Physical Therapy Guide to Little League Shoulder (Proximal Humeral Epiphysitis)
Little League shoulder is an overuse injury in young throwing athletes. It affects the growth plate at the top of the upper arm bone, just below the shoulder. Growth plates are areas of developing bone in children and teens. These areas allow the bones to grow and lengthen during childhood and adolescence. Growth plates are not as strong as fully developed bone. Repeated throwing or overhead activities can place stress on this area, leading to irritation and pain. The condition is most common in youth baseball pitchers. It can also occur in other youth athletes who perform repeated overhead activities, such as tennis players, volleyball players, and swimmers. Increased throwing volume, year-round play, and not getting enough rest between overhead activities can increase the risk of injury.
Shoulder pain is common in young throwing athletes. Early care is important to prevent symptoms from getting worse. Physical therapists work with orthopedists or sports medicine doctors to evaluate and treat Little League shoulder. They assess strength, movement patterns, and throwing mechanics to identify factors that may stress the shoulder. They design individualized programs to reduce pain, restore strength, and guide a safe return to sport.
Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist near you, visit Find a PT.
What Is Little League Shoulder?
Little league shoulder is primarily seen in maturing children with open growth plates. Growth plates are typically found in the long bones of the body. The condition results from repeated stress to the shoulder region. Normally the body responds to pulling and stretching forces by healing any stressed tissue during times of rest in between periods of activity. Young athletes who specialize in a single sport, or who throw or pitch often without proper rest, may develop this condition.
Also, because throwing is a total body movement, lack of muscle strength or poor mechanics can lead to increased stress through the growth plate of the shoulder. This increases an athlete’s risk of injury. This condition is most common in young baseball pitchers. But any young person who throws or uses a racquet repeatedly could be at risk for this injury.
It is very important that the young athlete get the appropriate amount of rest between periods of activity to reduce the amount of strain on the shoulder area.
Signs and Symptoms
With little league shoulder, a young athlete may have:
- Pain in the shoulder while pitching or throwing.
- Tenderness along the upper arm.
- Pain when lifting the arm overhead.
- Decreased throwing speed or accuracy.
- Pain that gets worse as the sports season continues.
How Is It Diagnosed?
A sports medicine or orthopedic doctor diagnoses Little League shoulder with a detailed history and physical exam. They will examine the entire shoulder and upper arm area. They will also ask about throwing habits, recent increases in activity, and when pain occurs.
X-rays will often show widening at the growth plate at the top of the upper arm bone. This finding helps confirm the diagnosis. If X-rays are unclear, a doctor may order an MRI to examine the growth plate and surrounding tissues more closely.
If a child sees a physical therapist first, the physical therapist will gather detailed information about:
- Where is the exact location of pain, and when did the pain begin?
- What sport and position do you play?
- How often do you compete and practice?
- Have you recently increased your training time or intensity?
- If you throw, how much and how often do you throw? If you do not play baseball, what overhead activities do you perform?
- Have you recently grown taller in a short period of time?
After gathering this information, your physical therapist will perform a thorough physical and movement exam. The therapist will examine your shoulder and elbow movement on both sides, test muscle strength around the shoulder and shoulder blade, and assess your core strength (abdomen, back, and hips). They will look for any muscle imbalances or decreased movement (range of motion). The therapist also observes overall movement patterns during throwing or other overhead activity. Examining the entire body helps identify factors that may be contributing to the injury.
How Can a Physical Therapist Help?
Physical therapists develop a treatment plan based on the athlete’s specific needs and goals. Treatment focuses on restoring strength, improving movement, and reducing stress on the shoulder. A physical therapist will address:
- Muscle weakness.
- Decreased shoulder blade control.
- Limited shoulder motion.
- Throwing mechanics that increase stress on the shoulder.
- Tenderness and pain.
- Reduced core and hip strength.
Physical therapists design exercise programs to improve strength and endurance in the shoulder and arm muscles. They also strengthen the core, hips, and legs to provide a stable base for throwing or overhead activity. Research shows that movement patterns throughout the body can affect shoulder stress.
Physical therapists assess and correct throwing and overhead mechanics when needed. They create a gradual return-to-throwing plan once pain has improved and strength has returned. Returning too quickly may cause the symptoms to worsen.
