Elbow pain in children and teens: a pulled elbow, falls, the throwing elbow, and when it's urgent

Few children see a GP about the elbow, and what's common changes with ageEmerging evidence

Elbow pain is an uncommon reason for a child to see a GP. In 12 English practices, the elbow accounted for 8 consultations per 10,000 children aged 3 to 17 a year (23 in boys aged 14 to 17), fewer than the wrist (19) or the shoulder (13), and it wasn't among the 12 commonest places children had problems. In 2,953 Danish 12 to 19 year olds, 2.6% had elbow pain on the day they were asked, against 13.3% for the shoulder. Most children's elbow problems are injuries seen in emergency departments rather than aches that build up (our reading of these figures).

What is common depends on age. In toddlers it is a pulled elbow; in school-age children, a break after a fall, most often at about 6 to 8; in teenagers, overuse in throwing and gymnastics, and breaks of the bony bump on the inside of the elbow. Some groups are affected more often (links, not causes): boys in throwing injuries (310 of 317 children with Little League elbow at one US centre) and, in some studies, in elbow fractures (1.6 boys to each girl in Okinawa, though 54% were girls in Denmark); girls in pulled elbow in most countries, though not in Japan; children with very flexible joints among those whose pulled elbow keeps coming back; and young throwers who pitch a lot, pitch while tired or sore, or play all year.

Sources 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14

Toddlers: a pulled elbow is common, and it isn't always a pullStrong evidence

A pulled elbow (the medical name is radial head subluxation, and it is also called nursemaid's elbow) happens when the top of one of the two forearm bones, the radius, slips partly out of the ring of ligament that holds it at the elbow. It is common: in Aberdeen, 1.2% of young children had one each year, which would mean about 50,000 a year across Great Britain, and in the US it leads to over 20,000 emergency department visits a year, 68.6% of them at ages 1 and 2. In 1,307 children treated at one Japanese hospital, the commonest ages were about 6 months and 2 years, and NHS trust leaflets say it rarely happens after about 5 or 6.

It isn't always a pull. Of those 1,307 Japanese children, 51% had been pulled by the arm, 14% had fallen, 6% had rolled over in their sleep (more often babies), 2% had a knock to the elbow, and for 24% no one knew. No pull was found in 49% of 87 US episodes, and in two large sets of US emergency records falls were at least as common as pulls. "It does not mean that anyone has pulled too hard on the child's arm," an NHS trust leaflet says: some children are prone to it because of the shape of their growing bones.

The signs are typical: the child cries, then holds the arm still by their side or across the tummy, won't use it, and seems fine until the elbow is moved, with no obvious swelling or deformity. A child who fell, or whose elbow is swollen or bruised, may have a break instead, which is why that story changes what happens at hospital.

Sources 15, 3, 4, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25

School-age children: falls, and breaks around the elbowStrong evidence

Elbow fractures are common in children: 308 per 100,000 Danish children under 15 a year, at an average age of 7.9, and 58% of them were just above the elbow (supracondylar fractures). In 488 elbow fractures in Okinawa, Japan, the commonest age was 6; 43.8% were supracondylar and 22.3% were on the outer side (lateral condyle fractures), the second commonest. In Swedish children and teenagers, the lower end of the upper arm bone accounted for 5% of all fractures and the top of the forearm for 3%. Under 6, most follow falls indoors, from chairs, sofas and beds; at 6 to 10, falls from play equipment and trees and tumbles from skateboards. Monkey bars and trampolines are common causes, US orthopaedic surgeons say, and the Royal Society for the Prevention of Accidents (RoSPA) lists the elbow among the commonest trampoline injuries.

Being able to move the elbow doesn't rule out a break. In 778 children in 5 English emergency departments, 12 of the 287 followed up who could fully straighten the injured elbow had a fracture (4.2%), none needing an operation, against 210 of 491 (43%) who couldn't. A raised "fat pad" on the X-ray with no visible break means a hidden fracture in many children: 44.6% across 10 studies of 250 children, though the true figure could lie anywhere from about 30% to 60%, and 34 of 45 (76%) in one series.

