Little League Shoulder

Get CMEShoulder InjurySummertime is rapidly approaching (at least for us in the Northern Hemisphere).  While this is often met with great excitement as we ponder vacations, it also means that we need to prepare for the consequences of all of that leisure time.  We have previously discussed the importance of injury prevention, particularly with respect to submersion injuries and lawn mower injuries, but not all of the leisure activities will lead to such significant risk of mortality.  The majority of the injuries that we will manage are the more common orthopedic varieties (ex, Patellar Dislocation, Shoulder Dislocation, Supracondylar Fracture). Unfortunately, while we all want/need our children to be active, this activity may lead to some injuries, even some from the repetitive nature of an activity like Osgood Schlatter Disease or Little League Shoulder.


The Child Athlete is at Risk

  • Over the past decades there has been greater participation in youth sports.
    • 60 million children (6-18 yrs) participate in athletics. (National Council of Youths Sports)
    • ~37 pediatric sport/recreational injuries are treated HOURLY in the US. [Schwebel, 2014]
  • Level of competitiveness has increased as well.
    • Leads to more training, practicing, and competition
    • Leads to more physical stressors
  • Immature skeletal structures are at distinct risk for injury. [Lomasney, 2013]
    • Growth plates are weaker than surrounding tendons and ligaments
    • Particularly vulnerable to fracture during growth spurts
  • At risk for high velocity injuries.
  • Also at risk for overuse injuries:
    • Both Females and Males are at risk, although with different patterns of injuries. [Stracciolini, 2015]
    • All sports can lead to overuse injuries, but greatest percentages are seen with: [Stracciolini, 2015]
      • Tennis
      • Swimming
      • Track/Field
      • Dance
      • Running
      • Gymnastics
      • Cheerleading


“Little League Shoulder”


  • “Little League Shoulder” = Proximal humeral epiphysiolysis
  • Overuse condition that affects the proximal humeral physis
    • Distinctly different that adult shoulder injury from same mechanism.
      • Once growth plates are closed, more commonly injure rotator cuff or shoulder joint itself.
    • Proximal humeral physis is weakest point in shoulder girdle of younger patients.
    • Exact pathophysiology is not completely understood. [Heyworth, 2016]
    • Thought to result from repetitive microtrauma from the rotational torques involved during throwing.
  • Often described in children who play baseball, but has also been seen in other sports.
    • Diagnosis of has increased annually over past decade. [Heyworth, 2016]
    • Any sport involving forceful overhand throwing motion. [Lomasney, 2013]
      • Softball
      • Tennis
      • Cricket [Drescher, 2004]
      • Football


  • Diffuse pain in shoulder or upper arm [Heyworth, 2016]
    • Initially, occurs only during throwing activity.
    • With more severe injury, pain can occur with all activities or even at rest.
  • Elbow pain (13%) [Heyworth, 2016]
  • Shoulder fatigue / weakness (10%) [Heyworth, 2016]
  • May have history of accelerated intensity of activity recently. [Lomasney, 2013]


  • Examination
    • 30 % have glenohumeral internal rotation deficit – decreased rotational ROM of the shoulder [Heyworth, 2016]
    • Tenderness over the region of the proximal humeral physis. [May, 2013]
  • Radiographs
    • Physeal widening can be seen
      • Represents a Salter-Harris I fracture of the proximal humeral physis
      • May be better seen with external rotation view
      • Compare to contralateral
    • Increased sclerosis
    • Lucency
    • Metaphysical calcification
    • Fragmentation adjacent to physis


  • Most often resolves with rest
    • Convincing the patient to avoid the sport that lead to this injury is the hardest part!
    • May still be able to play sport, but change positions (ex, moving from pitcher to 1st base).
    • Continued activity can lead to acute fracture completion. [Lomasney, 2013]
  • Physical therapy
  • Particular training to improve throwing mechanics


Moral of the Morsel

  • Think twice before labeling a child’s joint pain as a “sprain or strain.” (See Ankle Injury)
  • Consider obtaining comparative films if thinking of overuse injuries.
  • While the therapy for Little League Shoulder is primarily rest, it does require good education to help the family understand why that rest is important!




Heyworth BE1, Kramer DE2, Martin DJ2, Micheli LJ2, Kocher MS2, Bae DS2. Trends in the Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016 Mar 16. PMID: 26983458. [PubMed] [Read by QxMD]

Stracciolini A1, Casciano R, Friedman HL, Meehan WP 3rd, Micheli LJ. A closer look at overuse injuries in the pediatric athlete. Clin J Sport Med. 2015 Jan;25(1):30-5. PMID: 24926911. [PubMed] [Read by QxMD]

Schwebel DC1, Brezausek CM. Child development and pediatric sport and recreational injuries by age. J Athl Train. 2014 Nov-Dec;49(6):780-5. PMID: 25162780. [PubMed] [Read by QxMD]

Pengel KB. Common overuse injuries in the young athlete. Pediatr Ann. 2014 Dec;43(12):e297-308. PMID: 25486038. [PubMed] [Read by QxMD]

Lomasney LM1, Lim-Dunham JE, Cappello T, Annes J. Imaging of the pediatric athlete: use and overuse. Radiol Clin North Am. 2013 Mar;51(2):215-26. PMID: 23472587. [PubMed] [Read by QxMD]

May MM1, Bishop JY. Shoulder injuries in young athletes. Pediatr Radiol. 2013 Mar;43 Suppl 1:S135-40. PMID: 23478929. [PubMed] [Read by QxMD]

Osbahr DC1, Kim HJ, Dugas JR. Little league shoulder. Curr Opin Pediatr. 2010 Feb;22(1):35-40. PMID: 19926993. [PubMed] [Read by QxMD]


Sean M. Fox
Sean M. Fox
Articles: 583


Comments are closed.