Little League Shoulder (Proximal Humeral Epiphysiolysis)

By admin On Oct 7, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Mike LaGrange

Tracy Ray

Basics

Description

Remodeling and deformation of the proximal humeral physis
Overuse injury from recurrent, excessive torque placed on the growth plate
Typically seen in overhead athletes, especially adolescent baseball pitchers. Results from recurrent, excessive overhead activity.
1st described in 1966 as osteochondrosis of the proximal humeral epiphysis and then reported again in 1974 as proximal humeral epiphysiolysis in adolescent baseball players

Epidemiology

Uncertain exact prevalence due to under-reporting of pain with throwing
Most common in male baseball players between ages of 11 and 13
Has also been reported in swimming, volleyball, and cricket
Can occur in any adolescent athlete involved in repetitive overhead rotational activities

Risk Factors

The following risk factors are based on expert opinion, as no studies have evaluated this to the author's knowledge:

Year-round pitching without 3 mos of rest from throwing during the course of the year
Playing in multiple leagues at the same time
Going over recommended age-specific pitch count for game, season, or year
Inadequate rest between pitching outings
Improper throwing mechanics
Throwing with a fatigued shoulder

Genetics

No known genetic disposition

General Prevention

Prevented by avoiding excessive, repetitive overhead activities; having adequate rest between outings; and not throwing with shoulder fatigue or pain

Etiology

Unknown exact etiology
Biomechanical studies have revealed shear stress arising from high torque during late cocking phase is large enough to lead to deformation of the proximal humeral growth plate.

Diagnosis

Diagnosis based on history, physical, and classic radiographic findings

History

Patients typically complain of pain while throwing or with overhead activity.
Pain with throwing is typically constant throughout throwing cycle.
Most commonly presents with pain laterally over the proximal humeral physis, but can present with diffuse pain all over shoulder or referred pain to upper arm.
Insidious onset of pain
Patients may report recent increase in number of pitches thrown or recent change to playing on a larger field.

Physical Exam

Typical physical exam finding is tenderness to palpation over the proximal humeral physis without erythema, increased warmth, or soft tissue swelling.
Can present with painful range of motion, including pain with abduction or forward flexion >150 degrees
Can present with decreased strength of the rotator cuff musculature secondary to pain. Most common is reduced strength and pain with resisted external rotation.

Diagnostic Tests & Interpretation

Standard x-rays are the diagnostic gold standard.

Imaging

Anteroposterior of the affected shoulder in external rotation and internal with comparison films of the unaffected side are standard.
Typical findings are widening of the affected growth, plate especially on the lateral side of the growth plate.
May also see osteolysis and cortical irregularity of the bone surrounding the physis
MRI will also show widening of the growth plate on the T1-weighted images with possible extension of signal into the metaphysis on T1 and gradient echo images.

Differential Diagnosis

Rotator cuff tendonitis/impingement
Multidirectional instability
Labral tear (usually SLAP tear)
Salter Harris I fracture of the proximal humeral physis
Biceps tendonitis
Osteochondral fragment of the glenoid

P.363

Treatment

Treatment consists of rest from throwing and limited use of OTC pain medications such as acetaminophen or NSAIDs as needed for pain.
Recommend rest from throwing for 3 mos
Physical therapy during rest period should focus on rotator cuff strengthening and improved range of motion at the shoulder.
Recommended to complete an interval throwing program after finishing physical therapy/3 mos rest before returning to full activity

Medication

Age-appropriate dose of any NSAID or acetaminophen can be used as needed for pain during initial period of rest.

Surgery/Other Procedures

No surgical correction required

Ongoing Care

Follow-Up Recommendations

Recommended to re-evaluate the patient in office again after 3 mos rest/physical therapy to reassess exam and give guidance on starting an interval throwing program
Repeat x-rays are not necessary at return visit, as it can take up to a year for growth plate to return to normal.

Patient Education

Patients, parents, and coaches should be educated on age-appropriate pitching recommendations, including pitch counts and age restrictions on throwing specialty pitches.
Should also stress importance of not throwing with a fatigued arm or painful shoulder as this can lead to future injury

Prognosis

Patients treated with appropriate rest have an excellent long-term prognosis.

Complications

Alteration of throwing mechanics from throwing with pain may lead to other injuries, such as labral tears or injuries to the elbow of the same arm.

Additional Reading

Adams JE. Little league shoulder: osteochondrosis of the proximal humeral epiphysis in boy baseball pitchers. Calif Med. 1966;105:22–25.

Drescher WR, Falliner A, Zantop T, et al. Little league shoulder syndrome in an adolescent cricket player. Br J Sports Med. 2004;38:E14

Johnson JN, Houchin G. Adolescent athlete's shoulder: a case series of proximal humeral epiphysiolysis in nonthrowing athletes. Clin J Sport Med. 2006;16:84–86.

Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med. 2000;30:117–135.

Obembe OO, Gaskin CM, Taffoni MJ, et al. Little Leaguer's shoulder (proximal humeral epiphysiolysis): MRI findings in four boys. Pediatr Radiol. 2007.

Sabick MB, Kim YK, Torry MR, et al. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med. 2005;33:1716–1722.

Codes

ICD9

732.3 Juvenile osteochondrosis of upper extremity