What is the recommended approach for a shoulder exam in an 11-year-old?

Shoulder Examination in an 11-Year-Old

For an 11-year-old, the shoulder examination should focus on identifying proximal humeral epiphysiolysis (Little League shoulder) and rotator cuff dysfunction, with particular attention to palpating the proximal humerus and lateral aspect for tenderness, assessing range of motion, and evaluating scapular mechanics. 1, 2

Age-Specific Considerations for the 11-Year-Old

At age 11, the child is at peak risk for proximal humeral epiphysiolysis (Little League shoulder), which typically occurs between ages 11 to early teenage years due to open growth plates and repetitive stress. 1 This population also has anatomic vulnerabilities including:

• Atraumatic microinstability of the glenohumeral joint 1
• Weak rotator cuff muscles predisposing to secondary impingement 1
• Open proximal humeral physis susceptible to torsional overload 1

Systematic Examination Approach

Positioning and Initial Assessment

• Position the patient sitting with 90° elbow flexion and hand supinated on top of the thigh for static examination 2
• Observe for visible asymmetry, swelling, or muscle atrophy (though these are uncommon in Little League shoulder) 1
• Assess scapular position and movement for winging or dyskinesia, which may contribute to rotator cuff injury 2

Palpation (Critical in This Age Group)

• Palpate the proximal humerus and lateral aspect of the proximal humerus for point tenderness - this is the hallmark finding in Little League shoulder, present in most cases 1
• Examine the acromioclavicular joint, sternoclavicular joint, and bicipital groove 2
• Identify areas of swelling, warmth, or crepitus 2

Range of Motion Assessment

• Evaluate both active and passive range of motion through full shoulder motion including:
  • Forward flexion (0-180°) 2
  • External rotation (0-90°) 2
  • Internal rotation (ability to reach up the back) 2
• Have the patient perform active and passive external and internal rotation with 90° flexed elbow to assess dynamic function 2
• Note that loss of motion, weakness, and atrophy are uncommon in proximal humeral epiphysiolysis 1

Strength Testing

• Test rotator cuff muscles individually:
  • Supraspinatus (empty can test/Jobe's test) 2
  • Infraspinatus and teres minor (external rotation strength) 2
  • Subscapularis (lift-off test, belly press test) 2
  • Deltoid (resisted abduction) 2
• Assess shoulder motion, flexibility, strength, and other components of the kinetic chain for athletes and throwers 2

Red Flags Specific to This Age Group

• Progressive worsening upper arm pain with throwing - classic presentation of Little League shoulder 1
• Decreased throwing velocity or decreased ability to locate pitches 1
• Upper extremity joint pain during throwing activity 1
• History of pitching more than 100 innings per year (3.5 times increased injury risk) 1
• Throwing sliders or curveballs (increases shoulder loads on open growth plates) 1

Imaging Considerations

• If proximal humeral tenderness is present, obtain internal and external rotation comparison anteroposterior radiographs of both shoulders to assess for widening of the proximal humeral physis 1
• Standard radiographs should be the initial imaging study, including anteroposterior views in internal and external rotation, plus axillary or scapula-Y view 2
• All 23 patients in one case series demonstrated radiographic widening of the proximal humeral physis on comparison views 1

Common Pitfalls to Avoid

• Do not dismiss normal-appearing range of motion - swelling, weakness, atrophy, and loss of motion are uncommon findings in Little League shoulder despite significant pathology 1
• Do not overlook the kinetic chain - evaluate scapular mechanics, core strength, and lower extremity function as these contribute to throwing mechanics 1, 2
• Do not obtain single-shoulder radiographs - comparison views are essential to identify subtle physeal widening 1
• Be aware that physeal widening may continue even after symptoms resolve, indicating this is similar to a stress fracture or Salter-Harris type I injury 1