My son started having elbow pain while pitching during a baseball game several weeks ago. It still hurts when he tries to pitch. What should he do?

Sports Medicine Specialist, Matthew Smith, MD:

Pain on the inside of the elbow can be a difficult problem for throwing athletes, especially baseball pitchers. Any pitcher who develops arm pain during a game or practice should stop throwing. If the pain does not go away within a week, or returns with pitching, he or she should seek medical attention.

Pain on the inside of the elbow can come from a number of different sources. Discomfort that develops during the late cocking or early acceleration phase of the throwing motion may be related to an injury to the ulnar collateral ligament (aka Tommy John Ligament). Pain on the inside and by the tip of the elbow that occurs at the end of the throwing motion is more likely due to bone spurs along the inside edge of the joint. Lastly, excessive soreness that is associated with numbness or tingling in the ring and small finger may be related to irritation of the ulnar nerve (the "funny bone" nerve).

The initial treatment for each of these problems is rest from throwing and physical therapy to improve upper extremity strength and endurance. If pain recurs after several months of rest and physical therapy, surgery may be necessary to treat one or all of the sources of pain. Surgery for isolated bone spurs on the edge of the joint can usually be done arthroscopically through small incisions. A longer incision on the inside of the elbow is used to treat ulnar nerve irritation or to reconstruct the Tommy John ligament. A Tommy John ligament reconstruction has an 85-90% success rate in getting throwers back to the same level of play. However it takes about one year of rehabilitation for pitchers to return to competition.

To protect the shoulder and elbow from injury in young baseball pitchers, a few simple guidelines have been developed by the USA Baseball Medical and Safety Advisory Committee. Pitch counts should be limited to 50 pitches per game/day in 9-10 year-olds and 75 pitches per game/day in 11-14 year-olds. Players should not play in multiple leagues or for more than one team in the same season and should avoid pitching in showcases. Players should take at least three months per year off from throwing and other overhead sports.