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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?
Septic arthritis of the shoulder
Little Leaguer’s shoulder
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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.
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.
Chen FS, Diaz VA, Loebenberg M, Rosen JE.
J Am Acad Orthop Surg. 2005 May-Jun;13(3):172-85. PMID: 15938606 (Link to Abstract)
McFarland EG, Ireland ML.
Instr Course Lect. 2003;52:37-42. PMID: 12690839 (Link to Abstract)
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