Working Diagnosis:
Right shoulder proximal humerus epiphysiolysis (little league shoulder) in the setting of underlying glenoid dysplasia, labral pathology and acromial apophysiolysis.

Treatment:
In addition to rest and abstaining from throwing until asymptomatic, he had physical therapy with an upper extremity specialist with attention paid to throwing mechanics as well as rotator cuff strengthening and periscapular stabilization.

Outcome:
Patient continued to work with physical therapy with gradually decreasing pain and improving range of motion. After about 5 months, he was able to throw up to 45 feet with no pain. He was just released to go back to gym. He will continue to follow with sports medicine and orthopedics to determine return to play status.

Author's Comments:
Little League shoulder, also known as osteochondrosis of the proximal humeral epiphysis and rotation stress fracture of the proximal humeral epiphyseal plate, classically affects baseball pitchers between ages 11 to 16, whose physis remains open. Diagnosis is primarily clinical suspicion. Xrays can be negative in many athletes, but a wide proximal humeral physis can be seen. MRI, while not always necessary, can reveal edema around the physis. Treatment is typically 3-6 months of rest and discontinuation of overhead activity. With physical therapy, there is a gradual progression to rotator cuff strengthening, throwing, and eventually competition.

Our patient was initially thought to have a rotator cuff injury, but the atypical exam/Xray findings prompted advanced imaging, which helped make the diagnosis of his acute on chronic issue and likely predisposing mechanical factors, specifically his GH dysplasia.

Editor's Comments:
This case was notable because even with a diagnosis of proximal humeral osteochondrosis or physeal stress fracture, there were other suspicious findings on exam and radiographs including scapular dyskinesis, decreased arc of motion, supraspinatus and infraspinatus provocative maneuvers and irregularity of inferior acetabulum to lead to MRI and diagnosis of glenoid dysplasia.
Proximal humeral physeal osteochondrosis/stress fracture/episphysiolysis is common before physeal closure in overhead athletes. As stated, many times radiographs may appear normal but radiographs taken of the nonaffected shoulder for comparison can reveal a few mm of difference side to side revealing the diagnosis. MRI can be used as well showing edema at the physis with changes and may show separation. It most often is from overuse and pitch counts are very helpful. Treatment generally consists of rest from throwing and overhead activity which usually takes about 3 months. When pain free, physical therapy should be started. After pain free, strength and motion deficits are corrected, a return to throwing program may be initiated. Throwing mechanic deficits should also be corrected.

References:
Casadei K, Kiel J. Proximal Humeral Epiphysiolysis (Little League Shoulder) [Updated 2020 Jan 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

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