here that may be able to answer my questions/concerns. My son will be 10 next month and plays on a 10U travel team. He has also swam competitively year-round for the last 3 years and plays flag football in the winter. Baseball, pitching to be specific, is his number 1 passion and we want to make sure we do what’s in his best interest. First, is anyone familiar with apophysitis being an acute injury? A week ago, during a casual fly ball practice session with his dad he got mad and “whipped the ball as hard as he could and let out a yell”. He said he got a sharp pain to medial elbow area and felt a pop at that time. After a few days of rest and attempting just some soft toss throws he got pain again and stopped. X-rays (completely normal) and pediatric ortho appt. yielded a diagnosis of medial epicondyle apophysitis. Everything I’ve read seems to imply this is a chronic injury with gradual onset. Upon questioning at the Dr.'s office he admitted that he felt soreness only once for only a few hours after pitching an entire game in May–denies feeling anything since. He does throw very hard, and did throw a lot last season due to that team’s lack of pitchers and over dependence on him to win games, but had never complained of soreness or pain at all. That season ended June 30th and he only had minimal pitching practice with dad over summer. He has since recently changed to a different (better) team where this overpitching should no longer be an issue, as everyone on this team pitches. Seemed more like an acute injury to me since there was no pain prior and he’s been practicing with his new team for a few weeks now.
The big question now is what to do about his other sports. We always thought that the year-round swimming was great strength and conditioning for him and was probably the reason he was as great and strong of a pitcher/baseball player that he is. Now I’m reading conflicting information that swimming may be bad for a pitcher and contribute to overuse injuries? He’s been swimming 5 days/week, sometimes going straight from swim practice to baseball practice. He desires to play baseball for a long time and yes, like many young players even has dreams of becoming an MLB pitcher. Does anyone have any thoughts or experience with baseball players, pitchers particularly swimming as well? When he comes out of the “rest period” of his injury recovery in a few weeks, we’re not sure if swimming should continue. We’re contemplating taking him out of swimming to protect his shoulder & elbow from additional wear & tear. Thoughts on playing baseball/pitching and swimming?

I am not qualified to address this, however, others will chime in and offer their experiences and advice as a matter of being helpful.
I just want to point out that the responses that follow will be honestly helpful - NOT MEDICAL ADVICE. There are so many variables with the physical condition that keyboard approach to this, or any other physical impairment, is not the way to go.
So take away whatever good intentions may follow, just be advised of the limitations with those good intentions and advice.

Coach baker is right in that this is not medical advice, merely just our observations and opinions. We haven’t seen anything of your son, for example videos and such so what i say might not apply to your son. Now with me swimming hurt me when it came to pitching. Multiple sources advise against swimming saying it causes glaring scapular instability, big internal rotation deficits, and insufficient dynamic stability. (Eric Cressey) and Swimming actually is counter productive and lowers your velocity (Brent Pourciau). For me my scapular instability actually came back to bite me, putting stress on my UCL. I’d advise against swimming and pitching at the same time, or at least not doing it during the same season. ~an Ex swimmer who swam competitively for 5 years.

Thank you very much. I was not looking for medical advice but information/educated opinions about whether playing baseball and swimming 5 days/week was a good idea, or could potentially lead to increased shoulder and/or elbow issues. Your thoughts and information is exactly what I was searching for. We had always assumed he would do both for a long time to come and had actually thought the swimming helped and made him a better conditioned, stronger baseball player. It is only after this sudden injury and reading that it occurred to us that these might not be 2 sports that should be done together. We are all about being multi-sport, even though baseball is his 1st choice if he had to choose. Now considering breaking from swimming, but allowing flag football (no QB or throwing) this winter during his team’s baseball break. He needs to stay fit and be active, but not stress the arm so he’ll be good for spring season. I guess after that may be good time to try out soccer or basketball? He loves all sports and would honestly play everything if there was enough time.

I’m a big fan of playing multiple sports – baseball in the spring and summer, maybe soccer or football in the fall, basketball, swimming or weightlifting in the winter.

There are just so many benefits to playing different sports, plus it’s a lot of fun.

While baseball (specifically, pitching) and competitive swimming during the same season is usually not recommended, I see no issue with participating in them in different seasons. As a parent myself, if my son loved both and wanted to do both, we’d do both.

Good luck with your decision!

