Overview
Definition:
Little league shoulder and elbow refer to overuse injuries affecting the physes (growth plates) of the proximal humerus and distal humerus, respectively, in young throwing athletes
These injuries are characterized by pain and dysfunction due to repetitive stress exceeding the bone's capacity for remodeling
Little league shoulder is essentially a stress reaction or fracture of the proximal humeral epiphysis or apophysis
Little league elbow encompasses a spectrum of injuries to the medial elbow, including apophysitis (inflammation of the growth plate) and stress fractures of the olecranon or medial epicondyle.
Epidemiology:
These injuries are most common in children and adolescents aged 9-16 years who participate in overhead throwing sports, particularly baseball pitching
Pitchers are at highest risk
Incidence is increasing with the rise in early sport specialization and competitive youth leagues
Factors include increased pitching volume, velocity, poor biomechanics, and inadequate rest.
Clinical Significance:
These physeal injuries can lead to long-term morbidity if not properly diagnosed and managed
They can result in growth disturbances, premature physeal closure, chronic pain, recurrent injuries, and impaired athletic performance
Early recognition and appropriate intervention are crucial to prevent permanent damage and ensure a safe return to sport
Understanding these injuries is vital for pediatricians, sports medicine physicians, and orthopedic surgeons involved in the care of young athletes.
Clinical Presentation
Symptoms:
Dull ache in the shoulder or elbow, typically on the throwing side
Pain usually worsens with throwing activities, especially after pitches
Tenderness over the affected physis
Decreased throwing velocity or accuracy
Pain that may persist even at rest in severe cases
Inability to throw at full effort
Weakness and fatigue in the affected limb.
Signs:
Point tenderness over the proximal humerus (anterosuperiorly) for shoulder injuries, or over the medial epicondyle or olecranon for elbow injuries
Pain elicited with passive or active range of motion, especially during external rotation and abduction for the shoulder, or with valgus stress for the elbow
Swelling may be present but is often subtle
Signs of muscle fatigue
Palpable deformity is rare in early stages.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by imaging
Key features include a history of repetitive throwing, localized pain over the physis, and pain reproduced with specific provocative maneuvers
Radiographic findings confirm the diagnosis and assess severity
No universally accepted formal diagnostic criteria exist beyond a combination of clinical suspicion and imaging evidence of physeal stress or injury.
Diagnostic Approach
History Taking:
Detailed history of the throwing mechanism: sport, position, frequency, intensity, duration of play, number of pitches per game/season
Recent increases in pitching volume or intensity
History of previous injuries
Mechanism of pain onset: gradual or sudden
Any changes in throwing mechanics or coaching
Warm-up and cool-down routines
Presence of other musculoskeletal complaints
Red flags: severe pain, night pain, inability to bear weight on the arm, signs of systemic illness.
Physical Examination:
Begin with a complete orthopedic and neurological examination of the affected upper extremity
Assess active and passive range of motion of the shoulder and elbow
Palpate for tenderness over the proximal humerus, glenoid, distal humerus (medial epicondyle, olecranon)
Assess strength and stability of the shoulder and elbow
Evaluate for signs of impingement or instability
Assess for any associated injuries in the kinetic chain (e.g., scapular dyskinesis, lumbar spine issues).
Investigations:
Radiographs: Standard anteroposterior (AP) and scapular Y views of the shoulder, and AP, lateral, and oblique views of the elbow are essential
Early findings may be subtle or absent
Look for widening of the physeal plate, periosteal elevation, sclerosis, or lucency suggestive of stress reaction or fracture
MRI: The gold standard for diagnosing subtle physeal injuries, stress reactions, and soft tissue involvement
Can identify edema within the bone marrow, widening of the physis, and soft tissue pathology (e.g., UCL injury)
Ultrasound: Useful for assessing soft tissues and potential effusions, but less sensitive for intraosseous pathology.
Differential Diagnosis:
Little league shoulder: Proximal humeral epiphysitis, avulsion fracture of the greater tuberosity, rotator cuff tendinopathy, glenohumeral instability
Little league elbow: Medial epicondylitis (in mature athletes), UCL insufficiency, osteochondritis dissecans of the capitellum, lateral epicondylitis, olecranon apophysitis or stress fracture.
Management
Initial Management:
Immediate cessation of all throwing and aggravating activities is paramount
Rest is the cornerstone of treatment
Pain management with ice application for 15-20 minutes several times a day
Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for symptomatic relief and to reduce inflammation, though their role in bone healing is debated
Patient and parent education regarding the nature of the injury and the importance of rest and adherence to the treatment plan.
