Little Leaguer’s Shoulder

ABSTRACT & COMMENTARY

Synopsis: Little Leaguer’s Shoulder is throwing related pain in the proximal humerus and the radiologic finding of widening of the proximal humeral physis in young or adolescent baseball players. Twenty-three children with this syndrome were treated by rest from baseball throwing for an average of three months. Ninety-one percent became asymptomatic and were able to resume playing baseball.

Source: Carson WG, Gasser SI. Little leaguer’s shoulder: A report of 23 cases. Am J Sports Med l998;26:575-580.

Twenty-three cases of little leaguer’s shoulder Syndrome were studied by Carson and Gasser at the Sports Medicine Clinic of Tampa. The average age of the patients was 14 years, and they were followed for an average of 9.6 months until they had either returned to baseball playing or their symptoms had resolved. The chief complaint of all patients was pain localized to the proximal humerus during the act of throwing. Physical examination revealed tenderness to palpation over the lateral aspect of the proximal humerus (87%). All patients had radiographic widening of the proximal humeral physis of the throwing arm on internal and external rotation radiographs of the affected shoulder. All patients were treated with rest from baseball for an average of three months. Twenty-one of 23 patients (91%) became asymptomatic and returned to baseball playing. Rest from throwing for at least three months followed by a gradual return to throwing when the shoulder is asymptomatic is recommended.

The report of 23 cases by Carson and Gasser is an excellent review of another overuse injury seen in children and reemphasizes the growing nature of this type of problem. As seen with other overuse injuries in children, mid-adolescence is the age of peak frequency and the symptoms are insidiously progressive. Focal tenderness is frequently present, but signs of active inflammation are not.

COMMENT BY BARRY GOLDBERG, MD, FAAP

Overuse problems are increasing in youth sports and pitching creates repetitive microtrauma on the shoulder and elbow as a result of the kinetic forces applied. Prevention is a critical component and incorporates a large number of issues. The most significant include total number (not innings) and type of pitches thrown, proper biomechanics, consistent supervised conditioning, control of "outside" pitching, and not ignoring early signs and symptoms, such as discomfort or dropping of the elbow in delivery. Of recent concern are young pitchers who participate in multiple leagues to pitch a greater number of innings. In many instances, overzealous parents are responsible for these excesses.

Treatment of Little League shoulder has no absolutes in terms of restricted pitching, but therapy ranges from 6-16 weeks, depending on such variables as the symptoms and x-ray findings. When the shoulder has been entirely asymptomatic for a week, a slow graduated program of long, light toss followed by increasing distance to 45 feet as well as increasing velocity can be introduced.

Eventually, the youthful pitcher should be able to move to regulation distance and pitch off the mound. This time of rehabilitation should not only be used to allow for epiphyseal healing but also for identification of risk factors, such as poor mechanics, excessive pitching, types of pitches thrown, etc., so that these factors can be reviewed and corrected. (Dr. Goldberg is Director of Sports Medicine, Yale University Health Service, New Haven, CT.)