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