Why does my son's elbow hurt after he pitches?

What's actually going on

Elbow pain in a pitcher, especially on the inside of the elbow, is almost never a single-cause problem. It is the visible result of several things going wrong at once, none of which would have been enough by itself.

That matters because the way most people try to solve it is to find the one thing. Change the mechanics. Cut the pitch count. Rest it for two weeks. Sometimes one of those works, and when it does, everyone concludes they found the cause. More often the pain comes back, because the other contributors were never addressed.

We sort those contributors into six categories, and we examine all six rather than picking one.

  • Physical restrictions. Whether the body has the range of motion and stability to reach the positions throwing requires. If the hips do not rotate, the elbow pays for it.
  • Movement pattern. Not good mechanics versus bad mechanics, but specific inefficiencies that increase load on the medial elbow.
  • Preparation and recovery. What happens before and after throwing, which for most young athletes is very little.
  • Training. What the athlete is doing in the weight room and in his throwing program, and whether any of it transfers.
  • Workload. Not only pitch counts, but ramp-up rate, time off, and whether he is throwing for more than one team.
  • Sleep, nutrition, and hydration. A teenager running on six hours of sleep is a different athlete.

The inside of the elbow is under stress in every throw because of what physics does to that joint. Four forearm muscles, the flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, and pronator teres, act as the elbow's first line of defense. Research indicates they absorb roughly fourteen percent of the load that would otherwise fall on the ulnar collateral ligament. Anything that reduces their contribution, or increases the load they have to share, raises the stress on that ligament.

Several common patterns do exactly that. When the angle between the forearm and the upper arm exceeds ninety degrees at front foot plant, the American Journal of Sports Medicine reports increased stress on the UCL. When an athlete releases the ball too early relative to his body, medial elbow stress rises. When the forearm is preset into extreme pronation on the takeaway, those four muscles fire early and then switch off during the throw.

But none of those patterns exist in isolation either. A pitcher whose lower half is not producing energy efficiently will find it somewhere else, and that somewhere else is usually the arm. The upper body compensates for what the legs and trunk did not deliver.

That is why we look at all six categories. It is not thoroughness for its own sake. It is a recognition that the contributor causing the pain and the contributor that needs to be fixed are frequently not the same thing.

What to do about it

This week, before you spend any money:

Get an honest answer about the pain. Do not ask whether his arm hurts. He has been trained his whole life to say no. Ask him to point to exactly where it is with one finger. Ask whether it happens during the throw or after. Ask whether it wakes him up or is stiff in the morning. Ask how many days it lasts.

Track his total throwing across every team. Not just pitch counts in games. Bullpens, long toss, warmups, catching, infield. If he plays for a school team and a travel team, neither coach can see the whole picture. You are the only one who can.

Change nothing about his mechanics on your own. This is the most common well-intentioned mistake parents make. Changing a delivery without knowing which contributor you are addressing usually adds a contributor rather than removing one.

Look at sleep first, because it is free and because it is the one most families can actually change this week.

When this doesn't apply, and when to call a doctor

Everything above assumes we are talking about pain that a training and movement approach can address. Some elbow pain is not that, and it is important to know the difference.

Stop throwing and see a physician if any of these are present:

  • Pain accompanied by numbness or tingling in the hand or fingers
  • A pop, snap, or sudden sharp pain during a throw
  • Visible swelling, or loss of the ability to fully straighten or bend the elbow
  • Pain that persists beyond several days of complete rest
  • Pain in a skeletally immature athlete, meaning growth plates are still open, which requires imaging that no coach or physical therapist can substitute for

A young pitcher's elbow contains growth plates that a ligament-focused approach does not address. In a still-growing athlete, an injury that looks like a ligament problem may be a growth plate problem, and the management is different. That determination requires a physician.

We are not a substitute for medical care and we never have been. What we do is address the contributors once a physician has ruled out what needs ruling out. Frequently families come to us after a doctor has said the imaging looks fine and the arm still hurts. That is exactly the space we work in.

Related questions

Find out what's driving your son's arm pain.