| April 2005 Case of the Month |
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Compiled By: Donald Reynolds. Jr., D.O.
History: 14 year old with shoulder pain and decreased range of motion. Initially hurt while playing baseball.
Exam: MRI of shoulder. Coronal T1 and T2, sagital STIR and axial PD fat sat at the level of the lateral physis.
Findings: Widening of the lateral humeral physis with increased signal on water weighted images in the physis, adjacent epiphysis and metaphysis.
Diagnosis: Little leaguer's shoulder.
Discussion: Various terms have been used to describe little leaguer’s shoulder such as osteochondrosis of the proximal humeral epiphysis, proximal humeral epiphyseolysis, stress fracture of the proximal humeral epiphyseal plate and rotational stress fracture of the proximal humeral epiphyseal plate. It is unknown whether it is caused by overuse inflammation of the proximal humeral physis or is actually a stress fracture of the physis. It appears to be caused by rotational stress applied to the proximal humeral physis during throwing.
Widening of the proximal humeral physis will be seen on plain films in internal and external rotation. MRI will also show edema along the physis and adjacent epiphysis and metaphysis. Associated findings include demineralization, sclerosis of the proximal humeral metaphysis, and fragmentation of the lateral aspect of the proximal humeral metaphysis. Complications include premature closure of the affected proximal humeral physis, salter-harris fracture and possible avascular necrosis and loose body formation.
The proximal humeral epiphysis is very stable because of its pyramid shape and strong posteromedial periosteum.
Common clinical presentation is discomfort with resistance testing, especially suprasinatus testing and shoulder abduction and external rotation against resistance. Only 25% report weakness with external rotation. Before returning to throwing the athlete should have full strength, full range of motion, and no apprehension or discomfort in the cocking phase of throwing. Athletes under the age of 14 should avoid throwing a curveball or slider.
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References:
Carson, William G., M.D., et.al. “Little Leaguer’s Shoulder” The American Journal of Sports Medicine. Vol. 26, No. 4, pp. 575-580.
Walter, Kevin D., M.D., Congeni, Joseph A. M.D. “Don’t let Little League shoulder of elbow sideline your patient permanently.” www.contemporarypediatrics.com. | |
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