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http://upload.orthobullets.com/topic/3056/images/Xray - widening physis - colorado_moved.jpg
http://upload.orthobullets.com/topic/3056/images/XR - AP - left_moved.jpg
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Introduction
  • A Salter Harris Type I physeal injury to proximal humerus 
  • Epidemiology
    • seen in adolescent pitchers
    • occasionally seen in tennis players
  • Mechanism
    • arm overuse causes repetitive microtrauma at physis
      • from high loads of torque
      • breaking pitches are implicated
  • Pathophysiology
    • hypertrophic zone is affected 
      • due to being weakest portion of the growth plate
Presentation
  • Symptoms
    • arm and shoulder pain with throwing
      • worse in late cocking or deceleration phases
      • pain resolves with rest
    • may be associated with decreased velocity and control
  • Physical exam
    • point tenderness over shoulder physis
    • pain reproduced with shoulder rotation
Imaging
  • Radiographs
    • may be unremarkable
    • findings
      • widened proximal humerus physis
      • metaphyseal bony changes
  • MRI
    • shows edema around physis
    • may be helpful to rule out other pathology
      • labral pathology
Treatment
  • Nonoperative
    • rest, ice, PT, progressive throwing program
      • indications
        • mainstay of treatment
      • technique
        • refrain from pitching for 2-3 months
          • return to play only after asymptomatic
        • PT focuses on
          • rotator cuff strengthening
          • posterior shoulder capsule stretches
          • core strengthening and stretching
        • progressive throwing program
          • starts with short tosses at low velocity
          • slowly progresses distance and velocity
  • Prevention
    • correction of pitching mechanics
      • using pitching coaches
    • discourage breaking ball pitches
      • until skeletal maturity
    • enforcement of pitch counts
Pitch Count Recommendations
Age (years of age)  Pitches per Game
Max Games per Week
8-10 yrs. 52 2
11-12 yrs. 68 2
13-14 yrs. 76
2
15-16 yrs. 91 2
17-18 yrs. 106 2
 
Complications
  • Premature growth arrest of proximal humeral epiphysis
    • can cause
      • growth arrest
      • angular deformity
 

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Questions (1)

(OBQ13.64) A 12-year-old right-hand-dominant pitcher presents with progressive right shoulder pain. He is now unable to pitch. He is tender to palpation over the lateral shoulder and has pain with rotation. An AP radiograph of the affected shoulder is shown in Figures A and a contralateral radiograph is shown in Figure B. What is the most likely diagnosis? Review Topic

QID:4699
FIGURES:
1

Septic arthritis of the shoulder

0%

(14/3370)

2

SLAP tear

1%

(24/3370)

3

Little Leaguer’s shoulder

96%

(3248/3370)

4

External impingement

1%

(34/3370)

5

Internal impingement

1%

(38/3370)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Considering the patient’s history and clinical findings, the patient most likely has Little Leaguer’s shoulder.

Little Leaguer’s shoulder is the result of repetitive microtrauma to the physis of the proximal humerus. Patients may report a recent increase in pitching regimen. On examination, there is focal tenderness at the level of the physis. Treatment focuses on rest, physical therapy and a progressive throwing program. Pitching is often stopped for 2-3 months during rehabilitation.

Chen et al. review shoulder and elbow injuries in the young athlete. Little Leaguer's shoulder results from epiphyseal lysis secondary to microtrauma. Pain over the anterolateral shoulder may be elicited on examination. The mainstay of treatment is 2-3 months of rest and return to pitching via a progressive throwing program.

Mcfarland et al. review techniques to prevent injuries in the throwing athletes. They note that overuse injures can be avoided when appropriate throwing mechanics are enforced and pitch counts are limited.

Figure A is an AP radiograph of a patient with Little Leaguer’s shoulder. There is physeal widening noted especially when compared to the contralateral normal pediatric shoulder view seen in Figure B.

Incorrect Answers:
Answer 1: There is no indication of an infectious process.
Answer 2: This clinical scenario is not consistent with a SLAP tear.
Answer 4: External impingment may be a cause of subacromial bursitis and rotator cuff tears.
Answer 5: Internal impingement can occur in pitchers, but is not consistent with this clinical scenario.


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