Updated: May 5, 2022
Little League shoulder is a difficult condition to treat and manage, even though there are excellent return rates to previous competition level. According to a study by Bednar, et al. 92.5% of athletes who suffer from Little League shoulder return to their pre-injury competition level. However, treatment typically involves a few months off from throwing. If you factor in that most athletes deal with some pain and discomfort for a couple of months, are told to take 3 months off from throwing, and then require a couple of months to perform a throwing program, you are looking at a potentially lost year of development. Also, no child should have to take a year off from sports, as there are many physical, mental, and emotional consequences as a result.
Let’s take a step back and understand what causes Little League shoulder. Anatomically, we have growth plates at the end of long bones in our body until we stop growing. Boys typically stop growing around 16 years old, while girls stop around 14-15 years old per kidshealth.org. Growing involves the lengthening of bones first, and this occurs at the growth plates. The technical name for growth plates is the epiphysis and the one that causes Little League shoulder is located at the top of your humerus. This image from luriechildrens.org provides a simple visual.
The growth plate is a less dense portion of bone, which allows it to grow but also opens it up to stress. In adults, the weakest anatomical areas are typically soft tissue such as ligaments or tendons. In children, the growth plate is typically the weakest area and the site of significant stress. This is part of the reason why children suffer “typical” injuries such as rotator cuff tears less frequently; the growth plate will typically be the first structure to fail.
Throwing places significant stress on the shoulder and humeral growth plate. Stress is not necessarily a bad thing, as it can lead to positive adaptations such as strengthening of bones and other tissues. Also, throwing at a young age can increase humeral retroversion. This is the process that allows increased external rotation or layback of the shoulder due to bony changes. If you never throw anything until you are 20 years old, you will be unable to have the same shoulder motion and therefore less ability to create power compared to someone who started throwing at a young age. This is the cause of “throwing like a girl” which is similar to when you try to throw with your non-dominant arm, but it is unable to lay back far enough to generate significant velocity.
Of course, stress can also be a bad thing if we are not prepared to handle it. Unfortunately, younger athletes are often underdeveloped regarding strength, which provides protection for stress. If the athlete’s muscles are unable to handle the load, then it will go to bones and other tissues. Young athletes are throwing at higher velocities and are making more throws every year, which only increases the stress that is placed on their underdeveloped bodies.
Little League Shoulder Symptoms
Little League shoulder is typically diagnosed based on pain. The player will have pain in their upper arm and shoulder region that is typically worse with throwing. As the condition worsens, it can become sensitive to any sort of shoulder movement, particularly with lifting weight. Symptoms can progress to the point that the shoulder hurts even at rest, which signifies significant trauma in the area.
Other symptoms that can be missed include a lack of control or decreased throwing velocity. These can be early warning signs that something is wrong with the shoulder, especially if they are paired with pain in the shoulder.
X-ray imaging is typically sufficient to diagnose Little League shoulder, as the growth plate should appear. Sometimes, an MRI is required to see the details of the growth plate. MRIs are also beneficial to rule out other soft tissue injuries such as the rotator cuff or labrum.
Little League Shoulder Treatment
Treatment for Little League shoulder should be above all collaborative. Everyone involved in the child’s healthcare and baseball teams should be on the same page, including the physician, physical therapist, team coach, skills coach, parents, and the athlete. There can be many factors leading to the injury that each discipline will be able to address. Throwing mechanics may be a point of focus for a pitching coach, while a team coach can look at overall workload. The physical therapist can perform movement screens to see if any strength or mobility issues are present, and the physician can provide imaging and medication if necessary. Parents and the child should be included in all of these discussions, as they best know how everything is feeling and progressing.
Typically, athletes will take a few months off from throwing to allow the growth plate to heal. After approximately 3 months, the physician will perform more imaging to confirm that the irritation has decreased. During those 3 months, the athlete should be in physical therapy to work on strengthening and mobility, as these are often root causes of the injury. The downtime from throwing and aggressive competition should allow for significant strengthening improvements, which can help address the Little League shoulder while also being beneficial from a performance perspective.
Once imaging reveals that the growth plate is healing, a gradual throwing program can be introduced. This should be a slow process with frequent input from the athlete that they are tolerating the stress well. Physical therapy should continue as needed at this point, as there should be open dialogue between coaches and medical professionals.
Little League Shoulder Exercises
Exercises for Little League shoulder involve mobility for the shoulder and surrounding areas including the neck and back. Often, athletes lack the ability to reach overhead fully due to muscular tightness or joint limitations in the back. Kids are often growing rapidly during this timeframe, and muscles can be slow to catch up to lengthening bones. This can cause growing pains, but it often results in mobility restrictions. The important factor is to have a qualified medical professional who specializes in baseball players provide a thorough movement analysis.
Foam rolling or similar mobility exercises can be helpful, particularly for the thoracic spine or mid-back. In order to reach fully overhead, we need to extend our back. Try to slouch down and reach over your head and then do the same thing with good posture. It is probably a lot easier with an extended, upright spine. Thoracic extension is a crucial movement to allow for shoulder range of motion, but one that is often overlooked.
As I previously mentioned, strength is often lacking in younger athletes who are going through growth spurts. The lower trapezius and serratus anterior are often muscles that are underdeveloped in this population. Rapid growth leads to rounding of the upper back and shoulders due to muscular tightness, which can cause upper trapezius tightening. This image from zachdechant.com highlights the relationship between the three muscles.
If the upper trapezius is significantly tighter, then the shoulder blade can become stuck in an upward position. When we lift our arm, there should be rotation of the scapula (shoulder blade) to take pressure off of the shoulder joint itself.
Imagine if the scapula was stuck pulled toward the clavicle? It would be unable to rotate and all of the stress would translate to the shoulder and the growth plate of the humerus. Strengthening of the lower trapezius and serratus anterior allows for relaxation of the upper trapezius and a smoother motion from all segments.
These are just a couple of structures that can be implicated in Little League shoulder, but individual assessments are crucial to give unique recommendations based on the athlete’s presentation.
How To Prevent Little League Shoulder
We have discussed the causes, diagnosis, and treatment of Little League shoulder, but how do we prevent it? It looks very similar to the treatment model where first and foremost, there needs to be communication between all parties. Too often, pitching coaches are not aware of how much the athlete threw and they overwork them without realizing. Also, athletes rarely have access to a physical therapist or strength coach at this age unless they are injured. At Eclipse Wellness, we work to assess athletes before the injury occurs and hopefully prevent it. Oftentimes, an assessment can provide valuable information even if there is no injury due to limitations that can be found regarding strength and mobility.