By Dr. James Gardiner
Sports Medicine Orthopedic Surgeon
March 2026
Every spring, as baseball season ramps up across the country, I start seeing a familiar pattern in my clinic: a young pitcher—usually between 11 and 15 years old—comes in with shoulder pain that gets worse every time he throws. The parents are worried, the coaches are confused, and the kid just wants to get back on the mound. More often than not, what we’re dealing with is a condition called Little League Shoulder, and while the name might sound minor, it’s an injury that deserves serious attention.
In my twenty + years of treating sports injuries, I’ve seen a significant increase in the number of young athletes presenting with this condition. Research confirms this trend—a study from Boston Children’s Hospital found that diagnosed cases of Little League Shoulder have been rising steadily alongside the growth of year-round youth baseball.1 The good news? With proper diagnosis and management, the vast majority of young athletes make a full recovery and return to their sport.
What Is Little League Shoulder?
Little League Shoulder—known in medical terms as proximal humeral epiphysiolysis—is a stress injury to the growth plate at the top of the upper arm bone, near the shoulder.2 Growth plates are areas of developing cartilage near the ends of long bones in children and adolescents. They’re the last parts of the bone to harden, which makes them more vulnerable to injury than the surrounding muscle, ligaments, and tendons.
During the throwing motion, especially in the late cocking and acceleration phases, enormous rotational forces are generated through the shoulder. Biomechanical studies have shown that these torsional stresses are concentrated right at the growth plate.3 When a young athlete throws repeatedly without adequate rest, this microtrauma accumulates and eventually irritates or partially separates the growth plate—similar to a stress fracture, but in growing cartilage rather than bone.
While this condition is most commonly seen in baseball pitchers, I’ve also diagnosed it in catchers, tennis players, swimmers, and volleyball players—essentially any young athlete who performs repetitive overhead motions.1,2
Who Is at Risk?
The typical patient I see with Little League Shoulder is a male baseball pitcher between the ages of 11 and 16, with peak occurrence around age 13.1,4 However, this condition can occur in any skeletally immature athlete up until the growth plate closes, which typically happens between ages 14 and 18.2
Several factors increase the risk. What I tell my patients and their families is to watch for these patterns:
Playing year-round without adequate rest periods is one of the biggest risk factors I see in my practice. Research shows that roughly 80% of athletes diagnosed with this condition were playing baseball nine or more months per year.5 Exceeding recommended pitch counts, pitching on consecutive days without rest, and pitching for multiple teams simultaneously all increase the repetitive stress on the growth plate. A recent growth spurt can also change the forces across the shoulder, which is why we often see this condition around ages 12 to 14.
How Is It Diagnosed?
When a young pitcher comes into my office with throwing-related shoulder pain, Little League Shoulder is always on my radar. The classic presentation is a gradual onset of pain in the upper arm or shoulder that worsens with throwing and improves with rest.4
On physical examination, I typically find tenderness over the outside of the upper arm near the shoulder. Many patients also show decreased range of motion or shoulder weakness. About 30% of patients in published studies demonstrated a loss of internal rotation in the throwing shoulder, a finding we call glenohumeral internal rotation deficit (GIRD)—and this is something I pay close attention to because it can affect recovery.1
The diagnosis is confirmed with X-rays. The hallmark finding is a widening of the growth plate on the throwing arm compared to the opposite side.2,4 I routinely order views of both shoulders for comparison. In some cases, we may also use MRI to get a more detailed picture, particularly if we want to rule out other injuries.
How Is It Treated?
Here’s where I can offer some real reassurance to families: surgery is almost never needed for Little League Shoulder. In my experience, this condition responds very well to conservative treatment.2,4
The cornerstone of treatment is rest from throwing. I generally recommend complete cessation of throwing for a minimum of three months, and sometimes longer depending on the severity. During this time, the athlete can still stay active—running, conditioning, and fielding are usually fine as long as they don’t involve overhead throwing.
Physical therapy is an important part of the recovery process. I refer about 80% of my Little League Shoulder patients to a physical therapist to work on flexibility and strength.1 The focus of therapy includes restoring full range of motion, strengthening the rotator cuff and scapular stabilizers, addressing core and lower extremity strength (which play a huge role in proper throwing mechanics), and correcting any glenohumeral internal rotation deficit.
Research shows that the average time to complete resolution of symptoms is about 2.6 months, with return to competition averaging around 4.2 months.1 I always use a graduated return-to-throwing program before clearing an athlete to compete—we start with light tosses at short distances and slowly build up intensity over several weeks.