Take a look at this article. Pay close attention to the time allotted for each technique during pool work. Hope this helps. http://www.thecompletepitcher.com/pitching_swimming.htm

Quick update and question:
After 4 wks off, no throwing (and no more swimming for now) my son started throwing again. Pretty light at 1st, soft toss, long toss. 1st session went ok, felt only a small “twinge” at the end in the inner forearm area. Went to team practice and threw with the team in practice drills for the 1st time, no pain, no problems. A couple days later, went out to the fields for some more short toss, long toss and about 20 pitches at about 60%. Felt a couple “twinges” again last few pitches at the end–again in the forearm. The original injury was acute pain in the elbow at the medial epicondyle. He has never had any forearm discomfort at all while throwing until now. He has rated these “twinges” 1/10 on pain scale, and we had thought may just tightness from not throwing at all for a while??. Practiced with the team again a couple days later with no pain, no issues throwing. Still no pitching in team practice or games. Played in a tournament this past weekend, 5 games between Sat & Sun. Put him in the outfield to minimize throwing, but he made 1 long hard throw to home from the outfield fence on a ball that got by him and felt it. He again reported feeling discomfort in the inner forearm during that throw, but this time a little more than previous, rated 3/10. He continues to deny any pain at all in the elbow, during or after throwing. No other problems or pain throughout the weekend–during warm ups or games. He’s probably made a couple hundred throws pain -free now in the past 2 weeks between soft/toss long toss sessions, practices and the tournament this weekend. “Twinges” felt in less than 10 total.

So what do you all think this new forearm discomfort is, that seems to be intermittently arising, seemingly on the hardest throws? He’s been doing forearm muscle building exercises included in his therapy/rehab exercises. Our first thought was muscle tightness from not throwing for 4 weeks and maybe needs more stretching, but not really sure what it is since he’s never had it before. We are just glad that there is no more elbow pain. He (and his coach) really wants to get back to pitching and is aiming to try to pitch in a tournament next month. His next follow-up appt. with the ortho is in 1 week, but thought I’d ask if anyone here could possibly shed some light on this.
Thanks!

First off let me say I am not a doctor and I am not offering medical advice.

With that said, when the forearm muscles are tight the elbow compensates for poor range of motion. The elbow tendons can become inflamed causing pain in the forearm. A myriad of reasons can cause the tendons to become inflamed, such as poor throwing mechanics, tight forearm muscles, overuse, etc …

Excessive force on wrist snap can be a culprit of medial epicondylitis (degeneration of the forearm tendon). If the pain is on the inside of the forearm; see if it extends to his little finger, if so, it may be the flexor tendon.

Another culprit can be an irritated ulnar nerve or ulnar neuritis that causes pain in the forearm and a tingling sensation in the little finger.

Mention these to your doctor just in case he or she may overlook these issues.

Hope this helps,
From a former college pitcher and current pitching coach.

Keep us informed.

Hi…I have a son, multi sport athlete, baseball pitching is his favorite activity who has experienced elbow pain. He throws above average speed.

My thoughts for other parents:

  1. It’s a fine balance on how much you train. You want to practice to improve, but a pitchers arm at a young age is not designed to throw high velocity.
  2. Be careful with weighted baseballs.
  3. Injuries take a long time to heal. Best is to have a plan to prevent it.

Here is what we’ve experienced.

Towards end of 11U season he noticed soreness. We did no training/throwing from Aug to Feb. Feb 12U season started up and found soreness was still there. Met with orthopedic sports doc who found no specific injury except tendon soreness. Did rehab for 6 months and slowly progressed from no throwing, to 1st base only, to 1st base and outfield, to being able to throw 2 innings each weekend for last 5 weeks. The soreness did not completely go away but he felt it was manageable. During that season used Ibuprofen and ice packs after each game/practice. Did not throw from July to Feb. He threw baseball for first time last week since July and noticed soreness returned. In the 4 days post the soreness seems to have bypassed.

Overall…it’s a fine balance. Clearly he has obtained an overuse injury. Is there a specific cause…not sure if it can be pin pointed. Abided by recommended pitch counts for a weekend. Could have been weighted ball training started during 11U season. Maybe too much use as he’d throw in backyard 2-3 times a week.

From the physical therapy and video analysis of his throw by therapist…there were only minor adjustments to be made (aka…stride bit more straight and bit longer). Also his back muscle of his throwing arm was slightly weaker than other side.

Not sure what plan is for this year. Will probably meet with ortho doc again and determine best plan.

Hope this is helps. Also open to any feedback as well.