Breaks of the bony bump on the inside of the elbow (the medial epicondyle) make up to 20% of children's elbow fractures, mostly at 9 to 14, and about 60% come with a dislocated elbow; in boys of about 14 and 15, arm wrestling causes some. Outer side fractures that have moved by more than about 2 mm are usually fixed with pins or screws, a review of their treatment says, and failing to join is uncommon: 7 of 500 children (1.4%) in one US centre.

Sources 5, 6, 26, 27, 28, 29, 30, 31, 32, 33, 8, 34, 35

Complications of a broken elbow: uncommon, and most recoverStrong evidence

UK standards ask doctors to check and record the pulse, the blood flow to the fingers and each nerve in the hand for every child with a supracondylar fracture. About 11% of these fractures come with a nerve injury (11.3% across 40 studies of 6,850 children), and most recover within 2 to 6 months. When the hand stays pink but has no pulse, the pulse came back within 24 hours in 61% of children after pinning alone and in 94% after the artery was explored, with similar long-term function.

Compartment syndrome, a build-up of pressure in the forearm muscles that needs urgent surgery, is rare: 21 of 4,308 children admitted with a supracondylar fracture (0.49%), and it happened in some children with none of the usual risk factors. In 33 children with compartment syndrome in an arm or a leg at one US hospital, the classic signs, such as paleness, tingling or a missing pulse, were unreliable, while a rising need for pain relief, together with other signs, was the more sensitive warning. That is why the warning signs ask you to act on pain that keeps getting worse.

Sources 36, 37, 38, 39, 40

Young throwers and gymnasts: overuse at a growth plateStrong evidence

Little League elbow is a strain on the growth plate of the bony bump on the inside of the elbow, from repeated throwing. It is most common at 8 to 15 but can happen up to 17 while the growth plate is open, the American Academy of Pediatrics says, and it is mostly seen in pitchers. Half of 476 US pitchers aged 9 to 14 had elbow or shoulder pain during one season. In 754 young pitchers, those who often pitched with arm pain had 7.5 times the odds of a pitching injury, and in 481 followed for 10 years, pitching more than 100 innings a year went with 3.5 times the risk of a serious injury (5% had one over the 10 years). Of 37 young throwers whose bony bump pulled off, 31 had elbow pain first.

On the outer side, osteochondritis dissecans (OCD) is a problem with the joint surface at the rounded end of the upper arm bone (the capitellum). Ultrasound screening in Japan found it in 3.4% of 2,433 teenage baseball players and 2.1% of 1,040 aged 10 to 12, and about a third of the younger players who had it had never had elbow pain. In gymnasts it typically shows at 10 to 14, and about 10% have it in both elbows. Early X-rays can miss it: first X-ray reports showed it in only 7 of 15 confirmed cases. Under 10, outer elbow ache and stiffness can be Panner's disease, which is very rare, mostly affects boys and settles on its own.

Sources 7, 41, 12, 13, 42, 43, 44, 45, 46, 47

Rare causes, and why it isn't tennis elbow or growing painsStrong evidence

A joint infection (septic arthritis) is rare: 2 to 7 per 100,000 children a year in Europe, mostly in the knee and hip. The elbow is an unusual place for it, which can delay the diagnosis: in one US series of 12 children with an infected elbow, 7 also had a bone infection, and in another series of 7, all were under 5. A bone infection (osteomyelitis) affected 13 per 100,000 Norwegian children a year, about 3 times more often under 3, and young children don't always get a high temperature with it, the NHS says.