What About Long-Term Outcomes?
The vast majority of young athletes with Little League Shoulder recover fully. A recent systematic review found that most patients returned to their preinjury level of participation after appropriate rest and rehabilitation.4
However, I do counsel families that there is a recurrence rate of roughly 7% to 25%, typically occurring within several months of returning to play.1,4,6 Athletes with GIRD appear to have a significantly higher risk of recurrence, which is why I emphasize addressing range-of-motion deficits during rehabilitation.6 A recent long-term follow-up study found that five years after diagnosis, about 40% of athletes had changed positions, and recurrence within the first year was associated with lower long-term outcomes.5
Some research has also identified potential long-term structural changes in the throwing arm, including increased humeral retroversion, which may affect future injury risk.7 This reinforces why proper treatment and prevention are so important.
Prevention: Protecting Your Young Athlete
In my practice, I spend a lot of time talking about prevention because Little League Shoulder is, at its core, an overuse injury. Here is what I recommend to every family with a young throwing athlete:
Follow pitch count guidelines. Major League Baseball’s Pitch Smart program provides age-specific recommendations. For example, 11- to 12-year-olds should throw no more than 85 pitches per game day, with mandatory rest days based on pitch count.
Take time off. I recommend at least two to three months per year completely off from overhead throwing. Playing baseball twelve months a year is one of the clearest risk factors I see.
Don’t pitch through pain. If your child complains of shoulder or arm pain during or after throwing, stop. Pain is the body’s warning signal, and ignoring it can turn a minor irritation into a significant growth plate injury.
Invest in proper mechanics. Work with qualified pitching coaches who understand the biomechanics of the developing arm. Good mechanics distribute forces more efficiently and reduce stress on the growth plate.
Prioritize overall conditioning. A strong core, flexible hips, and stable scapula take load off the shoulder. Many of the young athletes I treat have deficits in their lower body and trunk that contribute to shoulder overload.
When to See a Specialist
If your young athlete is experiencing persistent shoulder pain with throwing—especially if it’s been present for more than a week or two and isn’t improving with rest—I recommend scheduling an evaluation with a sports medicine orthopedic surgeon who has experience treating adolescent athletes. Early diagnosis means faster recovery and a better long-term outcome.
The most important thing I want parents to remember is that growth plates don’t last forever. Once they close in late adolescence, this particular injury is no longer a concern. But while those growth plates are open, we have a responsibility to protect them. Your child’s long-term athletic career is more important than any single season.
If you’re concerned about your child’s throwing shoulder, schedule a consultation with the sports medicine team at Maryland Orthopedic Specialists. Early evaluation and a personalized treatment plan can help your young athlete get back to the sport they love—safely.
References
- Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016;44(6):1431-1438. doi:10.1177/0363546516632744
- Casadei K, Kiel J. Proximal Humeral Epiphysiolysis. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2023. PMID: 30485006.
- 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;33(11):1716-1722. doi:10.1177/0363546505275347
- Bednar ED, Kay J, Memon M, Simunovic N, Purcell L, Ayeni OR. Diagnosis and Management of Little League Shoulder: A Systematic Review. Orthop J Sports Med. 2021;9(7):23259671211017563. doi:10.1177/23259671211017563
- Puzzitiello RN, Bram JT, Gausden EB, Ganley TJ, Lawrence JTR. What Happens to Youth Baseball Players Diagnosed With Little League Shoulder and Little League Elbow Syndrome? Am J Sports Med. 2024;52(11):2871-2878. doi:10.1007/s12178-024-09877-1
- Harada M, Takahara M, Maruyama M, et al. Outcome of Conservative Treatment for Little League Shoulder in Young Baseball Players: Factors Related to Incomplete Return to Baseball and Recurrence of Pain. J Shoulder Elbow Surg. 2018;27(1):1-9. doi:10.1016/j.jse.2017.08.018
- Ito A, Mihata T, Hosokawa Y, Hasegawa A, Neo M, Doi M. Humeral Retroversion and Injury Risk After Proximal Humeral Epiphysiolysis (Little Leaguer’s Shoulder). Am J Sports Med. 2019;47(13):3100-3106. doi:10.1177/0363546519876060
Disclaimer: This blog post is intended for patient education purposes only and does not constitute medical advice. Every patient’s condition is unique. Please consult with a qualified orthopedic surgeon for evaluation and treatment recommendations specific to your situation.
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