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Little Leaguer's Shoulder. Originally described by Dr. Dotter in 1953Best described as
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1. The Shoulder in Youth Baseball Koco Eaton, M.D.
2. Little Leaguers Shoulder Originally described by Dr. Dotter in 1953
Best described as a stress fracture of the proximal humeral physis
Overuse inflammation of proximal humeral physis vs. stress fracture of physis
3. Little Leaguers Shoulder Mechanism
Appears to be caused by rotational stress applied to proximal humeral physis during act of throwing
During throwing, shoulder is forcibly internally rotated and adducted from an externally rotated abducted position
Results in repetitive microtrauma caused by the large rotational torques needed to throw
4. Little Leaguers Shoulder Mechanism
Growing bones are very vulnerable to injury from repetitive microtrauma because of the weakness of the growth plate compared to the attached muscles
Once the growth plates fuse, the athlete is more likely to injure ligaments and tendons
Overuse injuries occur when tissue breakdown exceeds repair
5. Little Leaguers Shoulder Crockett, Gross, Wilk et al, AJSM 2002
Adaptive remodeling
High-level baseball pitchers have greater external rotation and less internal rotation in their dominant shoulder compared to the nondominant shoulder and the shoulders of nonthrowers
Adaptive remodeling occurs at the proximal humeral physis of skeletally immature athletes in response to muscular forces and torques that accompany pitching
6. Little Leaguers Shoulder Adaptive remodeling
Increases external rotation and reduces impingement of the rotator cuff on the glenoid rim
Helps create the anatomy necessary to become an elite pitcher as an adult, but does not mean that it allows unlimited throwing in the skeletally immature athlete
Young thrower's safe and successful development straddles a fine line between overuse and appropriate use
7. Little Leaguers Shoulder Risk Factors
Position played (pitcher, catcher, outfield, 3rd base, shortstop)
Higher than recommended number of throws
Nine to 12 months of play in a year
Poor pitching mechanics
Throwing pitches too advanced for age
8. Little Leaguers Shoulder Symptoms
Gradual onset of pain in throwing shoulder
Localized to proximal humerus during throwing
Pain worse with increased velocity and duration
Average age 14
Average duration of symptoms 8 months
9. Little Leaguers Shoulder
Diagnosis
Tenderness over physis
Pain with motion at extremes
Possible discomfort with resistance testing
10. Little Leaguers Shoulder Radiology
Widening of the proximal humeral physis
Easily seen on bilateral AP internal and external rotation x-rays
Associated findings
Demineralization
Sclerosis
Fragmentation of lateral aspect of proximal humeral metaphysis
11. Radiographic findings Affected shoulder Normal shoulder
12. Little Leaguers Shoulder Treatment
Rest until symptoms subside with pain-free ROM
Gradual return to throwing when symptoms subside remodeling on x-ray can take several months longer
PT usually not beneficial may have worse pain with strengthening exercises
13. Little Leaguers Shoulder
Guidelines for return to throwing
Full, painless ROM
Full strength
No apprehension or discomfort in the cocking phase of throwing
14. Little Leaguers Shoulder Carson & Gasser, AJSM 1998
Average patient age: 14
Average duration of symptoms: 7.7 months
83% of patients were pitchers
All 23 patients had widening of physis on x-ray
All patients treated with rest for an average of 3 months
91% returned to baseball and were asymptomatic
15. Little Leaguers Shoulder Conclusion