Juvenile arthritis affects at least 10,000 young people under 16 in the UK, with swollen joints and stiffness, especially in the morning or after rest. The elbow was involved in 8.1% of 1,065 children with it, most often in the type that affects many joints, and in another clinic the elbow carried a large share of the joint damage. Bone tumours are very rare: each year about 35 children in the UK develop an osteosarcoma and about 30 a Ewing sarcoma, and the pain often comes and goes at first, then becomes constant, especially at night. The National Institute for Health and Care Excellence (NICE) asks GPs to arrange very urgent tests for unexplained bone pain or swelling in a child.

Two common labels don't fit. Tennis elbow is an adult problem, mostly at 35 to 54, and a UK care pathway treats elbow pain in a child or teenager as a reason for referral to a specialist, not routine tennis elbow care. And the NHS describes growing pains as leg pain in children aged 3 to 12; no source we found says they affect the arms.

Sources 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61

When a scan or test helpsStrong evidence

A typical pulled elbow needs no X-ray, because there is no break and the ligament doesn't show on one. An X-ray is for a fall, swelling, bruising, a tender bone, an unclear story, an older child, or an arm still not used after treatment, because a few children first thought to have a pulled elbow turn out to have a fracture. Some emergency departments use a quick ultrasound scan at the bedside: fluid in the joint suggests a fracture and means an X-ray.

After a fall, a child who won't use the arm or has a swollen elbow needs an X-ray even if they can move it. A fat pad with no visible break is treated as a hidden fracture, and the fracture clinic follows it up.

In young throwers, X-rays, sometimes of both elbows to compare, look at the growth plate, though they "may show nothing abnormal", the American Academy of Pediatrics says. Magnetic resonance imaging (MRI) shows OCD that early X-rays miss and whether it is stable, and ultrasound screening finds early OCD in research programmes in Japan. A suspected joint infection needs blood tests, X-rays and often MRI in hospital, because a bone infection is often present too. For unexplained bone pain or swelling, NICE asks GPs to consider a very urgent X-ray and to offer a very urgent blood count.

Sources 23, 62, 63, 64, 65, 4, 66, 67, 29, 27, 30, 31, 7, 45, 46, 43, 44, 49, 68, 59

How it usually goesEmerging evidence

A pulled elbow: most children use the arm again within minutes of it being put back (76.8% within 10 minutes in one US series, more slowly under 2, and 53 of 54 within 30 minutes when a click was felt), and in the Japanese hospital's series 16% had gone back on their own before the child was seen. "Most children will forget about their arm injury within the first few days," an NHS trust says. It comes back in about 1 in 20 to 1 in 4 children (4.8% to 26.7% across studies), most often in those aged 2 or under, becomes rare after about 5 or 6, and leaves no long-term problems.

A broken elbow: casts or splints usually stay on for 3 to 6 weeks, and NHS Lothian's children's physiotherapists expect about 10 to 12 weeks for the injury to heal, adding that "It can sometimes take many months to fully regain your elbow range of movement". After pinning, elbows reached 72% of the other side's movement at 6 weeks, 86% at 12, 94% at 26 and 98% at a year, and in a larger group gains continued for up to 48 weeks, more slowly in children over 5 and after surgery. Nerve injuries mostly recover within 2 to 6 months.

The throwing elbow: at one US centre, children with Little League elbow returned to sport after a median of 12 weeks, and pain came back in 13%, a median of 2 years later (a conference report). Early, stable OCD healed in 90.5% with at least 6 months off heavy elbow use, taking 14.9 months on average, but in only 22.7% of children who didn't follow that advice. Panner's disease settles on its own, and a bone infection treated within 3 to 5 days of starting often clears up completely. No one can promise a timescale.

