Review Question - QID 219860

The patient’s history and imaging are classic for proximal humeral epiphsiolysis, or Little Leaguers’ Shoulder (LLS). Most patients will experience a return to pre-injury levels following a period of rest (Answer 1).

Little Leaguer’s shoulder is an overuse injury commonly seen in young athletes, particularly baseball pitchers. The condition occurs when there is repetitive stress and/or microtrauma to the proximal humerus growth plate (physis) due to excessive throwing or overhead activities. Typically the entity affects athletes aged 11 to 16, as the growth plates are still open and vulnerable to stress. Patients present with gradual onset of pain in the shoulder, particularly during or after throwing, decreased throwing velocity and accuracy, and tenderness and swelling around the shoulder with reduced range of motion particularly with overhead movements. The primary treatment is cessation of throwing activities to allow the growth plate to heal. Once symptoms resolve and strength is restored, athletes can gradually resume throwing, often under guided progression to avoid recurrence. Limiting pitch counts, proper technique, and avoiding year-round play in young athletes can reduce the risk of Little Leaguer’s shoulder. If not managed properly, this condition can result in long-term shoulder problems or even premature closure of the growth plate.

Bednar et al. performed a systematic review of Little League Shoulder (LLS) and included 23 studies with a total of 266 participants. They report progression from prolonged rest to shorter periods of activity and graduated return to sport (RTS). Despite the prevalence, less than half of the studies reported specific criteria for RTS. Overall, 94% of participants returned to sport at any level, 93% returned to their pre-injury level, and 19% experienced a recurrence of symptoms after RTS. The authors conclude that young athletes with LLS can return to sports after a short period of rest and are most likely to regain their prior functional level.

Heyworth et al. reviewed trends in the presentation, management, and outcomes of Little League Shoulder in their series of 95 patients with LLS. They report an overall increased incidence over the study period and a preponderance for baseball pitchers (86% of all study participants). Nearly every patient (99%) was prescribed rest while the majority were also prescribed physical therapy (79%). The average time to full resolution of symptoms was 2.6 months, and the average time to return to competition was 4.2 months. Recurrent symptoms were reported in 7% of the overall cohort, occurring at a mean of 7.6 months after initial diagnosis. The authors conclude that Little League shoulder is being diagnosed with increasing frequency, especially amongst male baseball pitchers but most return to play within several months.

Figure A shows widening of the proximal humeral physis consistent with Little leaguers shoulder.

Incorrect answers:
Answer 2: With adequate rest and symptom resolution, most patients will return to preinjury levels.
Answers 3-5: The patient has radiographic evidence of proximal humerus epiphysiolysis and should be prescribed rest. Continuing to pitch risks developing growth arrest or angular deformities.