Update:
We did meet with the ortho after my October post and he examined him and said it was likely just forearm tightness from not throwing for a while and did clear him to pitch. We made sure he was very vigilant about doing his arm exercises, stretches and icing after throwing. My son pitched in 3 tournaments between mid October and 1st weekend in December. Each outing went very well pain free, with one small exception. During our last tournament for fall season Dec. 2-3, he came up to me after the game and told me his elbow hurt “a little” the last 5 pitches or so (out of 55 pitches). He did not tell his coaches or me until after the game. I only wonder if he would have said anything or would have kept pitching with pain if the coach had not pulled him. Needless to say we had to have a redundant conversation about the need to tell his coaches if he has any pain or issues with his arm. It can be so hard to corral a 10yr old that just wants to pitch. It’s difficult to get them to understand they are not invincible. Luckily, that was the last baseball event until Spring season practices started a few weeks ago, so he had another month and a half without throwing. We paid the ortho another visit mid December and were basically just reassured that all looked good and he should be good to go without problem for the spring. He has been attending practices for about 3 weeks now, pitched in 1 scrimmage game and started weekly private pitching instruction–had 2nd session today. So far so good and pain free. Praying for an uneventful spring season to come. Thanks everyone for input and sharing your experiences.

When does your son “Take at least 4 months off from throwing every year, with at least 2-3 of those months being continuous,” as recommended by Major League Baseball’s “Pitch Smart” guidelines for 10 year olds?

We do live in Florida, so baseball is sort of a year-round sport around here. That being said, he usually finishes up Spring season mid June and doesn’t start back up for fall until around Sept. 1st. (2- 2 1/2 mo. off there). Our team plays a very low key fall schedule, with only a few scrimmage games and about 1 tournament/month–this past fall played 1 in Oct., 1 in Nov. and 1 the first weekend in December. The team then took off again from Dec. 3rd until mid January (another 1 1/2 mo. off). So, he has been getting 4 months off from throwing, with about 2 1/2 months of that being continuous. If we qualify this Spring however, I’m told we may play later to play in the Elite World series in July this year. He’s also been playing flag football Nov.-Feb (playoffs and championship game this weekend) with a no throwing stipulation. Our coach knows we don’t want him playing QB, as this is supposed to be time off from throwing. Besides, our son is a better wide receiver and pass rusher and safety on defense anyway. We also plan to let him continue to swim summer league during the summer, but stopped swimming year round.

That sounds good. My concern is that youth pitcher arm injuries are almost always from overuse. While resting your son for the bare minimum recommended by these guidelines is commendable, these guidelines don’t always work the same for everyone, especially in the case of youth who are at different stages of biological development. If my son had elbow problems following the bare minimum of these guidelines, I would increase the rest to something like 4 continuous months off from all throwing. Have him play other sports during that time. 4 months off means 8 months of continuous throwing, which is plenty, especially for a 10 year old.

I understand what you’re saying, but I also still question the “little league elbow” diagnosis and assumed chronic nature of his injury in my gut. My son had never had any pain or soreness–even when he was pitching admittedly way too much previous seasons. This injury came in 1 hard, non-mechanically correct throw (whipping of the ball) in the midst of an angry temper tantrum with his dad immediately following 2 1/2 months off from throwing. His injury occurred on 9/1 and he had only had 2 practices since June. His arm was well rested when this occurred.
If he does develop any recurrent issues this spring, we will obviously have to re-evaluate his schedule/activities, as well as likely have some further imaging. So far nothing has shown up.

Hopefully, I can help. My son is/was a pitcher/swimmer.

The problem does not necessarily rest solely in the sports he plays, but with child physiology and development while playing all of these sports.

That being said, you need to understand at least 2 things: 1) His condition may be to overuse, but it doesn’t have to mean long term pain and or physical problems. Accepting the pain is really not a good approach. 2) Swimming and throwing a baseball are not the same, though most would assume it is very similar. Therefore, the biggest thing you have to realize is that ALL swimmers eventually develop shoulder pain (and joint paint) from overuse if they are competing competitively, trust me.

There are many opinions on whether swimming is good or bad. I’ll say they are all correct, based on the experiences they had. But most likely, they aren’t really understanding what is going on.

Now, muscularly, what happens is that swimming lengthens the muscle. Swimming is great for pitching because of the total body movement it requires. However, that lengthening works counter to throwing a baseball really hard for a period of time. Think of it as a rubber arm…but not in the old baseball folklore. So, my son, who swam, went from State Championships on Tuesday to baseball on Friday. His velocity was down, Arm strength for baseball down. But as he practiced, whew! velocity jumped as the arm and shoulder became baseball ready and stronger.