They also help athletes and families understand safe training habits. Managing throwing volume and allowing proper rest are important parts of recovery. Treatment plans are tailored to the athlete’s age, sport, and stage of growth.
Can This Injury or Condition Be Prevented?
No injury can be completely prevented. However, players, parents, and coaches can take steps to reduce the risk of a Little League shoulder injury. These include:
Pitch count and rest. The body needs rest to recover from repeated throwing. Research shows that repeated stress without enough recovery increases the risk of injury in young athletes. Following age-based pitching and rest guidelines is important. Major League Baseball’s Pitch Smart USA program provides current recommendations for safe pitching and required rest periods. Physical therapists help athletes and families apply these guidelines based on the athlete’s age, growth, and training level.
Body mechanics. Proper throwing mechanics help reduce stress on the growing shoulder. Coaches and parents should watch for changes in throwing form, especially when an athlete appears tired. If shoulder pain develops, the athlete should stop throwing and seek care.
Movement variety. Playing multiple sports and varying positions can help reduce repeated strain on the shoulder. Encouraging a range of activities during growth supports balanced muscle development.
Prescribed rest after injury. If an athlete develops Little League shoulder, rest from overhead throwing is necessary to allow healing. A physical therapist will guide safe cross-training during recovery and create a gradual return-to-throwing program. Returning too quickly may increase the risk of symptoms coming back.
Parents, coaches, and athletes all play a role in prevention. Monitoring workload, allowing recovery time, and responding early to pain help protect the growing shoulder.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat Little League shoulder. However, you may want to consider:
- A physical therapist with experience in treating young athletes and shoulder injuries. Some physical therapists focus on orthopedic or pediatric sports care and work closely with sports medicine doctors.
- A physical therapist who is a board-certified clinical specialist in sports or pediatric physical therapy. These physical therapists have advanced knowledge, experience, and skills that may apply to your child’s condition.
- A physical therapist who has completed a residency or fellowship in sports or pediatric physical therapy. This additional training provides a physical therapist with the experience required to treat young athletes.
You can find physical therapists near you with specific experience or expertise using the American Physical Therapy Association’s Find a PT tool.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family, friends, or other health care providers.
- Ask about the physical therapists' experience in treating people with your specific symptoms or condition when you contact the clinic for an appointment.
- Be prepared to describe your symptoms as fully as possible and share your goals during your first visit. Make a note of what makes symptoms better or worse.
The Academy of Pediatric Physical Therapy contributed to this consumer resource. It is for informational purposes only and is not intended to represent the position of APTA Pediatrics.
The American Physical Therapy Association believes consumers should have easy access to clear, reliable information that helps them make informed health care decisions and feel prepared for visits with their providers.
The following resources offer the latest and best scientific evidence on physical therapy for little league shoulder. They cover recent research and standards of practice in the United States and globally. Whenever possible, they link to PubMed* abstracts (some of which offer free full-text access) or to other resources. You can read them to learn more or share them with your health care provider.
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. Article Summary on PubMed
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. Article Summary on PubMed
Greiner JJ, et al. Pitching behaviors in youth baseball: comparison with the Pitch Smart guidelines. Orthop J Sports Med. 2021;9(11):23259671211050127. Article Summary on PubMed
Myers NL, Kennedy SM, Arnold AJ, Gehring ZA, Kruseman KJ, Conway JE, Paine RM, Bailey LB, Garrison JC. A narrative review of Little League shoulder: proximal humeral physis widening is only one piece of the puzzle. JSES Int. 2024;8(4):724-733. Article Summary on PubMed
Major League Baseball; USA Baseball. Pitch Smart: pitching guidelines. MLB.com. Accessed February 15, 2026. https://www.mlb.com/pitch-smart/pitching-guidelines
*PubMed is a free public website run by the National Library of Medicine. It allows people to access summaries and references from health research articles published in scientific journals, including those indexed in MEDLINE.
Expert Review:
Feb 15, 2026
Revised:
Aug 2, 2021
Content Type: Guide
Little League Shoulder
PT, DPT
Jill Kissel
PT, DPT, board-certified clinical specialist in pediatric physical therapy
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