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Little Leaguer’s shoulder (proximal humeral epiphysiolysis) is an overuse injury of the growth plate at the top of the upper arm bone in young throwing athletes. Repeated throwing stresses the growth plate, which is weaker than the surrounding bone and tendons in a growing child, causing pain and widening of the growth plate on X-ray. It is essentially a stress injury to the growth plate. Dr. Andrew Dold, a board-certified, fellowship-trained sports medicine surgeon in Frisco, Texas, evaluates and treats young throwers and helps families plan a safe return to the sport.

On this page:Who gets it · Symptoms · Diagnosis · Treatment · Return to throwing · Prevention · FAQs · Research
At a glance

  • Usually seen in baseball pitchers in early adolescence (average age about 13)
  • The main symptom is pain in the upper arm or shoulder when throwing hard
  • Treatment is rest from throwing, physical therapy and a gradual, structured return
  • Most young athletes return to their previous level of play
  • Workload limits and rest help prevent it

Who gets Little Leaguer’s shoulder?

In a series of 95 patients from a children’s hospital, the average age was 13 (range 8 to 16), 97% were baseball players, most of them pitchers, and a small number were tennis players. The number of diagnosed cases increased each year over the study period.1

Symptoms

  • Pain at the top or side of the upper arm or shoulder when throwing, especially throwing hard
  • Pain that eases with rest and returns when throwing resumes
  • Shoulder fatigue or weakness, or loss of velocity or control
  • Sometimes elbow pain as well: 13% had elbow pain in one series1

Diagnosis

Dr. Dold examines the shoulder for tenderness over the growth plate, checks range of motion (including loss of internal rotation (GIRD)) and examines the elbow. X-rays of both shoulders are compared: widening or irregularity of the growth plate on the throwing side confirms the diagnosis. An MRI is occasionally used when the diagnosis is unclear. In one series, 30% of patients also had GIRD.1

Treatment

Little Leaguer’s shoulder is treated without surgery:

  • Rest from throwing until pain resolves and tenderness is gone, while staying active in other ways
  • Physical therapy to address shoulder and core strength, shoulder-blade control and any loss of internal rotation
  • A structured return-to-throwing program once symptoms resolve, sometimes with a temporary position change away from pitching or catching

In the 95-patient series, symptoms resolved in an average of 2.6 months and athletes returned to competition at an average of 4.2 months.1 Treatment recommendations have shifted from long periods of complete rest toward shorter rest and a graduated return to sport.2

Return to throwing

A systematic review of 266 young athletes found that 94% returned to sport and 92.5% returned to their previous level. However, symptoms came back in 18.7% after returning, which is why a gradual, monitored progression is important.2 Recurrence was more common in athletes with GIRD in one series, although the difference was not statistically significant.1

Players who had Little Leaguer’s shoulder may continue to have higher rates of shoulder and elbow pain in high school, so ongoing attention to workload and mechanics is worthwhile.3

Prevention

  • Follow age-appropriate pitch-count and rest-day guidelines for your league
  • Take regular breaks from throwing, including time off each year
  • Avoid pitching on multiple teams at the same time, and avoid pitching and catching on the same day
  • Stop throwing and get evaluated if pain develops

What the research shows

  • Diagnosis: Little Leaguer’s shoulder is a stress injury to the growth plate at the top of the arm bone. It causes pain with throwing, and comparing X-rays of both shoulders typically shows widening of the growth plate on the throwing side. Most cases occur in baseball pitchers around ages 11 to 15, but catchers, other position players and tennis players can be affected too.
  • Rest, then a graduated return: a systematic review found that after a period of rest from throwing (often about 3 months) followed by a structured throwing program, about 94% of young athletes returned to sport and 92% to their previous level. About one in five had symptoms return, so a gradual progression matters.
  • Workload is the main risk factor: studies of youth pitchers link injury to pitching more pitches per game and season, pitching more than 8 months a year, pitching with arm fatigue, and pitching for multiple teams or showcases. Players also make many more hard throws than official pitch counts capture.
  • Prevention: follow age-based pitch count and rest guidelines from USA Baseball and Little League, avoid year-round pitching, take at least a few months off from overhead throwing each year, stop when the arm is tired or sore, and work on mechanics and shoulder and core strength.

Why see Dr. Dold

  • Board certified by the American Board of Orthopaedic Surgery, with subspecialty certification in Sports Medicine
  • Sports medicine and arthroscopy fellowship at NYU Langone / Hospital for Joint Diseases; orthopedic residency at the University of Toronto
  • Fellow of the American College of Surgeons (FACS), the American Academy of Orthopaedic Surgeons (FAAOS), the American Orthopaedic Association (FAOA) and the Royal College of Surgeons of Canada (FRCSC)
  • Author of a SLAP repair book chapter (Springer, 2017) and research on shoulder suture anchors (KSSTA, 2013)
  • Team physician and surgical consultant to Rugby Canada; has cared for professional athletes from the NFL, NBA, NHL, MLS, PGA Tour and Major League Rugby
  • D Magazine Best Doctors (Collin County), 2019–2026 · Rated 4.9 on Google

Frequently asked questions

Is Little Leaguer’s shoulder a fracture?

It is a stress injury to the growth plate at the top of the upper arm bone, caused by repeated throwing.

How long does my child need to stop throwing?

It depends on the severity. In one series, symptoms resolved in an average of 2.6 months and athletes returned to competition at an average of 4.2 months.1

Will my child be able to pitch again?

Most young athletes return to their previous level of play, but symptoms can come back, so a gradual return is important.2

Does it need surgery?

No. Little Leaguer’s shoulder is treated with rest, therapy and a structured return to throwing.

