Proximal Humeral Epiphysiolysis

Last updated: February 8, 2026Reviewed date: February 8, 2026Reading time: 3 min read
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Article Summary

Proximal humeral epiphysiolysis (Little League shoulder) is a shear or stress injury of the epiphyseal cartilage of the proximal humerus. Little League shoulder has also been referred to as osteochondrosis of the proximal humeral epiphysis and rotation stress fracture of the proximal humeral epiphyseal plate. Little League shoulder is usually caused by overuse or poor throwing technique, and most often occurs in pitchers, catchers, and other athletes...

Key Takeaways

  • This article explains Pathophysiology in simple medical language.
  • This article explains Causes in simple medical language.
  • This article explains Risk Factors in simple medical language.
  • This article explains Differential Diagnosis in simple medical language.
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Proximal humeral epiphysiolysis (Little League shoulder) is a shear or stress injury of the epiphyseal cartilage of the proximal humerus. Little League shoulder has also been referred to as osteochondrosis of the proximal humeral epiphysis and rotation stress fracture of the proximal humeral epiphyseal plate. Little League shoulder is usually caused by overuse or poor throwing technique, and most often occurs in pitchers, catchers, and other athletes who do overhand activities, including volleyball and tennis players. There are three bones that make up a shoulder — the collar bone, the upper arm bone, and the shoulder blade.

Other Names

  • Little League Shoulder
  • Little Leaguer’s Shoulder
  • Proximal Humeral Epiphysiolysis
  • Osteochondrosis of proximal humeral epiphysis
  • Stress fracture of the proximal humeral epiphyseal plate
  • Rotation stress fracture

Pathophysiology

  • General
    • Defined as a shearing or stress injury of the epiphyseal cartilage of the proximal humerus
    • Represents a Salter-Harris 1 Fracture

Causes

  • Occurs as a result of excessive rotational, distraction forces that occur with repetitive overhead throwing
  • Repetitive microtrauma leads to cartilage damage of the proximal humeral epiphysis
  • Epiphyseal plate injury is the weakest point in the kinetic chain
  • Believed to occur during the late cocking phase of throwing
    • At this point, there is significant rotational torque immediately prior to acceleration

Osteology

  • Proximal Humeral Epiphysis
    • Four growth centers: head, shaft, greater tubercle, lesser tubercle
    • Typically fuses between ages 14-20
    • Contributes about 80% of longitudinal growth of humeral shaft

Risk Factors

  • Male > Female
  • Age (11-16, average 14)
  • Overhead/ Throwing Sports
    • Baseball, especially pitching
    • Tennis
    • Volleyball
    • Swimming
  • Pitching specific
    • Poor throwing mechanics
    • High pitch count
    • “Breaking” pitch
  • Playing year-round sports
  • Glenohumeral Internal Rotation Deficit (GIRD)

diagnosis: Differential diagnosis is a list of possible conditions that may explain symptoms. সহজ বাংলা: একই লক্ষণের সম্ভাব্য রোগের তালিকা।" data-rx-term="differential diagnosis" data-rx-definition="Differential diagnosis is a list of possible conditions that may explain symptoms. সহজ বাংলা: একই লক্ষণের সম্ভাব্য রোগের তালিকা।">Differential Diagnosis

  • Fractures
    • Proximal Humerus Fracture
    • Humeral Shaft Fracture
    • Clavicle Fracture
    • Scapula Fracture
    • First Rib Fracture (traumatic or atraumatic)
  • Dislocations & Separations
    • Acromioclavicular Joint Separation
    • Glenohumeral Dislocation (Acute)
    • Sternoclavicular Joint Dislocation
    • Glenohumeral Instability (Chronic)
  • Arthropathies
    • Glenohumeral pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">Arthritis
    • Acromioclavicular Joint pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">Arthritis
  • Muscle & Tendon Injuries
    • Pectoralis Major Injuries
    • Pectoralis Minor Injuries
    • Proximal Biceps Tendon Injuries
    • Scapular Dyskinesis
  • Rotator Cuff
    • Rotator Cuff Tear
    • Rotator Cuff Tendonitis
    • Calcific Tendinitis of the Rotator Cuff
    • Subcoracoid Impingement Syndrome
  • Bursopathies
    • Subacromial Bursitis
    • Scapulothoracic Bursitis
  • Ligament Injuries
    • Glenoid Labral Tears
  • Neuropathies
    • Suprascapular Nerve Injury
    • Parsonage-Turner Syndrome
    • Quadrilateral Space Syndrome
    • Winged Scapula
  • Other
    • Adhesive Capsulitis
    • Paget-Schroetter Syndrome
  • Pediatrics
    • Coracoid Avulsion Fracture
    • Humeral Head Epiphysiolysis (Little League Shoulder)

Diagnosis

  • History
    • Typical age 10 to 16
    • Onset is by definition insidious although an acute trauma or event could occur
    • Pain initially only with significant exertion (i.e. hard-throwing)
    • Eventually progresses to pain at rest or with light exertion (i.e. soft, short throws)
    • May endorse decreased throwing accuracy, velocity
  • Physical: Physical Exam Shoulder
    • The patient will be tender along the humeral epiphysis, especially laterally
    • Can have pain, weakness in external rotation
    • May have Glenohumeral Internal Rotation Deficit
    • Painful range of motion

Radiographs

  • Standard Radiographs Shoulder initially
  • Findings
    • May be normal
    • May show widened physis
    • Less commonly: demineralization, sclerosis, cystic changes, and lateral fragmentation of the prox humeral metaphysis
  • Compare to unaffected shoulder if needed

MRI

  • Rarely required
  • If highly suspicious with uncertain radiographs or clinical exam, can clarify the diagnosis
  • Findings: physical edema

Ultrasound

  • Can be used to help confirm the diagnosis
  • Findings
    • Increased hypoechoic swelling not seen on the contralateral side

Classification

Neer and Horwitz’s classification

  • Displacement[7]
    • Grade I: Less than 5 mm
    • Grade II: Less than one-third of shaft width
    • Grade III: Two-thirds of shaft width
    • Grade IV: More than two-thirds of shaft width

Treatment

Nonoperative

  • Remove from play/ activity modification
    • No throwing or overhead activities for at least 6 weeks, often 8-12 weeks
    • Ok to do general conditioning, lower extremity training
  • Ice
  • Analgesia including NSAIDs, Acetaminophen
  • Consider a Shoulder Sling for comfort
  • Prevention
    • Proper pitching mechanics
    • Educate athletes, parents, coaches
    • Avoid single sport, year-round activity
    • Rigidly follow pitch count guidelines
    • Avoid “breaking” pitch
    • Improve core strength, cardiovascular fitness
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