Your son is probably experiencing overuse and child development issues. The fact that this pain is not persistent indicates it comes from use, and he most likely does not have a physical joint structural issue. However, medial epicondyle apophysitis, is common with kids whose growth plates/joints are not fully developed. Your son’s age puts him squarely in this camp of possibilities. The body has natural imbalances that aren’t exposed unless the child is pushed too far. It isn’t called Little League Elbow for nothing! The generic term is glaringly telling you that this is a pediatric/child development issue that goes away with time, unless overuse over time causes it to be a permanent disability. It is possible that the elbow medial epicondyle is ever so slightly being pulled away from itself. This is happening over and over as it oscillates from healing to damaging and back. I was told a story by someone his son had a detached medial epicondyle after throwing a ball. Sounds eerliy similar to your experience, eh?..this is a situation where the knob (epicondyle) of the elbow is pulled away from the other parts of the elbow bone structure by the tendon(s) that connect to the elbow. A fractured elbow can result as the bones in the elbow are not being fully developed …the growth plates haven’t yet fully developed and fused together to become adult like and strong.

What people don’t realize is that kids develop large amounts of relative torque because they are inherently very flexible as young kids. Adults do it with physical maturation and grownup strength.

Last bit of advice. If you want your son in the future to pitch in the MLB, or at some high level of competition, you should limit his pitching to 3 innings or 55 pitches at any time. And pitch once a week at a travel ball/competitive team level. The best teams are the ones with lots of pitchers who get equal work. There is so much more to gain by not overusing than there is to gain by pitching so much. It’s what you do in between pitching that counts most…again, trust me.
And as for swimming, use it as a tool for pitching excellence. It’s a tool in the shed for training. If you want him to swim competitively year round, you WILL wear his body out.

Thank you for your very thoughtful and comprehensive reply. Luckily, imaging was negative and all seems back to normal again. He rested another month and a half–December and 1/2 of January. He’s been back at it since mid January without any complaints. I pulled him from his competitive swim team immediately after the injury 9/1/18 and he hasn’t swam since. Debating signing him back up for summer swim league which starts practicing in April and swim meets through July. It just overlaps a bit with baseball season so not sure if schedule will allow. I can say I have learned a lot since his injury. I had never given pitch counts or arm injuries a thought before September. We are now much more informed and do proper arm care daily now-- exercises and stretches given to us from ortho and icing. His new team this season does have a lot of pitchers, unlike last year, but he is still the “go to” pitcher/ace. I have noticed past couple tournaments they like to use pitchers for 2 innings in pool play on Saturday and then pitch them again a few innings on Sunday. It’s very difficult to get through a 2-day tournament (pool play and bracket play) without pitching them some both days. I was actually very content that they didn’t pitch him at all at last weekend’s tournament. They were saving him to pitch the championship game and then the tournament got called in the semifinal game after a thunderstorm rolled in and flooded the fields. He is much more rested for this week’s big super NIT tourney. Monitoring pitch counts and his arm is definitely much more of a priority for us this year.

My 2 cents…

When throwing a pitch, the elbow naturally separates about a quarter of an inch and the shoulder about a half an inch. It is my understanding that swimming (probably certain strokes more than others) is a joint loosening activity for the shoulder. So, while swimming may be beneficial from a strength perspective, stretching out the connective tissues in the shoulder joint is bad for pitchers.

My son is going through this now. He doesn’t swim, but plays football and baseball. We’ve seen 4 ortho/sports medicine doctors over the last month including the Yankees team physician and the NY Jets team physician. Here’s what we learned. No youth baseball player should ever experience pain, tightness, or stress when throwing or pitching. At these ages the growth plates will endure stress, and these growth plates are the weak link until they fuse usually between the ages of 14-17 years old. Every time a youth player pitches or throws with any stress or pain you are setting the player up for problems down the road. My advice especially with a younger player is to always get multiple opinions. Every time the player throws through pain of any level there is damage being done. The good thing is that kids recover quickly with appropriate rest.

Not always. There is a point of no return. I know a 13-year old pitcher whose elbow did not improve with rest and had to have Tommy John surgery for a torn UCL. Yup, at 13. I know another 13-year old pitcher whose elbow did not improve with rest and had to have surgery for osteochondritis dissecans. Yup, at 13. Both played year round, winning lots of travel ball trophies.

My 2 cents…the fact that the growth plates are forming is a good thing and actually allows for all that flexibility. But, overuse is the real issue. And it is my belief, based on experience, that pain is usually a reaction to a developmental issue that has to do with with shoulder strength and stability, especially with the rotator cuffs muscles.