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https://upload.orthobullets.com/topic/3056/images/XR - AP - left_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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