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https://upload.orthobullets.com/topic/3056/images/Xray - widening physis - colorado_moved.jpg
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Introduction
  • An overuse injury resulting in epiphysiolysis of the proximal humerus
    • a Salter Harris type I physeal injury 
  • Epidemiology
    • seen in skeletally immature overhead athletes
      • adolescent pitchers
        • 10% of all shoulder pain in pediatric patients is related to throwing
      • occasionally seen in tennis players
    • males > females
    • age 11-16 years
  • Pathophysiology
    • mechanism
      • repetitive torsional and distractive stresses at the physis
      • pitching
        • phases
          • late cocking
            • shoulder is maximallt externally rotated, leading to extreme rotatory torque through the growth plate, approximately 400% greater than the fragile physeal cartilage can tolerate
          • deceleration
            • opposing forces of forward arm motion and rotator cuff results in excessive eccentric physeal stress
        • breaking pitches are implicated
        • number of pitches is the most important factor
    • cell biology
      • hypertrophic zone of the physis is affected 
      • weakest portion of the growth plate
Presentation
  • History
    • decreased pitch velocity
    • decreased pitch accuracy
  • Symptoms
    • diffuse arm and shoulder pain with throwing
      • worse in late cocking or deceleration phases
      • pain resolves with rest
  • Physical exam
    • point tenderness over lateral proximal humerus, at the shoulder physis
    • pain reproduced with shoulder rotation
    • glenohumeral internal rotation deficit
Imaging
  • Radiographs
    • recommends views
      • AP in external rotation, scapular Y and axillary views
      • contralateral shoulder can obtained for comparison in subtle cases
    • findings
      • widened proximal humerus physis in comparison to contralateral shoulder 
      • metaphyseal bony changes
      • may have normal radiographs (17%)
  • MRI
    • findings
      • edema around physis
    • may be helpful to rule out other pathology
      • labral tear
      • partial articular-sided rotator cuff tears (less likely)
Treatment
  • Nonoperative
    • cessation of throwing, followed by PT and progressive throwing program after sufficient rest 
      • indications
        • mainstay of treatment
      • technique
        • refrain from pitching for 3 months
          • start progressive throwing program only after symptom resolution
        • physical therapy
          • rotator cuff strengthening
          • posterior shoulder capsule stretching
          • core strengthening
        • progressive throwing program
          • start with short tosses at low velocity
          • slowly progress distance and velocity of throws
  • Prevention
    • proper pitching mechanics
      • using pitching coaches
    • discourage breaking ball pitches
      • until skeletal maturity
    • enforcement of pitch counts
      • as well as days off for shoulder rest
    • avoid year-round pitching
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 (4)

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(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?
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QID: 4699
FIGURES:
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1

Septic arthritis of the shoulder

0%

(20/4559)

2

SLAP tear

1%

(32/4559)

3

Little Leaguer’s shoulder

97%

(4402/4559)

4

External impingement

1%

(40/4559)

5

Internal impingement

1%

(46/4559)

L 1

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(SAE07SM.64) A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of Review Topic

QID: 8726
FIGURES:
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1

rest from throwing activities.

96%

(144/150)

2

a subacromial corticosteroid injection.

0%

(0/150)

3

open reduction and internal fixation.

0%

(0/150)

4

arthroscopic labral repair.

1%

(1/150)

5

biopsy of the proximal humerus.

3%

(4/150)

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