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 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
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.140) A 12-year-old male pitcher has been complaining of shoulder pain in his dominant arm for 3 weeks. He describes that the pain occurs while throwing. On physical examination, he has tenderness to palpation over the proximal humerus and pain with external rotation of the shoulder with limited internal rotation compared to the contralateral side. Imaging is shown in Figure A. What is the next best step in treatment? QID: 213036 FIGURES: A Type & Select Correct Answer 1 Cessation of throwing activities until completely asymptomatic and initiate physical therapy 89% (1837/2075) 2 Continue activity as tolerated and initiate physical therapy 2% (39/2075) 3 Closed reduction and percutaneous pinning of the proximal humerus 2% (35/2075) 4 Obtain magnetic resonance imaging (MRI) of the shoulder 2% (46/2075) 5 Answers 2 and 4 4% (78/2075) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4699 FIGURES: A B Type & Select Correct Answer 1 Septic arthritis of the shoulder 0% (25/5901) 2 SLAP tear 1% (36/5901) 3 Little Leaguer’s shoulder 97% (5707/5901) 4 External impingement 1% (44/5901) 5 Internal impingement 1% (63/5901) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (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 QID: 8726 FIGURES: A B Type & Select Correct Answer 1 rest from throwing activities. 95% (505/531) 2 a subacromial corticosteroid injection. 0% (0/531) 3 open reduction and internal fixation. 0% (1/531) 4 arthroscopic labral repair. 1% (6/531) 5 biopsy of the proximal humerus. 3% (15/531) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
All Videos (4) Podcasts (1) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2019-2020 Shoulder Throwing Conditions - David Veltre, MD David Veltre Shoulder & Elbow - Little Leaguer's Shoulder C 9/16/2020 31 views 0.0 (0) Login to View Community Videos Login to View Community Videos 2018 Baseball Sports Medicine: Game-Changing Concepts Case Presentations and Panel Discussion with Q&A SESSION VI: Adolescent Issues and Biologics - Moderator Lee Kaplan, MD (BSM 2018, #48) Lee Kaplan Shoulder & Elbow - Little Leaguer's Shoulder E 12/21/2018 151 views 4.0 (1) Login to View Community Videos Login to View Community Videos 2018 Baseball Sports Medicine: Game-Changing Concepts Baseball Specialization and Injury Prevention in Youth Baseball - Christopher S. Ahmad, MD (BSM 2018, #45) Christopher S. Ahmad Shoulder & Elbow - Little Leaguer's Shoulder E 12/21/2018 152 views 4.0 (1) Shoulder & Elbow⎜Little Leaguer's Shoulder Shoulder & Elbow - Little Leaguer's Shoulder Listen Now 13:10 min 10/21/2019 303 plays 4.2 (6) See More See Less