Little League Shoulder (LLS)

**Definition and Pathophysiology**

Little League Shoulder is a type of overuse injury that affects the proximal humeral growth plate in children and adolescents, specifically due to repetitive throwing motions. The shoulder, especially the upper arm or humerus, is susceptible to stress during high-velocity throwing. Over time, repeated stress or overload from pitching or throwing can lead to inflammation or even microfractures in the growth plate, potentially causing pain, weakness, and limited motion.

This condition is often seen in athletes between the ages of 9 and 14, coinciding with peak growth periods. The risk increases when players are involved in year-round competitive play without adequate rest and recovery periods.

**Mechanism of Injury**

The primary mechanism of Little League Shoulder is excessive or repetitive overhead throwing. The shoulder undergoes rapid acceleration and deceleration during the throwing motion, which places a high force on the humeral head and the surrounding structures. In growing athletes, the soft tissue structures (like muscles and tendons) develop faster than the bones, leading to a mismatch in strength and stability.

Recent conversations around pitch count haven’t moved the needle as much as we would like. New research indicates pithes per inning as a more accurate assessment to strain on the arm. Throwing excessive pitches per inning, which is an individualized number based on an athlete’s shoulder strength, power, imbalances, and capacity, puts excessive strain on the shoulder's growth plate, which is more vulnerable than mature bone.

**Symptoms**

The hallmark symptom of LLS is pain in the shoulder, which is typically worsened with throwing activities. Other symptoms may include:

* Pain localized in the front of the shoulder or upper arm

* Decreased range of motion (especially with external rotation or abduction)

* Weakness in the shoulder muscles

* Pain during pitching or throwing

* Swelling or tenderness over the shoulder joint (in some cases)

In severe cases, there may be signs of a stress fracture in the proximal humerus.

**Diagnosis**

The diagnosis of Little League Shoulder is largely clinical but is confirmed through imaging, particularly X-rays, which can reveal widening or irregularity of the proximal humeral growth plate. In some cases, MRI or CT scans are utilized to assess soft tissue involvement, such as tendons and ligaments, and rule out other injuries like rotator cuff tears or labral injuries.

There are two primary mechanisms for LLE:

1. **Medial Tension**: The repetitive stress on the medial side of the elbow, specifically the ulnar collateral ligament and the flexor-pronator muscle group, can cause microtears and inflammation.

2. **Lateral Compression**: Repeated throwing also places compressive forces on the lateral side of the elbow, which can contribute to the breakdown of the cartilage and other tissues.

**Symptoms**

* Pain localized to the inside (medial) side of the elbow

* Pain during the acceleration phase of throwing (the period when the ball is released)

* Decreased throwing velocity and accuracy

* Tenderness over the medial epicondyle

* Swelling or warmth around the elbow joint

* Pain when the elbow is extended fully

In severe cases, there may be a loss of grip strength and an inability to straighten the arm completely.

**Diagnosis**

Diagnosing Little League Elbow begins with a detailed clinical history and physical examination. Key findings include pain during resisted wrist flexion, elbow extension, forearm pronation, and compression of the medial epicondyle or bony prominence. X-rays are the primary imaging tool for diagnosing LLE, which may show medial epicondylar apophysitis, growth plate irregularities, or signs of avulsion fractures. MRI scans can be helpful to assess soft tissue injuries, such as ligament or tendon tears, as well as to rule out other injuries.

Treatment of Little League Shoulder and Little League Elbow

**Conservative Management**

Both Little League Shoulder and Little League Elbow are typically treated with conservative measures, which may include:

1. **Rest**: This is the most important aspect of recovery. Players are advised to stop throwing for several weeks to months to allow for healing of the injured structures. Research indicates a wide variance of this healing phase which could be 2-8 months (though most will narrow the growth plate within 3 months). Generally, the injury responds very well to conservative management with over 90% of players returning to baseball. There are a smaller percentage of players that return to baseball, but change positions and no longer pitch that season. Unfortunately, the injury has a relatively high rate of recurrence with around 19% of players having setbacks with recurrent shoulder pain.