Sources 18, 69, 4, 65, 10, 70, 16, 17, 71, 27, 72, 73, 74, 37, 9, 75, 47, 52

A pulled elbow is put back in minutes, usually without an X-ray or a slingStrong evidence

NHS trust emergency department leaflets describe the same care: a doctor or nurse gently turns and bends the forearm, often with a click, and most children start using the arm again within minutes, often while they play in the waiting area. A typical case needs no X-ray and no sling. If your child is still reluctant to use the arm afterwards, NHS Lothian puts on a collar and cuff sling for 1 to 2 days, followed by a review, and leaflets ask you to come back if the arm isn't being used normally within about 2 days (they give anything from 48 hours to 3 days). This is consistent health-service advice rather than trial evidence, and it matches the studies of how quickly children recover.

Sources 22, 62, 21, 24, 18, 69, 23, 64, 65, 17

Which way to turn the arm: palm down worked first time more oftenEmerging evidence

Turning the palm down firmly (hyperpronation) failed at the first attempt less often than turning it palm up and bending the elbow: 9.2% against 26.4% across 8 trials of 811 children, low-quality evidence in a Cochrane review, and a later review agreed. After a failed first attempt, another palm-down turn worked more often. This is for the doctor or nurse: parents shouldn't try either.

Sources 76, 77, 78

Preventing a pulled elbow: lift under the arms, not by the handsEmerging evidence

Every NHS trust leaflet gives the same advice: lift a young child by the upper arms or under the armpits, don't pull, lift or swing them by the hands, wrists or forearms, take tight sleeves off carefully, and reins can help when you're out walking. "The practice of swinging children while holding their hands should be abandoned," a review for family doctors says. Pulls cause about half of pulled elbows, so the advice makes sense, but no study has tested whether it prevents them.

Sources 23, 62, 17, 21, 25, 4

After a broken elbow, movement comes back with use, and physiotherapy isn't usually neededStrong evidence

In a trial of 61 children aged 5 to 12 whose supracondylar fracture was treated in a cast for about 3 weeks, a short course of physiotherapy gave no benefit: function scores were better without it at 9 and 15 weeks, and movement was the same at every point. After an operation, weekly physiotherapy improved movement at 12 and 18 weeks in a trial of 43 children, but made no difference at a year. Either way, movement keeps coming back with everyday use for many months.

So the plan uses NHS Lothian's home exercises for children after a broken elbow: gentle exercises 3 to 4 times a day once the cast is off, then harder ones that "should feel comfortable and not increase your pain at all". NHS Lothian's fracture leaflet says to start moving because "The elbow can get very stiff after these injuries", and to avoid sport and heavy arm use, such as climbing, for a month after the sling or cast comes off.

Sources 79, 80, 73, 74, 72, 81

Displaced breaks of the inner elbow bump: a cast or sling did as well as surgeryStrong evidence

In a UK-led trial called SCIENCE, 334 children aged 7 to 15 with a displaced fracture of the bony bump on the inside of the elbow had either surgery or a cast or sling. At 12 months, arm function was almost the same (a difference of 1.57 points on a children's arm function score, below the 4 points judged to matter), and the surgery group needed more further operations (24 children against 3). The authors conclude that care without surgery "should be adopted as the default". Your child's fracture clinic decides what suits their break.

Source 82

Young throwers: stop when it hurts, and keep to pitch countsStrong evidence

"An athlete who complains of pain around the elbow or shoulder, popping, or discomfort with throwing should not be allowed to throw anymore that day until pain-free," the American Academy of Pediatrics says, and the evidence backs it: pitching often with arm pain went with 7.5 times the odds of injury. Treatment is rest from throwing, then rehabilitation and a gradual return, while the child keeps fit in other ways.

Limits help. Pitch Smart, from Major League Baseball and USA Baseball, sets a daily pitch limit and rest days by age, no pitching on 3 days in a row, and at least 4 months a year off throwing, and British youth baseball allows at most 85 pitches a day under 12 and 95 under 14 and 16. In US high schools, a rule on rest between pitching days went with an injury rate about a third as high, and a 105-pitch daily limit with a rate less than half as high, though the national rules as a whole made no measurable difference. A short warm-up of stretching, mobility and balance cut shoulder and elbow injuries from 3.1 to 1.7 per 1,000 sessions in 237 players aged 9 to 11. Across 14 studies that followed players, more than 100 innings a year, being 9 to 11, pitching or catching, more than 16 hours of training a week and earlier elbow pain all raised the risk, and specialising early in one sport went with more overuse injuries (1.81 times the risk).

