What is the appropriate evaluation and management for shoulder pain in an adolescent male?

Shoulder Pain in an Adolescent Male

In a teenage boy with shoulder pain, the most critical first step is to determine whether this is an overuse injury—particularly Little League shoulder (proximal humeral epiphysiolysis)—or an acute traumatic injury, as the management pathways differ substantially and missing physeal injury can lead to long-term complications. 1

Initial Clinical Assessment

Key Historical Elements to Obtain

• Document the exact mechanism: Is this related to repetitive throwing/overhead sports (baseball, swimming, volleyball) or a specific traumatic event (fall, collision, direct blow)? 1

• Timing and evolution: Acute onset (<2 weeks) versus insidious, progressively worsening pain over weeks to months suggests overuse pathology. 2

• Activity-specific pain patterns:

  • Pain during the throwing motion, decreased velocity, or inability to locate pitches strongly suggests Little League shoulder or rotator cuff dysfunction 1
  • Pain during specific phases of throwing (arm cocking, acceleration, deceleration) helps localize the pathology 1

• Age-specific considerations: Little League shoulder typically occurs between ages 11-16 years, coinciding with peak growth velocity and physeal vulnerability. 1

Physical Examination Priorities

• Proximal humeral tenderness: Point tenderness over the proximal humerus and lateral aspect is the hallmark finding of Little League shoulder—this is the single most important physical finding in adolescent throwing athletes. 1

• Assess for instability: In adolescents, glenohumeral instability is a primary underlying cause of shoulder pain, unlike adults where rotator cuff disease predominates. 3, 4

• Rotator cuff assessment: Focal weakness with decreased range of motion during abduction with external or internal rotation suggests rotator cuff dysfunction, which occurs differently in adolescents (undersurface tears from eccentric stress) than adults (primary impingement). 1

• Scapular dyskinesis: Poor scapular coordination contributes significantly to rotator cuff injury and should be assessed, as it may be both cause and effect. 1

Imaging Strategy

Mandatory Initial Imaging

Plain radiographs are the required first imaging study, with specific views essential for adolescents: AP views in internal and external rotation PLUS axillary or scapular-Y view bilaterally (comparing throwing arm to non-throwing arm). 1, 2

• Critical finding in Little League shoulder: Radiographic widening of the proximal humeral physis on the throwing arm compared to the contralateral side is diagnostic. 1

• Do not skip comparison views: The diagnosis of physeal widening requires side-to-side comparison—single-arm imaging is inadequate. 1

Advanced Imaging Indications

• MRI is NOT needed initially if clinical examination and plain films are diagnostic for Little League shoulder. 1

• Consider MRI without contrast if:

  • Radiographs are normal but high clinical suspicion for rotator cuff pathology, labral tear, or occult fracture persists 2
  • Symptoms fail to improve after 6-8 weeks of appropriate conservative management 2
  • Instability is suspected (though in adolescents <35 years, MR arthrography is superior for labral pathology) 2

Management Algorithm

For Little League Shoulder (Proximal Humeral Epiphysiolysis)

Complete cessation of throwing for a minimum of 6 weeks after diagnosis, followed by an additional 6 weeks of no throwing during the strengthening phase, for a total of at least 3 months rest from throwing. 1

• This is non-negotiable: Continued throwing with physeal injury can lead to permanent growth disturbance and deformity. 1

• Rehabilitation protocol:

  • Implement proper pitching mechanics education 1
  • Preseason strengthening emphasizing rotator cuff, periscapular muscles, and core musculature 1
  • Flexibility work for the capsule 1

• Return to throwing: Only after completing a functional, progressive, individualized throwing program over 1-3 months without symptoms. 1

For Rotator Cuff Dysfunction/Secondary Impingement

Complete rest from aggravating activities until asymptomatic, followed by a structured rehabilitation program focusing on rotator cuff and scapular stabilizer strengthening. 1

• Key distinction from adults: Adolescent rotator cuff injuries result from undersurface tears due to repetitive eccentric stress, NOT primary impingement. 1

• Secondary impingement mechanism: Weakness in rotator cuff muscles combined with ligamentous laxity prevents the humeral head from staying centered in the glenoid during motion. 1

• Rehabilitation components:

  • Rotator cuff and scapular stabilizer strengthening once pain-free motion achieved 1
  • Re-establish proper mechanics of shoulder and spine 1
  • Restore full range of motion 1
  • Avoid overhead pulleys, which encourage uncontrolled abduction and worsen rotator cuff pathology 2

• Timeline: 1-3 months depending on severity before return to competition. 1

For Glenohumeral Instability

• Initial treatment is conservative with a minimum of 6 months of well-conducted rehabilitation before considering surgery. 5

• Surgical stabilization is reserved for symptomatic forms unresponsive to conservative treatment that impact daily life or sports participation. 5

• Critical caveat: Adolescent glenohumeral dislocations have a very high recurrence rate—this must be discussed when formulating the treatment plan. 6

Prevention Strategies

Pitch Count and Rest Restrictions

Strict adherence to age-appropriate pitch count limits is essential for injury prevention:

• Ages 13-14: Maximum 75 pitches per game, 125 per week, 1000 per season 1

• Ages 11-12: Maximum 75 pitches per game, 100 per week, 1000 per season 1

• Ages 9-10: Maximum 50 pitches per game, 75 per week, 1000 per season 1

• Mandatory rest periods based on pitch count: 66+ pitches requires 4 days rest; 51-65 pitches requires 3 days rest 1

Critical Pitfalls to Avoid

• Do not assume absence of trauma means absence of fracture: Physeal injuries can occur with minimal recognized trauma in adolescents. 2, 7

• Do not treat adolescent shoulder pain like adult rotator cuff disease: The pathophysiology, injury patterns, and treatment priorities differ substantially. 1, 3

• Do not allow return to throwing before complete healing: Continued physeal widening has been documented even after symptom resolution, indicating ongoing injury. 1

• Do not miss posterior sternoclavicular dislocations: These require differentiation from medial clavicular physeal injuries and prompt reduction, as they can be life-threatening. 6

Red Flags Requiring Urgent Evaluation

• Neurological deficits in the upper extremity mandate urgent specialist referral 2, 7

• Unstable or significantly displaced fractures on imaging require orthopedic consultation 1, 2

• Suspected posterior sternoclavicular dislocation requires immediate evaluation due to potential mediastinal structure compression 6

• Systemic symptoms (fever, chills, constitutional symptoms) raise concern for septic arthritis and require immediate workup 2, 8