Little League shoulder is an overuse condition that affects the upper arm growth plate in the throwing arm of skeletally immature youth baseball players. The image above (A) shows widening of the upper arm growth plate in a young athlete diagnosed with Little League shoulder. The condition is characterized by generalized shoulder or upper arm pain during throwing. In more severe cases, Little League shoulder may cause pain with activities of daily living or at rest.
Little League shoulder is treated with a period of rest, physical therapy, and programs to improve strength and throwing mechanics. Premature closure and fractures of the growth plate have been reported in association with Little League shoulder but these are extremely rare complications. Most will eventually ‘‘outgrow’’ the condition spontaneously with normal growth plate closure. However, some continue to experience pain during the preadolescent or adolescent years which may considerably limit participation.
Little League shoulder most commonly occurs in youth overhead athletes between the ages of 11 and 16 years. Thirteen years is the most common age at which players move out of Little League and to a larger diamond. This requires a longer distance for pitches to cross home plate. Therefore this is the period where coaches and parents should most closely monitor youth athletes for early signs of pain. Below are five key considerations for returning injured youth baseball players back to play safely.
#1 Little League Shoulder is Occurring with Increasing Frequency
The increasing frequency of Little League shoulder is due to overuse and throwing with arm fatigue. This trend is likely due to greater numbers of youth pitchers participating in competitive leagues and doing so at increasingly younger ages. Increased velocity of pitches thrown, as compared with previous decades, is also a likely contributor. Year-round participation, participation on multiple teams in a season, the influence of private pitching coaches, and ‘‘showcase’’ events all contribute to increasing stress to the skeletally immature athlete. It is imperative that coaches and parents monitor players in accordance with Little League pitch count recommendations. It is also strongly recommended that players take at least 3 to 4 months per year off from throwing.
#2 Little League Shoulder Treatment Always Includes Rest from Throwing
During the late portion of the arm-cocking phase of throwing, there are considerable rotational forces acting on the shoulder. These forces can deform the cartilage of the growth plate and play a role in the development of Little League shoulder. The only way to remove these stresses and allow for healing is to stop throwing. The longer players throw with arm pain, the longer resolution of symptoms will take. Therefore, the initial treatment plan for Little League shoulder always consists of cessation of throwing. This period typically lasts 2 to 4 months. Pain usually resolves within the first 1 to 2 months of rest. However, premature return to throwing often leads to recurrence of symptoms. It has been estimated that approximately 25% of injured players will experience a recurrence of pain within 6 months of resuming throwing.
#3 Early Physical Therapy Should be Prescribed
Physical therapy treatment is initiated early to normalize shoulder range of motion and to begin a progressive strengthening program. Differences in side-to-side shoulder rotation ROM is believed to contribute to shoulder pain in the youth baseball player. These asymmetries have also been associated with a recurrence of Little League Shoulder. Therefore, it is important that youth athletes with Little League Shoulder are evaluated and treated by a physical therapist in order to address these risk factors. The cross body stretch targets posterior shoulder tightness which contributes to loss of motion in overhead athletes.
Strengthening the rotator cuff and shoulder blade muscles is important to build arm strength while resting from throwing. Weakness of the rotator cuff muscles has been shown to be a risk factor for shoulder and elbow injury in adolescent pitchers. Youth baseball players should demonstrate full pain-free strength of the rotator cuff muscles before throwing is resumed. Sidelying external rotation and prone horizontal abduction exercises target the posterior rotator cuff muscles which are often weak in young throwers. It is also important for athletes to strengthen the lower body and core musculature. Weakness in these areas will result in increased stress transferred to the throwing arm.
#4 Throwing Programs Should be Undertaken after Arm Strength is Developed
Structured interval throwing programs allow for a safe transition back to play. These programs are designed to replicate game conditions in a progressive and safe manner. Because individual differences exist, these programs must be tailored to the injured athlete’s physical and emotional needs. Omitting or rushing throwing programs often leads to recurrence of symptoms and delayed return to play. Also, long toss throwing should be used judiciously due to increased rotational forces imposed on the healing growth plate. Communication between the medical team and coaching staff is important to ensure the success of interval throwing programs.
#5 Flaws in Pitching Mechanics Should be Corrected Before Returning to Play
Before returning to unrestricted play, injured athletes should have their throwing mechanics assessed by a coach. In particular, the rate of trunk and pelvis rotation during the acceleration phase of throwing has been linked to shoulder injuries in youth baseball players. Hip-to-shoulder separation refers to the position of the hips relative to shoulder just prior to the front foot contacting the ground. Under ideal pitching mechanics, the hips are facing home plate and the shoulder continues to face towards third base in a right-handed pitcher. This allows for the optimal transfer of force from the core to the throwing arm. As fatigue increases, the hips and shoulder begin to rotate in unison resulting in an open hip-to-shoulder separation. This loss of force transfer and power generation results in increased stress placed upon the shoulder and elbow. This flaw should be correctedto reduce shoulder stress in the youth overhead athlete.
Little League shoulder usually resolves with 3-4 months of rest but symptom recurrence may occur. It is important to not rush youth athletes back to throwing before range of motion and strength are normalized. Correcting any pitching mechanic flaws and a progressive throwing program is also required before unrestricted return to play. Even after returning to play, close monitoring of athletes for at least 1 year is recommended to ensure prevention of recurrence. Finally, current guidelines regarding pitch counts, rest, and activity modification should continue to be emphasized for long-term health.
- Harada M, Takahara M, Maruyama M, et al. Outcome of conservative treatment for Little League shoulder in young baseball players: Factors related to incomplete return to baseball and recurrence of pain. J Shoulder Elbow Surg. 2018;27:1-9.
- Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of little league shoulder. Am J Sports Med. 2016;44(6):8-11.
- Sabick MB, Kim Y, Torry MR, Keirns MA, Hawkins RJ, Frcs C. Biomechanics of the shoulder in youth baseball pitchers implications for the development of proximal humeral epiphysiolysis and humeral retroversion. Am J Sports Med. 2005;33(11):1716-1722.