Sources 7, 12, 83, 84, 85, 86, 87, 14, 88

Outer elbow pain: early OCD needs months off heavy elbow useStrong evidence

Early, stable OCD heals with rest from throwing and from weight through the hands: in one Japanese group, 90.5% of the earliest lesions and 52.9% of the next stage healed with at least 6 months off heavy elbow use, while carrying on stressing the elbow gave the worst results. In a teenager whose growth plates have closed, an unstable lesion does better with surgery. Gymnasts with pain at the inner elbow growth plate rest from weight on the arms "for a minimum of 6 weeks, or until there is no tenderness", a review of gymnastics injuries says, and it calls the belief that elbow soreness is normal in gymnasts a cause of delayed care.

Sources 75, 89, 45

Painkillers, and no aspirinStrong evidence

Children's ibuprofen (most children over 3 months) or paracetamol (most over 2 months) at the dose for their age is the NHS's advice, for no more than 3 days without speaking to a doctor or pharmacist. Don't give them at the same time, and alternate them only if a health professional tells you to. Do not give aspirin to children aged 15 or under. For a suspected broken arm, NICE suggests ibuprofen, paracetamol or both for mild to moderate pain, and stronger pain relief in hospital for severe pain.

Sources 90, 91, 92, 93

Strength training is safe when a qualified adult supervises itStrong evidence

The NHS asks children and young people aged 5 to 18 to do activities that strengthen muscles and bones each week, including press-ups and similar exercises for young people. A review of 22 training studies in children found real strength gains, no harm to growth, and only 3 injuries in the 10 studies that recorded them, with supervision. That is why the plan's later stages suit teenagers when a qualified adult teaches technique, while younger children can play the animal moves instead.

Sources 94, 95

Very flexible joints: strength and fitnessEmerging evidence

Joint hypermobility, joints that bend further than usual, can bring aches after activity. The NHS says the main treatment is improving muscle strength and fitness so the joints are better protected. In 329 children with pulled elbow, very flexible joints were more common in those whose pulled elbow kept coming back.

Sources 96, 11

A toddler who won't use an arm: what to do (written steps)

Our 3D figure can't show these. Each step names its source.

• 1. Keep your child comfortable and take them to an urgent treatment centre or A&E the same day (our suggestion, from NHS trust leaflets). Don't try to put it back yourself (an NHS trust leaflet).
• 2. Tell the staff exactly how it happened, including any fall: that decides whether an X-ray is needed (an NHS trust page and a US emergency department study).
• 3. Children's paracetamol or ibuprofen if they're sore (an NHS trust leaflet).
• 4. Once it's back, encourage play and normal use of the arm (an NHS trust leaflet), with regular paracetamol or ibuprofen if it's still sore (another).
• 5. If your child still isn't using the arm normally after about 2 days, or you think it has happened again, go back to the emergency department or see your GP (NHS trust leaflets).

Sources 62, 64, 65, 23, 97, 16, 17, 21

Lifting, dressing and walking with a toddler (written steps)

Advice from NHS trust leaflets, which no study has tested; each step names its source.

• 1. Lift your child under the armpits or by the upper arms, not by the hands, wrists or forearms, and don't swing them around by the wrists or forearms (Alder Hey's leaflet).
• 2. Take tight clothes off carefully and try not to pull on their arms (Oxford's leaflet).
• 3. Reins can help when you're out walking (York and Scarborough's leaflet). Holding hands near roads is still right; for a toddler who darts off, reins or a buggy saves sudden jerks on the arm (our suggestion).
• 4. Swinging games by the hands are best dropped until about 6, when pulled elbows become rare (our suggestion, from a review for family doctors and NHS trust leaflets).