2. **Therapeutic Exercise**: Rehabilitation exercises focusing on shoulder, elbow, or forearm mobility, strength, and power are crucial. Physical therapists and chiropractors often implement stretching, strengthening, and joint mobility exercises to correct muscle imbalances and improve throwing mechanics. You can learn more about what that should look like in the link below.

3. **Pain Modification**: The use of ice or medications should be used sparingly and for short periods of time. Current research indicates prolonged use of either may actually inhibit, or slow, healing times.

4. **Biomechanical Correction**: Working with a coach or trainer to adjust the athlete’s throwing mechanics can reduce stress on the injured joint or bone.

**Surgical Treatment**

Surgery is typically reserved for more severe cases, such as when there is a fracture or ligament tear. Surgical options may include:

* **Medial Epicondyle Release** (for LLE): If the injury involves a significant tear or avulsion of the ulnar collateral ligament, surgical intervention may be necessary.

* **Proximal Humeral Epiphysiodesis** (for LLS): In cases of severe growth plate injury with fractures, surgery may be required to stabilize the bone.

However, surgical options are rare, and most cases of LLS and LLE resolve with conservative treatment.

Prevention

The best way to prevent Little League Shoulder and Little League Elbow is through education, proper training, and adherence to pitches/inning limits. Several strategies can help reduce the risk of these injuries:

1. **Pitches/Inning Limits**: While many subscribe to a pitch count to guide how much they should be throwing, we need to realize athletes need individualized approaches. What causes muscle fatigue for some may be different for others. Some throwers are stronger, longer, or larger and that creates a completely different thrower profile. As a general rule many throwers will start to fatigue significantly if they continuously reach 20-30 pitches/inning.

2. **Rest Periods**: Ensuring players get adequate rest between pitching appearances is crucial. Players should have at least one day of rest between pitching outings, and multiple days of rest are recommended after heavy workloads.

3. **Proper Throwing Mechanics**: Coaches should work with young athletes to ensure proper throwing mechanics, which can reduce stress on the shoulder and elbow joints. Avoiding excessive use of the arm and focusing on body rotation can improve throwing efficiency and reduce injury risk. Advancements here for high school and above pitchers should include some sort of biomechanics evaluation; 3D motion capture is an emerging science that helps biomechanist understand how efficient an athlete is moving in their sport.

4. **Cross-training and Diversification**: Encouraging young athletes to participate in multiple sports rather than specializing in baseball year-round helps prevent overuse injuries. This reduces the risk of strain on specific muscle groups, joints, and bones.

5. **Other Influencing Factors**:

• Proper use of warm-ups. J-bands are a common and easily used device for engaging the muscles of the shoulders. Other devices such as waterbags, perturbation exercises, and isometrics have significant value for priming muscles before an outing.

• Training related factors. Poorly planned and timed gym training can cause and even enhance imbalances related to injury. We suggest working with a team of professionals to cover all of your bases.

• Non-negotiables. Nutrition, hydration, sleep, and psychological stresses if not well managed can wreak havoc on an athletes ability to recover and perform. As an example, lack of sleep can significantly increase an athletes exposure to injuries.

**Conclusion**

Little League Shoulder and Little League Elbow are significant concerns for youth baseball players, as they are injuries caused by overuse and repetitive stress on developing bones and joints. Both conditions are preventable and treatable with proper training, rest, and adherence to age-appropriate pitch count limits. Coaches, parents, and athletes must remain vigilant about the importance of rest, good throwing mechanics, and balanced training to minimize the risks of these injuries. Early diagnosis and appropriate treatment can help athletes recover fully, preventing long-term damage and enabling them to continue participating in sports safely.

The research highlights the importance of a multifaceted approach to preventing and managing these injuries, as well as understanding the growing body’s vulnerability to repetitive motion stress.

If you or someone you love has suffered a little league shoulder or elbow injury in the Omaha or Lincoln, Nebraska-area, ChiroSport, Chiropractic & Sports Medicine can help! We are accepting new patients, same day appointments or weekend visits are available. For additional information or to schedule an appointment, please contact us today.

We also offer a Free Discovery Visit where we can chat about possible next steps or treatment options.