Growth-plate injuries are among the most commonly reported injuries for youth and teenage athletes—becoming an issue for even 16 and 17 year olds.. Also referred to as Little League Elbow or Little League Shoulder, these injuries occur to an area of the body responsible for roughly 80% of growth to the humerus, the bone running between the elbow and shoulder. As with any injury, the severity of the problem varies with each individual. However, being able to recognize the risk factors associated with growth-plate injuries, as well as the signs and symptoms, plays an important role in reducing the likelihood that these types of injuries will have a major effect on an athlete’s playing career.
First, we must understand what the growth plate is and how it can become injured. The growth plate, also known as the epiphyseal plate or the physis, is an area of cartilage at the end of a bone and is where new bone is made. There are two growth plates in the humerus: one near the shoulder, and one by the elbow. In adults, these areas close and bone no longer grows. In children and teenagers, this area remains open. Because these areas are open zones of soft cartilage, they are actually one of the weakest spots in the upper arm—weaker even than the attaching ligaments and muscles, including the UCL (the ligament needing repair in Tommy John surgeries).
Because throwing puts high amounts of distraction, or pulling, forces on the shoulder and elbow, the growth plates are susceptible to small, microtrauma with each throw. Over time, this trauma can lead to inflammation, adaptive bony changes, such as the widening of the growth plate, or in more extreme cases, fragmentation or avulsion fractures, in which the attaching soft tissues can rip off a small piece of the bone.
Early detection is very important to help reduce the risk of a mild injury becoming more severe, which could remove an athlete from several months of competition. Elbow or shoulder pain is the most obvious indicator that something may be happening at the level of an athlete’s growth plate.
In the shoulder, pain is most commonly present in the front and lateral portion. There may be swelling, tenderness to touch, loss of range of motion that may include pain, as well as weakness, pain, or both with resistance to external rotation of the shoulder.
In the elbow, pain will most likely be present around the medial epicondyle, the bony prominence of the inner elbow. There may also be swelling, tenderness to touch around the medial epicondyle, pain with bending or straightening the elbow, and decreased grip strength with or without pain.
From a performance perspective, an athlete could demonstrate a decrease in throwing velocity, and in some instances may also have decreased accuracy due to a loss of grip strength.
Knowing the risk factors associated with growth-plate injuries is also beneficial for parents and coaches so they can help reduce the risk of occurrence. Among the biggest risk factors is the amount of throwing an athlete does throughout the calendar year. USA Baseball has developed the Pitch Smart program that governs how many pitches a pitcher is allowed to throw and the number of days rest following a pitching outing. Pitch Smart also makes recommendations to reduce the number of throws a pitcher does in a 12-month period, depending on the athlete’s age.
This includes such recommendations as not throwing a baseball for 2-3 months. While Little League and most youth leagues enforce the pitch-count guidelines, there is no enforcement of the amount of throwing an athlete can do throughout the year. With travel teams and tournaments taking advantage of year-round practice, it becomes very easy for these recommendations to be neglected and for young arms to amass a lot of throws throughout the year. In addition to excessive throwing, other risk factors include muscle tightness that can occur with growth spurts, muscle weakness and/or poor body control, poor throwing mechanics, and joint hypermobility—which is another way of saying an athlete is too flexible.
Diagnosing a growth-plate injury can only be done by a medical professional. To fully understand the severity of an injury, imaging will have to be done to see whether there is only inflammation or some other type of widening or fracture of the actual growth plate. Even if there is no fracture or widening present, rest for 4-6 weeks may still be recommended to allow the inflammation to decrease. During this time, the athlete should work with a rehab professional to improve the strength and range of motion in the area, along with other areas of the body, including the scapula, spine, and hips. If left untreated, the injury can progress to a fracture, which in many instances can result in surgery to repair the area. In these cases, the athlete will be splinted for several weeks, will need physical therapy for 4-6 months, and will be unable to throw a baseball for upwards of 6 months.
Injuries to the growth plate are not completely preventable. However, the likelihood of an injury happening can certainly be reduced. The most important guideline to follow is to limit the amount of throwing an athlete does throughout the year. While this does mean adhering to the Pitch Smart guidelines, it also includes avoiding playing other positions that require a high amount of throwing—such as catcher, outfield, or shortstop—if that athlete is pitching regularly. Additionally, athletes should not be throwing year-round. It is widely recommended that youth athletes take at least 4 months off from competitive pitching as well as 2-3 months off from throwing a baseball at all. When athletes are throwing, it is very important they participate in the proper warm-up and recovery protocols to ensure the tissues around the shoulder and elbow are ready to take on the stress of throwing. Finally, if athletes are doing a considerable amount of throwing throughout the year, they should work with a rehab or strength and conditioning professional to address any weaknesses or mobility restrictions that may be present, which could lead to increased stresses on the elbow or shoulder during the throwing motion.
Growth-plate injuries continue to be one of the leading injuries that youth baseball players endure at some point in their playing career. Identifying possible risks, knowing the signs, and making the appropriate modifications are extremely important when it comes to limiting the risk of significant injury. As coaches and parents, a lot of this task relies on us. Following the appropriate recommendations can help keep your young ballplayer on the field throughout the course of a long, hard season.
This article was written by our in-house physical therapist Terry Phillips
Binder, Harald, et al. “Physeal Injuries of the Proximal Humerus: Long-Term Results in Seventy Two Patients.” International Orthopaedics, vol. 35, no. 10, 2011, pp. 1497–1502., doi:10.1007/s00264-011-1277-8.
“Elbow Injuries in Young Throwers.” Nationwide Children’s Hospital, www.nationwidechildrens.org/specialties/sports-medicine/sports-medicine-articles/elbow-injuries-in-young-throwers.
Fleisig, Glenn S., and James R. Andrews. “Prevention of Elbow Injuries in Youth Baseball Pitchers.” Sports Health, SAGE Publications, 4 Sept. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3435945/.
Klingele, Kevin E., and Mininder S. Kocher. “Little League Elbow.” Sports Medicine, vol. 32, no. 15, 2002, pp. 1005–1015., doi:10.2165/00007256-200232150-00004.
Murachovsky, J, et al. “Does the Presence of Proximal Humerus Growth Plate Changes in Young Baseball Pitchers Happen Only in Symptomatic Athletes? An x Ray Evaluation of 21 Young Baseball Pitchers.” British Journal of Sports Medicine, vol. 44, no. 2, 2008, pp. 90–94., doi:10.1136/bjsm.2007.044503.
Pytiak, Andrew V., et al. “Are the Current Little League Pitching Guidelines Adequate? A Single-Season Prospective MRI Study.” Orthopaedic Journal of Sports Medicine, vol. 5, no. 5, 2017, p. 232596711770485., doi:10.1177/2325967117704851.
Thigpen, Chuck, and Ellen Shanley. “Throwing Injuries in the Adolescent Athlete.” International of Sports Physical Therapy, vol. 8, no. 5, Oct. 2013, pp. 630–640.