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4.3

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(46)

Images
https://upload.orthobullets.com/topic/3056/images/Xray - widening physis - colorado_moved.jpg
https://upload.orthobullets.com/topic/3056/images/XR - AP - left_moved.jpg
https://upload.orthobullets.com/topic/3056/images/19a_moved.jpg
  • summary
    • Little Leaguer's shoulder is an overuse injury occuring in young baseball pitchers resulting in epiphysiolysis of the proximal humerus (a Salter Harris Type 1 injury).
    • Diagnosis is made with radiographs of the shoulder showing a widened proximal humerus physis in comparison to contralateral shoulder.
    • Treatment is cessation of throwing, followed by PT and progressive throwing program after sufficient rest.
  • Epidemiology
    • Demographics
      • 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
  • Etiology
    • Pathophysiology
      • mechanism
        • repetitive torsional and distractive stresses at the physis (Saltar Harris 1 injury)
        • pitching
          • phases
            • late cocking
              • shoulder is maximally 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
        • patients with GIRD are three times more likely to experience recurrent symptoms
  • 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) 
          • Pitches per Game
          • Max Games per Week
          • 8-10
          • 52
          • 2
          • 11-12
          • 68
          • 2
          • 13-14
          • 76
          • 2
          • 15-16
          • 91
          • 2
          • 17-18
          • 106
          • 2
  • Complications
    • Premature growth arrest of proximal humeral epiphysis
      • can cause
        • growth arrest
        • angular deformity
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