How can we prevent it?

Follow pitch-count and rest guidelines, take regular breaks from throwing and stop throwing if pain develops.

Do you accept my insurance?

Dr. Dold accepts most major insurance plans, including Medicare and Tricare. Please call 469-850-0680 to confirm your coverage.

Research cited on this page

  1. Heyworth BE, Kramer DE, Martin DJ, et al. Trends in the Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016;44(6):1431-1438. PubMed
  2. Bednar ED, Kay J, Memon M, et al. Diagnosis and Management of Little League Shoulder: A Systematic Review. Orthop J Sports Med. 2021;9(7):23259671211017563. PubMed
  3. Ito A, Mihata T, Hosokawa Y, et al. Humeral Retroversion and Injury Risk After Proximal Humeral Epiphysiolysis (Little Leaguer’s Shoulder). Am J Sports Med. 2019;47(13):3100-3106. PubMed
  4. Osbahr DC, Kim HJ, Dugas JR. Little league shoulder. Curr Opin Pediatr. 2010;22(1):35-40. PubMed
    Review: highest shoulder stress occurs at maximum external rotation and ball release; prevention focuses on mechanics, motion deficits and pitching guidelines.
  5. Gross ML, Flynn M, Sonzogni JJ. Overworked Shoulders. Phys Sportsmed. 1994;22(3):81-6. PubMed
    Review: widening of the proximal humeral growth plate on X-ray is the characteristic finding; rest is the cornerstone of treatment.
  6. Hatem SF, Recht MP, Profitt B. MRI of Little Leaguer’s shoulder. Skeletal Radiol. 2006;35(2):103-6. PubMed
    Imaging study: MRI appearance of Little Leaguer’s shoulder.
  7. Fleming JL, Hollingsworth CL, Squire DL, et al. Little Leaguer’s shoulder. Skeletal Radiol. 2004;33(6):352-4. PubMed
    Case review: widening of the proximal humeral growth plate in a skeletally immature thrower.
  8. Pennock AT, Dwek J, Levy E, et al. Shoulder MRI Abnormalities in Asymptomatic Little League Baseball Players. Orthop J Sports Med. 2018;6(2):2325967118756825. PubMed
    MRI study: shoulder abnormalities were common in Little League players, especially single-sport, year-round athletes.
  9. Matsuura T, Suzue N, Iwame T, et al. Epidemiology of shoulder and elbow pain in youth baseball players. Phys Sportsmed. 2016;44(2):97-100. PubMed
    Survey of over 1,000 players aged 7 to 12: 15.9% reported throwing-arm shoulder pain and 29.2% elbow pain.
  10. Olsen SJ, Fleisig GS, Dun S, et al. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34(6):905-12. PubMed
    Case-control study: injured adolescent pitchers pitched more months, games, innings and pitches, and more often with arm fatigue and pain.
  11. Lyman S, Fleisig GS, Andrews JR, et al. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30(4):463-8. PubMed
    Prospective study: pitch counts per game and season were associated with shoulder and elbow pain; curveballs increased shoulder pain risk by 52%.
  12. Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. 2001;33(11):1803-10. PubMed
    Longitudinal study: arm fatigue and pitch volume were risk factors for shoulder and elbow pain in youth pitchers.
  13. Fleisig GS, Weber A, Hassell N, et al. Prevention of elbow injuries in youth baseball pitchers. Curr Sports Med Rep. 2009;8(5):250-4. PubMed
    Study: youth pitchers who pitch more than 85 pitches per game, more than 8 months a year, or with arm fatigue have several times the injury risk.
  14. Rice SG, Congeni JA, Council on Sports Medicine and Fitness. Baseball and softball. Pediatrics. 2012;129(3):e842-56. PubMed
    American Academy of Pediatrics statement on youth baseball safety, including pitch limits and rest periods.
  15. Feeley BT, Schisel J, Agel J. Pitch Counts in Youth Baseball and Softball: A Historical Review. Clin J Sport Med. 2018;28(4):401-405. PubMed
    Review: published pitch count guidelines and the challenge of early sport specialization.
  16. Wahl EP, Pidgeon TS, Richard MJ. Youth Baseball Pitch Counts Vastly Underestimate High-effort Throws Throughout a Season. J Pediatr Orthop. 2020;40(7):e609-e615. PubMed
    Study: youth players make many more high-effort throws than official pitch counts record.
  17. Zaremski JL, Krabak BJ. Shoulder injuries in the skeletally immature baseball pitcher and recommendations for the prevention of injury. PM R. 2012;4(7):509-16. PubMed
    Review: USA Baseball, Little League and other bodies have developed pitch count and rest recommendations.
  18. Kim HHR, Menashe SJ, Ngo AV, et al. Uniquely pediatric upper extremity injuries. Clin Imaging. 2021;80:249-261. PubMed
    Imaging review of uniquely pediatric upper-extremity injuries.
Ready to get it checked? Request an appointment online or call 469-850-0680. Our staff will contact you by phone and text within an hour of your request (during business hours, Monday–Friday, 8 am–5 pm). Walk-in visits are welcome Monday, Wednesday and Friday, 8:30–10:30 am at 6700 Dallas Parkway, Suite 100, Frisco, TX 75034. We see patients from Frisco, Plano, McKinney, Prosper, Little Elm, The Colony, Allen, Dallas and across North Texas. Same-day appointments available.

Request an AppointmentCall 469-850-0680

Medically reviewed by Andrew P. Dold, MD, FAOA, FAAOS, FACS, FRCSC. Last reviewed October 2026. This page is general information, not medical advice. Individual results vary.