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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


  • 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


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


  • 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]



  • 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


  • 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


  • 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



  • 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


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


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


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



  • 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


  • 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


  • 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


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


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

See Also




  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
Last edited:
5 June 2023 14:56:43