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What is your diagnosis?

The most likely diagnosis is Little Leaguer’s Shoulder (LLS)

• Pearl: Little Leaguer’s Shoulder, also known as Proximal Humeral Epiphysitis, typically occurs in adolescent athletes. It is most commonly seen in pitchers and catchers. Patients are normally aged between 11 and 16 years old and LLS accounts for 10% of all cases of shoulder pain related to throwing in the pediatric population.

What is the mechanism of injury?

Repetitive rotational and shearing forces applied to the immature growth plate during overhead throwing activities are the primary mechanisms of injury. This repetitive stress results in the widening of the proximal humeral epiphysis.

• Pearl: For primary prevention of Little Leaguer’s Shoulder these are the recommended pitch counts and games per week by age.

What physical exam findings are expected?

At presentation, the patient may present with vague arm and shoulder pain with throwing that resolves at rest. On physical examination, the patient presents with point tenderness over the lateral proximal humerus at the proximal humeral physis.

Which imaging modalities can be used?

The standard imaging modality for this condition is plain radiographs. The recommended views are AP, scapular Y, and axillary views of the affected shoulder. A widened proximal humerus physis is the hallmark finding of LLS (image 2). Bedside ultrasound can be used to assess area of maximal tenderness and can show pays widening especially when compared to unaffected side. MRI can be used if the diagnosis is in doubt and may show edema around the physis.

Image 2: Widening of the humeral physics seen consistent with Little Leaguer’s Shoulder. Author's own image and annotation. 

What is the management in the ED?

Treatment of LLS in the ED is conservative. Control of pain and inflammation is the mainstay of treatment, and it is usually achieved via the use of NSAIDs. Patient education and activity restriction is paramount, as it is key to preventing further damage to the growth plate. A rest period of 6-12 weeks is usually recommended, followed by a progressive return to throwing activities after symptoms resolution. 

When do you consult orthopedics?

Orthopedic consultation for LLS is not routinely done Indications for orthopedic consultation include severe pain, functional impairment, or imaging findings of severe proximal humeral physis widening, suggesting growth plate disruption, or alternative diagnoses, such as fracture or ligament damage.