Sources 23, 62, 21, 25, 16, 17

After a fall, and in a sling or cast (written steps)

Each step names its source.

• 1. While you get help: use a towel as a sling, hold an ice pack wrapped in a tea towel on it for up to 20 minutes, and don't let your child eat or drink in case they need an operation. Don't drive to A&E yourself: ask someone to drive you, or call 999 for an ambulance (the NHS).
• 2. Children's paracetamol or ibuprofen at the dose for their age (the NHS).
• 3. In a collar and cuff or a cast: keep the cast and sling under clothing rather than through a sleeve, and in the first days rest the arm on pillows with the hand higher than the elbow and the elbow higher than the chest (NHS Lothian).
• 4. Encourage your child to bend and straighten their fingers often, and check the fingers for movement, feeling and colour. Don't scratch or push anything inside the cast, and seal it in a waterproof bag for washing (NHS Lothian).
• 5. Once the cast is off: gentle exercises 3 to 4 times a day, and warm water and a plain moisturiser for dry, flaky skin (NHS Lothian). Never force the elbow. Most children don't need physiotherapy, and movement keeps improving for months (a trial in 61 children and a US study).

Sources 99, 90, 91, 81, 72, 79, 73

School, PE, trampolines and arm wrestling (written steps)

Each step names its source.

• 1. Tell the school and the PE teacher what your child can and can't do. No climbing frames, PE or contact games until the fracture clinic says: NHS Lothian keeps sport and heavy arm use off for a month after the cast comes off.
• 2. After a pulled elbow, school and nursery carry on as normal (our suggestion).
• 3. Trampolining isn't suitable for children under 6, RoSPA says. One person at a time: 60% of injuries happen when more than one person is on the trampoline, and the lighter person is five times more likely to be hurt. No somersaults unless trained, and adult supervision "is no guarantee of safety".
• 4. Arm wrestling can pull off the bony bump on the inside of the elbow in boys of about 14 and 15 (a review of reported cases). Leave it out while an elbow hurts or is healing (our suggestion).

Sources 81, 28, 35

Throwing and gymnastics: pitch counts, rest and months off (written steps)

Each step names its source; our Little League elbow guide has the full return-to-throwing steps.

• 1. Count every pitch, across every team, and keep to the daily limits and rest days for your child's age; no pitching on 3 days in a row or in more than one game a day, and only one team at a time (Pitch Smart, from Major League Baseball and USA Baseball).
• 2. In Britain, youth baseball allows at most 85 pitches a day under 12 and 95 under 14 and 16, and says "Coaches should manage load appropriately, particularly early in the season" (the British Baseball Federation).
• 3. Rest from pitching for 24 to 48 hours after an outing, including backyard practice, and stop for the day at any pain, popping or discomfort (the American Academy of Pediatrics). Fastballs and changeups only under 14 (the American Academy of Pediatrics and Pitch Smart).
• 4. Take at least 4 months a year off throwing, and play other sports through the year (Pitch Smart).
• 5. Ask the morning after every session whether the elbow hurts, feels stiff or looks swollen; if the answer is yes, no throwing that day (our Little League elbow guide).
• 6. Gymnastics: elbow soreness isn't something to accept as normal. Get outer elbow pain checked, and rest from weight on the arms for inner elbow growth plate pain for at least 6 weeks, or until it is no longer tender (a review of gymnastics injuries).

Sources 84, 85, 7, 45

Pain relief

Children's ibuprofen or paracetamol at the dose for their age, for no more than 3 days without advice from a doctor or pharmacist. Don't give both at the same time, and alternate them only if a health professional tells you to. Don't give aspirin to anyone aged 15 or under (the NHS).

Sources 90, 91, 92