Medical Management:
Primarily focused on pain and inflammation control
NSAIDs (e.g., ibuprofen, naproxen) can be prescribed for short-term symptomatic relief
Doses: Ibuprofen 5-10 mg/kg/dose every 6-8 hours
Naproxen 5-10 mg/kg/dose every 12 hours
Nutritional support: Ensure adequate calcium and Vitamin D intake for bone health
Long-term management involves gradual return to activity, guided by symptom resolution.
Surgical Management:
Surgical intervention is rarely indicated for typical little league shoulder and elbow physeal injuries
It is reserved for cases with significant displacement, non-union, or associated complications like severe instability or ligamentous tears that do not respond to conservative management
Procedures may include internal fixation for displaced physeal fractures or reconstruction for ligamentous injuries in older adolescents
Surgical management decisions are made on a case-by-case basis after failure of extensive conservative treatment.
Supportive Care:
Physical therapy is crucial for rehabilitation
This includes a progressive program of stretching and strengthening exercises for the rotator cuff, scapular stabilizers, and core muscles
Focus on improving flexibility, endurance, and biomechanics
Gradual return-to-throwing program designed to progressively increase intensity, duration, and complexity of throwing motions, with strict pain monitoring at each stage
Education on proper throwing mechanics and pitch counts
Emphasis on adequate rest periods between throwing sessions and in-season breaks.
Complications
Early Complications:
Delayed healing
Increased pain with initial return to activity
Inadequate rest leading to worsening of the injury
Frustration and psychological distress in the young athlete due to prolonged absence from sport.
Late Complications:
Premature physeal closure leading to limb length discrepancies or deformities
Chronic pain and dysfunction
Recurrent injuries
Osteochondral defects
Development of osteoarthritis in the affected joint in the long term
Persistent instability or weakness
Impaired athletic career potential.
Prevention Strategies:
Strict adherence to pitch count guidelines and recommended rest days
Avoid year-round participation in a single sport (multi-sport participation is encouraged)
Proper coaching on throwing mechanics and biomechanics
Adequate warm-up and cool-down routines
Strength and conditioning programs focusing on the entire kinetic chain
Early recognition and treatment of any pain symptoms to prevent progression
Educate young athletes and parents about the risks of overuse injuries.
Prognosis
Factors Affecting Prognosis:
Early diagnosis and prompt initiation of treatment
Adherence to rest and rehabilitation protocols
Severity of the initial injury
Age of the athlete (younger athletes with open physes may have a higher risk of growth disturbance)
Quality of coaching and training
Return-to-sport strategy
Presence of co-existing injuries.
Outcomes:
With appropriate management, most young athletes can return to their previous level of athletic activity without significant long-term sequelae
Early diagnosis and conservative treatment typically result in good outcomes
However, delayed diagnosis or inadequate management can lead to chronic pain, growth abnormalities, and a higher risk of re-injury
Complete recovery may take several months.
Follow Up:
Regular follow-up appointments with the treating physician to monitor symptom resolution and progress
Serial radiographic or MRI assessments may be required to confirm healing or assess for complications
Physical therapy progress evaluations
Gradual progression through the return-to-throwing program requires close supervision
Long-term monitoring for any late complications, especially in athletes with significant growth remaining.
Key Points
Exam Focus:
Physeal injuries are characterized by pain at the growth plate due to overuse
Little league shoulder involves the proximal humerus physis
little league elbow involves the medial distal humerus physis
Diagnosis is clinical, confirmed by imaging (X-ray, MRI)
Treatment is conservative: rest, NSAIDs, physical therapy, and gradual return-to-sport
Prevention is key: pitch counts, proper mechanics, multi-sport participation.
Clinical Pearls:
Always suspect physeal injury in a young throwing athlete with shoulder or elbow pain, especially when localized to the growth plate
MRI is highly sensitive for detecting early stress reactions
A structured return-to-throwing program is essential for safe progression
Educate parents and athletes about the risks of early sport specialization.
Common Mistakes:
Mistaking overuse injuries for simple strains or sprains
Delaying diagnosis due to subtle initial symptoms
Inadequate rest period, leading to delayed healing or re-injury
Premature return to throwing without a structured program
Not addressing underlying biomechanical issues or training errors
Overlooking associated injuries in the kinetic chain.