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Humeral Head Epiphysiolysis

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Other Names

  • Little League Shoulder
  • Little Leaguer's Shoulder
  • Proximal Humeral Epiphysiolysis
  • Osteochondrosis of proximal humeral epiphysis
  • Stress fracture of proximal humeral epiphyseal plate
  • Rotation stress fracture

Background

  • This page refers Humeral Head Epiphysiolysis (HHE) or Little League Shoulder
  • Defined as an overuse injury to the epiphyseal cartilage of the humeral head seen in skeletally immature athletes

History

  • Initially described by Dotter in 1953[1]
  • Described by Adams in 1966 as Osteochondrosis[2]

Epidemiology

  • Very common in little league baseball players, especially pitchers
  • In one cohort of little leaguers with shoulder pain, 36.6% of players who agreed to an xray had radiographic findings of HHE[3]
  • Seen in youth throwing athletes between 11 and 16, peak age 13[4]

Introduction

General

  • Defined as a shearing or stress injury of the epiphyseal cartilage of the proximal humerus
  • Characterized by throwing related pain over proximal shoulder
  • Represents a Salter Harris 1 Fracture

Etiology

  • Occurs as a result of excessive rotational, distractional forces that occur with repetitive overhead throwing[5]
    • Specifically, significant external rotational torque
  • Repetitive microtrauma leads to cartilage damage of the proximal humeral epiphysis
  • Epiphyseal plate injury is the weakest point in the kinetic chain
  • Believed to occur during the late cocking phase of throwing
    • At this point there is significant rotational torque immediately prior to acceleration

Osteology of the Proximal Humeral Epiphysis

  • Four growth center: head, shaft, greater tubercle, lesser tubercle[6]
  • Typically fuses between ages 14-20
  • Contributes about 80% of longitudinal growth of humeral shaft

Risk Factors

  • Male > Female
  • Age (11-16, average 14)
  • Overhead/ Throwing Sports
    • Baseball, especially pitching
    • Tennis
    • Volleyball
    • Swimming
  • Pitching specific[7]
    • Poor throwing mechanics
    • High pitch count
    • "Breaking" pitch
  • Playing year round sports
  • Glenohumeral Internal Rotation Deficit (GIRD)

Differential Diagnosis

Differential Diagnosis Shoulder Pain

Clinical Features

History

  • Typical age 10 to 16
  • Onset is by definition insidious although an acute trauma or event could occur
  • Pain initially only with significant exertion (i.e. hard throwing)
  • Eventually progresses to pain at rest or with light exertion (i.e. soft, short throws)
  • May endorse decreased throwing accuracy, velocity

Physical: Physical Exam Shoulder

Evaluation

Radiographs

  • Standard Radiographs Shoulder initially
    • Best view of physis: anteroposterior view of the shoulder with the arm in external rotation
  • Findings
    • May be normal
    • May show widened physis
  • Less commonly
    • Demineralization
    • Sclerosis
    • Cystic changes
    • Lateral fragmentation of the prox humeral metaphysis
  • Compare to unaffected shoulder if needed

MRI

  • Rarely required
  • If highly suspicious with uncertain radiographs or clinical exam, can clarify diagnosis
  • Findings: physeal edema

Ultrasound

  • Can be used to help confirm the diagnosis
  • Findings
    • Increased hypo-echoic swelling not see on the contralateral side

Classification

Neer and Horwitz Classification

  • Displacement[8]
    • Grade I: Less than 5 mm
    • Grade II: Less than one third of shaft width
    • Grade III: Two thirds of shaft width
    • Grade IV: More than two thirds of shaft width

Management

Nonoperative

  • Remove from play/ activity modification
    • No throwing or overhead activities for at least 6 weeks, often 8-12 weeks
    • Ok to do general conditioning, lower extremity training
  • Ice
  • Analgesia including NSAIDS, Acetaminophen
  • Consider Shoulder Sling for comfort

Prevention

  • Proper pitching mechanics
  • Educate athlete, parents, coaches
  • Avoid single sport, year round activity
  • Rigidly follow pitch count guidelines
  • Avoid "breaking" pitch
  • Improve core strength, cardiovascular fitness

Rehab & Return to Play

Rehabilitation

  • Initiate after at least 6 weeks of rest from overhead or throwing
  • Initial: strengthening of rotator cuff, periscapular muscles
  • Initiate Throwing Program when patient is pain free at rest without tenderness to epiphysis
  • Correct throwing mechanics if necessary

Return to Play

  • Upon completion of physical therapy and throwing program without symptoms and normal throwing mechanics

Complications & Prognosis

Prognosis

  • Most athletes return to pre-injury level activity (need citation)
  • Resolves with skeletal maturity
  • Most athletes return to play in about 3 months

Complications

  • Premature physeal Arrest
  • Limb length discrepancy
  • Osteonecrosis of epiphysis

See Also

Internal

External

References

  1. ↑ Dotter, W. E. Little leaguer's shoulder-Fracture of the proximal humeral epiphyseal cartilage due to baseball pitching, Guthrie Clin. Bull. 1953 July; 23:68-72.
  2. ↑ Adams, JE. Little league shoulder: osteochondrosis of the proximal humeral epiphysis in boy baseball pitchers. California Medicine. 1966 Jul; 105(1):22-5.
  3. ↑ Kanematsu Y, Matsuura T, Kashiwaguchi S, et al. Epidemiology of shoulder injuries in young baseball players and grading of radiologic findings of Little Leaguer's shoulder. J. Med. Invest. 2015;62(3-4):123-5
  4. ↑ Sabick MB, Kim YK, Torry MR, Keirns MA, Hawkins RJ. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med. 2005 Nov;33(11):1716-22.
  5. ↑ Sabick MB, Kim YK, Torry MR, Keirns MA, Hawkins RJ. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med. 2005 Nov;33(11):1716-22.
  6. ↑ www.wheelessonline.com/ortho/anatomy_of_proximal_humeral_physis. Accessed March 7, 2010.
  7. ↑ Lyman S, Fleisig GS, Andrews JR, Osinski ED. 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;30:463-8.
  8. ↑ Neer CS 2nd, Horwitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop 41:24-31, 1965
Created by:
John Kiel on 30 June 2019 20:22:46
Authors:
Last edited:
5 June 2023 14:56:43

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