Shoulder Injuries in Children and Adolescents

The human shoulder complex comprises four joints; three bones; and many ligaments (tissues connecting two bones), tendons (tissues connecting muscle to bone), and muscles.

Both acute (sudden, traumatic) and chronic (long-term) injuries are common in this area. Children are prone to shoulder injuries because of their frequent involvement in sporting activities, their immature bones and joints, and the high demands that sport participation places on the shoulder. Early recognition and treatment of these problems can lead to more successful treatment and earlier return to sport participation.

Acute injuries
Acute injuries include fractures, dislocations of joints, and damage to ligaments, tendons, and muscles. Fractures of the shoulder in children and adolescents usually involve the clavicle (collar bone) or the humerus (upper arm bone). The clavicle is the most frequently fractured bone in the shoulder. Because it is located just under the skin, it is not well protected by fat and other tissue; therefore, it is especially prone to injury. The injury commonly occurs when a child falls on the outstretched arm or receives a direct blow to the clavicle. The doctor takes an x-ray to verify the presence of a fracture and to see the extent of the damage. Nearly all clavicle fractures can be treated with a sling or brace, and the child usually can return to sport participation within four to eight weeks.

Fractures of the upper humerus are also relatively common injuries in children, especially in adolescents. Like clavicle fractures, they may be caused by a fall or by a direct blow to the shoulder. The growth plate (soft area at the end of an immature bone where growth occurs) may be affected. The doctor takes x-rays to verify that the child has fractured the upper humerus. Most of these fractures are treated without surgery. However, surgery may be necessary if the fractured ends of the bone cannot be aligned for proper healing. (Click here for detail) Recovery usually takes four to eight weeks, at which time the child can return to sport participation.

Shoulder dislocation is extremely rare in young children but occasionally occurs in adolescents, especially due to a fall or to an injury during contact sports. When the shoulder is dislocated, the ball (top of the humerus) of the shoulder usually slips out of socket completely and sits in front of the joint. The adolescent must have an x-ray, and an experienced doctor must put the shoulder back in joint. Dislocation stretches the soft tissues that hold the shoulder in place, making another dislocation more likely. Therefore, to prevent recurrent dislocation, the adolescent needs extensive rehabilitation after the initial injury to strengthen the muscles around the joint. In addition, a sling is worn for a short period.

Sometimes, the joint between the shoulder blade and clavicle (acromioclavicular joint) is dislocated. This injury, commonly known as a separated shoulder, most often affects adolescent athletes who receive a blow to the tip of the shoulder during participation in contact sports. The injury may look like a dip in the contour of the shoulder. Most separated shoulders are treated with a sling. They usually heal completely by four to six weeks. When healing is complete, the child can return to sport participation.

Injuries to the muscles are known as strains. Injuries to the ligaments are known as sprains. These injuries can occur in contact sports or in other activities that place high demands on the shoulder muscles (such as baseball pitching). Early diagnosis and proper treatment are important so that these acute injuries do not turn into chronic problems. To treat a sprain or strain, the doctor directs the injured child to rest, ice the shoulder, and participate in a structured physical therapy program.

Overuse injuries
In many sports, athletes repeat the same motion over and over with the shoulder. This type of repetitive motion can cause injury over time. Baseball, tennis, and swimming are sports with a high incidence of overuse injury of the shoulder. These sports can place very high demands on the immature structures of the shoulder and may eventually result in symptoms that prevent athletes from participating. Athletes may experience pain in the shoulder during throwing or swimming, stiffness in the shoulder, or weakness in the arm. Overuse injuries generally include throwing injuries, shoulder tendinitis (inflammation of the tendons), and chronic shoulder instability.

Throwing injuries are most common in baseball and softball pitchers and in football quarterbacks. They are increasingly common among young athletes participating in year-round baseball. During throwing, the shoulder moves through an extreme range of motion that causes gradual stretching of the capsule and ligaments of the joint. Over time, these structures loosen and cannot hold the joint in place (instability). Instability exists when the ball of the shoulder can slip partially out of the socket. The muscles and tendons around the shoulder must work harder to keep the ball in the socket, which can result in inflammation of these structures. Excessive throwing can also cause inflammation of the growth plate of the upper arm, which is a condition known as epiphysitis. Practicing proper warm-up and throwing techniques and taking adequate time to rest between innings pitched in competition are important ways to minimize the risk of developing overuse injuries. Children and adolescents should pitch no more than six innings in competition each week and must ensure that they warm up properly before these innings. In addition to these innings pitched in competition, they can participate in practice and can pitch for batting practice. If the child develops symptoms of overuse, he or she needs to rest, ice the shoulder, and participate in an aggressive physical therapy program before returning to sport participation.

In sports, such as baseball, tennis, and swimming, athletes use their arms over their heads many times during practice and competition. This repetitive overhead use of the shoulder can lead to rotator cuff tendinitis. The rotator cuff is a group of muscles that surround the shoulder joint and help hold the ball of the shoulder in its socket. With overhead activity, the rotator cuff can get pinched under the shoulder blade, causing impingement or tendinitis. It usually gets better when the athlete rests, ices the shoulder, and participates in physical therapy.

Repetitive shoulder instability may result from a traumatic shoulder dislocation or from chronic stretching of the joint capsule. The latter injury is commonly seen in swimmers, who repeatedly move their shoulders through an extreme range of motion. Instability in this situation may also lead to tendinitis and can severely limit a swimmer's performance. Rest, ice, modification of swimming strokes, and physical therapy can help the athlete return to sport participation.

Children and adolescents who participate in sports are prone to shoulder injury. Parents and coaches should pay attention when a young athlete has significant shoulder pain. The athlete should not be encouraged to "play through" the pain. Prompt recognition of the problem and treatment by a doctor are important to help the athlete heal as quickly as possible. Delaying treatment can lead to long-term damage that prevents the child from participating in sports.

Mike Lauffenburger, MD
Columbus, Georgia

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