A 13-year-old female elite butterfly-stroke swimmer, presented with a five-week right shoulder pain. The medical history revealed gradual onset of pain that worsened during training and excluded prompt return to sports activity. No recent or remote shoulder injury was reported.
Physical examination revealed tenderness on palpation over the proximal humerus with no restriction in the range of motion. An MRI examination was performed that demonstrated subtle widening and oedema along the proximal humeral physis (Fig. 1). Correlation of the patient’s clinical history, the overhead sports activity, the physical examination and imaging findings suggested the diagnosis of Little Leaguer’s shoulder and she was instructed to rest and cease swimming. However, the athlete’s competitive nature resulted in non compliance with the treatment. She presented two months later with worse symptoms. Ultrasound and radiographs showed progression into a horizontal metaphyseal fracture (Fig. 2-3). Rest from overhead sports activities for an additional period of 3 months was advised. The athlete was asymptomatic at the end of the 3-month lay-off and was instructed to gradually resume activity over a one month period. She is currently pain-free and a gold medallist in her league.
Shoulder pain is a frequent problem among young athletes [1]. Little Leaguer’s shoulder represents an overuse-stress injury to the proximal humeral physis, that is seen commonly in adolescent athletes who participate in sports requiring overhead activity [1-2]. However, the true incidence of Little Leaguer’s shoulder is not known and has not been estimated so far [1-2]. Biomechanically the repetitive, excessive tractional and rotational forces across the open proximal humeral physis are thought to be the causative factors to this physeal stress fracture [1-3]. This injury was formerly known as proximal humeral epiphysiolysis, which is a misnomer since it is an overuse or stress injury of the proximal humeral growth plate and the adjacent metaphysis rather than an epiphyseal injury [1-3]. The typical clinical presentation is a patient (usually a male throwing athlete) between the ages of 13 and 16 years with complaint of gradual shoulder pain localised in the proximal humerus [1-3]. The pain is reported to be elicited and worsened during the overhead sports activity. Physical examination may show tenderness on palpation over the proximal humerus and may also reveal weakness in external rotation [1-3]. The diagnosis of Little Leaguer’s shoulder can be made on clinical grounds alone and imaging is rarely needed [1-4]. Nevertheless, when clinical history and physical examination are inconclusive musculoskeletal imaging can be a valuable tool for the referring orthopaedic or sports specialist [2-4]. The diagnostic radiographic signs have recently been published and include physeal widening and lateral fragmentation or calcification, sclerosis, demineralisation and cystic change of the physis and the adjacent humeral metaphysis [2-4]. The characteristic MRI findings are physeal widening with bone marrow oedema along the physeal line [2-5]. Mild periosteal oedema and small subchondral cysts adjacent to the physis have also been described as additional MR features [2-5]. In our case, the patient’s non compliance with the initial therapy resulted in a metaphyseal stress fracture and, to the best of our knowledge, this is the first report of such a complication in Little Leaguer’s shoulder. Regarding treatment, conservative measures of rest and physical therapy are sufficient in Little Leaguer’s shoulder [1-5]. It is of paramount importance that the athlete should be removed from the inciting sports activity until pain-free and then reintroduced gradually. In conclusion, close collaboration between the radiologist, sports physician, orthopaedic surgeon, physical therapist and the patient is mandatory for the correct management of this stress related shoulder injury.
Little Leaguer’s shoulder
Based on the provided images (including MRI and X-ray), the main observed features are as follows:
1. Near the proximal humeral physis (shoulder joint region), there is widening of the growth plate and uneven local signal, suggesting stress injury or inflammatory changes in the physis region.
2. On MRI sequences, bone marrow edema signals (high signal) close to the physis line can be observed, accompanied by mild edema in the outer cortical margin and soft tissues near the physis.
3. Some images show small subfracture lines or band-like low-signal changes, indicating a mild stress response or microfractures of the cortical bone or adjacent region.
4. On X-ray, the local physis appears irregularly widened with focal fragment-like or sclerotic bands, further supporting stress changes of the physis caused by repeated traction or torsional forces.
Based on the above imaging findings and the patient's background (13 years old, butterfly swimmer, progressive shoulder pain), the following diagnoses are considered:
1. Little Leaguer’s Shoulder (stress injury to the proximal humeral physis):
· Commonly seen in adolescent athletes who repeatedly perform overhead throwing or swimming movements.
· Imaging often demonstrates physeal widening, bone marrow edema, and possibly fragment-like changes.
2. Rotator cuff tendinitis or subacromial impingement syndrome:
· Common in athletes with excessive shoulder use, but more frequent in relatively older individuals or those with tendon degeneration; pure tendon pathology is less common in adolescents with open growth plates.
3. Glenoid labrum lesions:
· High-intensity upper limb movements may cause labral tears, presenting on MRI with abnormal signals in the glenoid or labrum region.
· The location of this case’s injury (physis) does not fully match a typical labral lesion.
Considering the patient’s age, symptoms (5 weeks of right shoulder pain, worsening during training), lack of significant trauma history, and imaging findings indicating stress changes at the proximal humeral physis, the most consistent diagnosis is:
Little Leaguer’s Shoulder (overuse injury of the proximal humeral physis in adolescents).
Treatment Strategy:
1. Conservative Therapy: The primary measure is to discontinue or reduce activities that provoke symptoms (e.g., butterfly stroke or other overhead movements) to allow adequate rest for the physis.
2. Medication: During the acute phase, a short course of non-steroidal anti-inflammatory drugs (NSAIDs) can be considered to relieve pain and local inflammation.
3. Physical Therapy: This includes isotonic, isometric, and isokinetic exercises targeting the shoulder muscles, emphasizing the rotator cuff and scapular stabilizers to build strength and endurance. Local physical modalities (e.g., cold therapy, ultrasound, or shortwave therapy) can help reduce pain and promote recovery.
4. Surgical Treatment: Usually not required unless there is severe physeal damage or significant fracture displacement.
Rehabilitation and Exercise Prescription (FITT-VP Principle):
1. Frequency: Perform shoulder-specific rehabilitation 3–4 times a week, gradually increasing to 4–5 times a week once pain is completely resolved.
2. Intensity: Start with low-intensity active motions and light resistance band exercises, ensuring no significant pain. Progress to moderate or higher resistance training in the mid and late stages, staying within tolerance.
3. Time: 20–30 minutes per session; adjust as needed based on pain and tolerance.
4. Type: Focus on stabilizing and improving range of motion around the shoulder joint, including external/internal rotation and scapular stabilizer exercises (e.g., wall slides, low-load resistance band abduction/adduction).
5. Volume: Each exercise can be performed for 2–3 sets of 10–15 repetitions. If pain increases, reduce the number of repetitions or sets, and extend rest periods.
6. Progression: As pain subsides and shoulder function improves, gradually increase difficulty and intensity, such as introducing higher resistance bands or water-based resistance exercises. Only when there is no pain response following activity should a gradual return to butterfly stroke or other sport-specific training be considered.
This report is for reference only and does not substitute an in-person consultation or professional medical opinion. Patients should undergo diagnosis and rehabilitation under the guidance of qualified physicians and therapists based on their individual conditions. If symptoms worsen or do not improve, seek prompt medical consultation for further evaluation and treatment.
Little Leaguer’s shoulder
