Background and Etiology
A fracture is defined as a partial or complete crack in a bone. Fractures can be minor with little or no displacement of the bone, or more severe with complete displacement of the two ends of the bone that requires surgery to realign. There are closed fractures that do not break the skin, and open fractures that do break the skin.
Shoulder Fracture Causes
Fractures of the shoulder are usually caused by direct trauma or a fall on outstretched hand (FOOSH). In the event a person suspects a shoulder fracture, radiographic study (X-Ray) of the shoulder is essential.
The shoulder is comprised of three bones: the humerus, scapula (shoulder blade) and clavicle (collar bone). These bones form three joints: the glenohumeral joint, sternoclavicular joint, and acromioclavicular joint. Fractures in the shoulder area can involve any of the bones that form the shoulder, including the proximal shoulder at the growth plate. This type of fracture, called Little Leaguer’s Shoulder, is typically caused by over the head throwing motions.
Little Leaguer’s Shoulder
This type of fracture is an injury to the proximal growth plate of the shoulder. The growth plate is an area of the bone that actively grows as a young person matures. If this area is injured, and not treated properly, it can disrupt normal bone growth. Due to the fact that this injury affects the growth plate, radiographic studies may take up to 4-6 weeks to show evidence of widening in the epiphyseal plate.
This injury is and over use injury occurs during the “follow through” (throwing) phase and “cocking” (maximum external rotation) phase of throwing a ball and other over head sport activities including volleyball or tennis. The pathology for this injury includes a fatigue fracture from repetitive use.
Symptoms of Little Leaguer’s Shoulder will vary depending on the severity of the fracture, but they may include some or all of the following:
- Moderate to severe or tenderness of the upper shoulder.
- Decreased ability to throw or perform over head activities.
- Loss of control or velocity with throwing.
- Redness, discoloration or bruising over the fractured area
- Stiffness
- Acute shoulder pain when attempting to throw a ball.
Treatment for Little Leaguer’s Shoulder may require resting the bone for 3-to-12 months to reossify (harden) and remodel following a growth plate fracture. Patients cannot return to sport until this injury is completely healed. Physical Therapy may be indicated to restore full strength motion and stability to the shoulder before returning to sport.
Can help improve: range of motion, strength, coordination, proprioception and endurance. Formal therapy and compliance with an extensive home program is the mainstay to restoring function of the shoulder.
Goals for physical therapy post fracture immobilization are optimal loading and restoration of normal tissue relationships to improve motion, strength and ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the shoulder, rotator cuff and scapula muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the upper extremity, improve proximal joint stability and improve movement technique and mechanics (for example: throwing) in use of the involved upper extremity in daily activities especially overhead activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the shoulder joint and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Most fractures can be diagnosed with X-Ray studies and when necessary a CAT scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or those that affect the integrity of the shoulder joint.
Prognosis
Rate of recovery and the prognosis from Little Leaguer’s Shoulder will depend on a number of factors:
- Severity – Minor fractures will heal and do well in 3 months with rest immobilization and physical therapy. More severe injuries may take longer to heal and recover. Patients may have residual motion and strength deficits, especially if the rotator cuff is involved.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.
Prevention
- Discourage athlete from pitching at home during and after the season
- Restrict or eliminate the throwing of curveballs, sliders, and other breaking balls
- Shorten playing season
- Restrict pitchers to two innings per game until growth plate is closed
- Control game and weekly pitch counts to prevent over use
- Provide three to four rest days between pitching
- Allow for proper conditioning and warm-up
- Instruct throwing athlete in proper throwing mechanics
- Educate coaches and parents of the risk and prevention of this injury
