Diagnosis and Management of Little League Shoulder: A Systematic Review

Background: Little League shoulder (LLS) is an overuse injury characterized by throwing-related pain that commonly presents in adolescent male athletes. Investigations into the optimal duration of rest from throwing and protocols for graduated return to sports (RTS) are lacking. Purpose: To summarize the current literature with respect to the diagnosis, management, RTS, and return to throwing for LLS. Design: Systematic review; Level of evidence, 4. Methods: The databases EMBASE, MEDLINE, and PubMed were searched between inception and April 22, 2020. References of retrieved records were reviewed for potentially eligible studies. English-language studies that reported the diagnosis and/or management of LLS in children or adolescents were included. Studies of animals or cadavers, review articles, and non—peer reviewed records were excluded. Data were summarized narratively using descriptive statistics. Results: Overall, 23 studies (21 level 4 studies, 2 level 3 studies) met the criteria for a total of 266 participants with a weighted mean age of 12.8 years (range, 7.4-17 years). Treatment recommendations evolved from prolonged rest and complete cessation of throwing to shorter periods of rest and graduated RTS. Less than half (11/23) of studies reported specific criteria to RTS; 1 case report discussed a coaching strategy to resume throwing, and 1 case report discussed a regimented throwing program. The proportion of participants returning to any sport participation was 94.0% (n = 157/167). The proportion returning to their preinjury level of sport was 92.5% (n = 123/133). Upon RTS, 18.7% (n = 35/187) of participants experienced a recurrence of symptoms. Premature closure of the epiphysis was reported in 1 participant. Conclusion: Young athletes with LLS may return to play after a period of rest, and a high proportion return to their preinjury level of sport. Further prospective studies are warranted to develop evidence-based, graduated RTS protocols and to better capture any long-term sequelae of the condition.

Traction apophysitis

Overuse injuries are undoubtedly one of the most frequent cause of pain in adolescent athletes which can result in limitation in sport activities and competition, prolonged pain and psychological consequences. We see different forms of this condition regarding the anatomical region at insertion sites of major tendons. Usually we treat conditions of the lower extremities like Osgood-Schlatter or Sinding-Larssen-Johansson disease. We diagnose less frequently overuse injuries of the upper extremities like Little League shoulder or elbow. Commonly they present with pain after activities and limitation in range of motion. Each form has to be treated slightly differently, initially with resting, followed by physical or local therapy. Besides presenting the most important and usual forms of traction apophysitis, we emphasize the aspects of prevention and point out some ideas regarding training techniques.

Investigation of Ultrasound as a Diagnostic Imaging Modality for Little League Shoulder

Objective Ultrasound (US) is an established imaging modality in adult sports medicine but is not commonly used in the diagnosis of pediatric sports conditions, such as Little League shoulder (LLS). This study was conducted to determine the reliability of US measurement of width of the physis at the proximal humerus in diagnosed LLS and to compare US to radiography (RA) in detecting a difference between the affected (dominant) (A) and unaffected (U) shoulders. Materials and Methods Ten male baseball players diagnosed with LLS were enrolled in the study. US images of the proximal humeral physis at the greater tuberosity of both shoulders were obtained by an US-trained sports medicine physician, and the physeal width was measured. Blinded to prior measurements, a separate physician performed measurements on the stored US images. Measurements were compared with RA on the anteroposterior (AP) view for both A and U at the time of the initial visit and for A at follow-up. Results The physeal width (mm) at A and U at the initial visit averaged 5.94 ± 1.69 and 4.36 ± 1.20 respectively on RA, and 4.15 ± 1.12 and 3.40 ± 0.85 on US. Median difference of averaged US measurements between A and U at initial evaluation was 0.75 mm (p = 0.00016). A linear model showed US measurements to be predictive of RA on A (R2 = 0.51) and U (R2 = 0.48). Conclusion US was able to reliably measure the width of the proximal humeral physis and detect a difference between A and U. US correlated well with RA (standard for LLS). US should be considered by the US-trained physician for the diagnosis of LLS.