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Cessation of throwing activities until completely asymptomatic and initiate physical therapy
89%
2273/2548
Continue activity as tolerated and initiate physical therapy
2%
44/2548
Closed reduction and percutaneous pinning of the proximal humerus
45/2548
Obtain magnetic resonance imaging (MRI) of the shoulder
52/2548
Answers 2 and 4
4%
93/2548
Select Answer to see Preferred Response
This patient has little leaguer's shoulder (LLS) and should be kept from throwing until he is completely asymptomatic. The athlete is usually held out of throwing for 6-12 weeks, and then once asymptomatic, may participate in a graduated return to throwing program. LLS refers to an injury to the proximal humeral physis in skeletally immature athletes, primarily youth baseball pitchers. Repetitive throwing activities apply rotational and shear stresses across the physis which eventually leads to injury of the unossified cartilage. It usually occurs in pitchers between the ages of 11 and 14 years, when physeal growth is at its peak. Patients report diffuse shoulder pain with throwing, which can progress to pain with daily activities and even at rest. Radiographic changes include physeal widening, metaphyseal sclerosis, fragmentation, and cystic changes. These are best seen on external rotation views of the proximal humerus with comparison to the contralateral side. Once the diagnosis has been made, the athlete should be held out of throwing activities until the pain subsides. After the athlete is pain-free, physical therapy may be initiated before returning to sport. Osbahr et al. performed a review of LLS. They report that LLS is most commonly seen in throwing athletes between 11 and 16 years of age. Clinical evaluation and radiographic imaging confirm the diagnosis. Prevention of developing LLS is most effectively performed by regulating the athletes' pitch count. Smucny et al. performed a review of shoulder and elbow injuries in the adolescent athlete. They report with the recent increase in youth sports participation and single-sport youth athletes over the past 30 years, there has been an increase in the number of acute and overuse sports injuries in this population. They conclude that the LLS is best treated with throwing cessation until the pain completely resolves. Figure A is a radiograph of the proximal humerus in a pediatric patient with physeal widening but no separation or fracture. Incorrect Answers: Answers 2 & 3: The treatment of LLS is throwing cessation until symptoms resolve. Answers 4 & 5: An MRI is not necessary in making the diagnosis of LLS.
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