It’s springtime in New England. The flowers are blooming, the birds are chirping, and Little League baseball and softball players have started presenting to the clinic with achy shoulders and elbows. May and June are prime months for Little Leaguer’s Shoulder and Elbow. After a long winter, the young bones, muscles and joints of our sons and daughters begin to become angry and painful due to the repetitive stress of throwing a ball during practice and games. Despite all of the recent literature that condones pitch counts, appropriate rest periods, position changes and pre-season conditioning, these issues continue to affect young pre-teens and adolescents as they begin to take the field for a fresh season.

Typically, young athletes between the ages of 10-16 will present to Physical Therapy after a recent history of shoulder or elbow pain, decrease in velocity of the upper extremity and an inability to throw at maximum effort. In the case of Little Leaguer’s elbow, patients will describe pain with throwing at the medial elbow joint over the proximal attachment of the wrist flexor muscles and/or the Ulnar Collateral Ligament. Little Leaguer’s Shoulder presents as superolateral shoulder pain exacerbated by overhead throwing motions. These conditions may happen concurrently or independent of each other but the root causes of these dysfunctions are closely related. Both diagnoses stem from poor biomechanics as a result of muscle weakness, shoulder hypo- or hypermobility, decreased core and lower extremity strength and pathological movement patterns compounded by the forces acting on these joints within the throwing mechanism. One of the first things that the Physical Therapist should check is if the patient has had any radiological studies performed relative to the pain. Most patients will be referred from a PCP or orthopedic physician with those studies in hand but some patients may be seeing the PT as the first healthcare provider. Injuries to the growth plates (epiphysis) of the proximal and distal humerus must be determined prior to beginning any rehabilitation program. In some cases, the injuries to these growth plates will necessitate a period of rest or immobilization to allow the epiphysis to heal prior to a structured rehabilitation protocol.

Once the rehab has started for these conditions it is crucial that the patient meet phased benchmarks before progressing back to sport. In the acute phases of these conditions, the therapist will not stress the involved tissues and will focus more on restoring pain free range of motion, proper scapular motion and stability, and lower extremity and core strengthening. Additionally, evaluation of the trunk and lower extremities is crucial in order to identify biomechanical faults that may be causing stresses to the upper extremity during the act of throwing. It is not uncommon to determine that decreased motion in the hips or inadequate stabilization of the trunk is the root cause of elbow or shoulder dysfunction. These “faults” must be addressed as part of the comprehensive plan of care to ensure regression of symptoms does not occur once the patient returns to activity.

The active rehabilitation phase consists of traditional physical therapy focusing on rotator cuff and scapular strengthening, shoulder range of motion, and, again, core/lower extremity conditioning. Of note, a large segment of young patients will have some degree of decreased internal rotation of their throwing shoulders that may need to be resolved prior to returning to throwing. This is the most overlooked sequelae of medial elbow or shoulder dysfunction but this is also where things get a little weird (and cool, if you ask me.) Sports med physicians and physical therapists are familiar with the concept of “GIRD” or Glenohumeral Internal Rotation Deficit. This is just a fancy way of saying that the internal rotation of the overhead athlete’s shoulder is not what it should be. However, it can be over diagnosed in throwing athletes because we’re not looking at the big picture. Decreased internal rotation of the shoulder in throwing athletes, for many years, was attributed to a tight posterior capsule (joint covering) of the throwing shoulder. Therapists would spend many painful sessions with patients mobilizing and stretching the posterior capsule to “free it up” to attain range of motion goals. Unfortunately, all that stretching and mobilization did not always resolve the biomechanical issues and the pain with throwing (and the GIRD!) was not resolved.

What we discovered was that GIRD was not always the root cause of shoulder dysfunction and that throwing athletes actually develop adaptations in their throwing shoulders to account for the mechanism and forces required to throw. WHAT?? Yep. Research showed that after studying a whole bunch of baseball players’ X-rays and traditional “normal” range of motion values that something really cool happens to the humerus: A true bony adaptation occurs as the overhead athlete continues to participate in throwing over his or her adolescence into adulthood. In other words, the upper arm bone develops a “torsion” allowing for more external rotation of the shoulder (necessary for throwing) with only the appearance of decreased internal rotation. In fact, most overhead athletes have the same available range of motion as their non-throwing counterparts but the range is “shifted” as the bony adaptation to throwing created humeral torsion. A better way to appreciate this is if the range of motion of external/internal rotation for a given non-throwing athlete is 90 degrees ER and 90 degrees IR for a total of 180 degrees of motion, that individual would have a “normal” range. Alternatively, if a throwing athlete presents with an internal ROM of 45 degrees we might surmise GIRD exists as a root cause of dysfunction. However, when we take the patient into external rotation and see 135 degrees of motion, this overhead athlete ALSO has 180 degrees of total motion. This is the physical manifestation of the torsion adaptation that we see in these overhead athletes and it’s wicked cool. Armed with this concept, physical therapists can identify true GIRD patients versus humeral torsion and expected anatomical and biomechanical values relative to pathology.

So why do we need to know this? Well, because those same “torsional forces” that lead to adaptations of the humerus in throwing athletes are the same that act upon our young Little Leaguers and cause shoulder and elbow pain. And while those forces acting over a long period of time (years) allow the torsional adaptation to occur, too much force over too little time periods can overstress the shoulder and elbow structures of these young athletes leading to painful conditions and time away from the game. Research has shown that pitch counts, rest, and position changes have addressed these conditions but they still occur because every athlete is different. I’ll say that again…every athlete is different. Average pitch counts or rest days may be appropriate for many athletes under the bell curve but, unfortunately, there are some athletes that need more rest, less pitches, or more overall conditioning to be able to demonstrate normal (read: pain free) movement patterns. In fact, after the active rehabilitation phase moves into the return to throwing phase, we need to evaluate the throwing mechanics of the athlete to determine if a dysfunctional movement pattern exists AND how it may be resolved prior to the return to sports phase.

In conclusion, it is important to rule out epiphyseal injuries prior to beginning any rehab protocol for both Little Leaguer’s Elbow and Shoulder. Once formal therapy begins, your therapist should focus on the athlete as a whole with the goal of returning the athlete to pain free sport and functional movement patterns that prevent further injury. Patient education is also crucial when addressing these conditions. The ability to explain the method of injury and prognosis to both the patient and the parents goes a long way to soften the blow of not being able to compete secondary to injury. Therapists, parents and coaches need to be on the same page with respect to the treatment plan especially if the plan involves an extended break from the game. Returning to sport too quickly has the potential for further structural damage that may require surgery. I’ve rehabilitated my share of 12-year-old baseball players post ulnar collateral ligament repair and they all have a similar story of ignoring symptoms or returning to the field too soon and against medical advice. Therapists should be able to communicate effectively with parents and coaches regarding limitations and goals for the injured athletes. Additionally, involving the other members of the health care team such as pediatricians or PCPs to back up your treatment plan may be in the best interest of the athlete to facilitate a safe return to sport and a healthy injury-free future on the field.