Small ligament injury

Abstracts

Apresentamos o relato de um caso de lesão da pequena liga no ombro num jovem atleta de 14 anos e do sexo masculino, jogador da seleção Brasileira de Beisebol. Esta lesão é incomum e pouco descrita na literatura. O tratamento realizado foi a suspensão das atividades esportivas por três meses, seguida do retorno gradual aos arremessos. O paciente evoluiu com a resolução do quadro clínico.

Fraturas de ombro; Beisebol; Epífise deslocada

CASE REPORT

Small ligament injury

Joel Murachovsky^I; Roberto Y. Ikemoto^II; Luis Gustavo P. Nascimento^III; Luis Henrique Almeida^IV

^IMaster in Medicine, Assistant Doctor of the Shoulder and Elbow Surgery Group

^IIMaster in Medicine, Head of the Shoulder and Elbow Surgery Group

^IIIPost-Graduation student, Assistant Doctor of the Shoulder and Elbow Surgery Group

^IVFormer volunteer Doctor of the Shoulder and Elbow Surgery Group

^{Correspondences to}

SUMMARY

Here we describe a case report of a small ligament injury in the shoulder of a 14-year-old young male athlete, player of the Brazilian Baseball National team. This kind of injury is uncommon and little described in literature. Treatment provided was the suspension of sport-related activities for three months, followed by a gradual return to throws. The patient evolved to clinical picture resolution.

Keywords: Shoulder fractures; Baseball; Epiphysis, Slipped

INTRODUCTION

With the introduction of increasingly organized sportive programs, children and adolescents are engaging in higher competitive activities ^(1-4). Baseball athletes, particularly the pitchers, have been submitted to a higher demand on upper limbs in an attempt to achieve a better performance and, as a result, an increased throw speed. Nevertheless, pursuing a better performance has led to an increased incidence of injuries, including shoulder’s small ligament injury ⁽²⁾.

The small ligament injury in the shoulder affects the physeal region of the humeral proximal third. In 1953, Dotter reported a fracture affecting the epiphyseal cartilage of humeral proximal third in a 12 year-old pitcher ^(5,6). Adams, in 1965, reported this pathology as being an epiphysitis ^(6,7). Cahill et al., after studying five cases, believed that this was fracture caused by stress on this region’s growth plate ⁽⁷⁾. Barnett, in 1985, described the term "proximal humerus epiphysiolysis" as being the most adequate one, according to his opinion ⁽⁶⁾.

The small ligament injury of the shoulder seems to be caused by stress to which the physeal region of humeral proximal third is submitted at the moment of throw ^(2,5,7). It is characterized by leading to pain during throw and to X-ray images changes, characteristic of physis of the humeral proximal third.

THE CASE

A 14 year-old patient, student and pitcher of the Brazilian Baseball National Team, was experiencing pain on the right shoulder (dominant shoulder) at the moment of throw for the last two months, after a preparatory game series for the world baseball championship, which would happen that year. According to the athlete, pain was progressively getting worse, disturbing his performance. Pain was worse in throwing movements, irradiating to the anterior region of the shoulder and arm, which improved with rest. At physical examination, motion of the affected shoulder was complete, with no restraints to arm inward rotation, when at 90º of abduction; in that position he referred pain when reached its maximum outward rotation. That pain was located at the anterior portion of the shoulder, and he experienced that pain, but in an increased strength, at apprehension maneuver. Nevertheless, questions existed if such pain improved with the relocation test. The O’Brien maneuver, for SLAP-type injury detection, was positive. The patient didn’t present any pain at shoulder palpation and in tests for Impact Syndrome detection.

X-ray images of the affected shoulder were requested, which were performed at that same day (Figures 1 and 2). We noticed the presence of an enlargement and irregularities at the growth physis of humerus proximal third. By physical examinations and by X-ray findings, we decided to request a tomography and an arthro-resonance. Obviously, the patient was immobilized with a canvas sling for a relative immobilization of the affected limb, being allowed assisted passive and active movements, as well as isometric exercises for scapular wrist muscles.

After 10 days, the patient brought us the imaging tests (Figures 3 and 4), which showed the presence of a fracture at growth physis site of the humerus proximal third, and no changes existed to rotator cuff muscles, labral tissue and arm’s biceps muscle. Then, the diagnosis of shoulder small ligament fracture was delivered. Thus, this patient was recommended to remain with affected limb in relative rest for three months.

When the patient came back for a follow-up visit, after three months, he reported no pain at all, even at the Apprehension maneuver and at the O’Brien’s test. X-ray images still showed an enlargement of affected physis. At that point, the patient was allowed to return to his athletic drills, according to a protocol of progressive return to throws ⁽⁸⁾ and six months later he was completed integrated to team, and pitching without complaints.

After one year of follow-up, the athlete was able to play an entire game without complaints, being satisfied with the outcome of his treatment, and does not present any motion deficit. Nevertheless, on X-ray images, we still see a little enlargement of growth physis at the affected humerus proximal third when compared to contra-lateral side (Figures 5 and 6).

DISCUSSION

During the acceleration phase, the shoulder goes from abduction and lateral rotation to adduction and medial rotation. By the action of rotator cuff muscles, inserted proximally to growth physis and to major pectoralis, deltoid and triceps muscles inserted distally to it, a stress occurs on physeal region ^(5,7,9,10). Physeal injuries are similar to a SALTER-HARRIS I- type detachment, where physis detaches at the hypertrophic layer, with proliferation layer remaining with the epiphysis and the calcification layer with the metaphysis ^(3,5,9-11).

The major complaint of patients is shoulder pain during and after throwing activities ^(4-6). Clinically, a normal range of motion is seen and, occasionally, a volume increase at anterior and lateral portions of affected shoulder ^(5,6). Imaging tests show the following features: physis enlargement, both at X-ray and at Nuclear Magnetic Resonance, as well as lateral fragmentation, sclerosis and calcification signs ^(2,4-7). These findings are compatible with other pathologies caused by chronic stress to a physis, such as at the distal third region of the radius, which may occur in young athletes ⁽¹²⁾. This enlargement of physis is due to the proliferation of germinative cells⁽⁵⁾.

The best X-ray plane for diagnostic purposes is: corrected front in inward and outward rotation of comparative shoulders ^(5,6). This pathology is more common in athletes in the age group of 12 – 16 years old because physis is growing fast, and, as a result, more fragile ⁽⁵⁾. Treatment consists of rest from any throwing activities until total remission of symptoms, which occurs within six weeks to three months in average ^(2,4-7). Resolution of X-ray findings is nor required ⁽⁵⁾.

In this case, the athlete had only pain complaints at the anterior portion of the shoulder at the moment of pitching. He did not present with pain after a drill or game. He had no pain at palpation on lateral portion of the shoulder (most common painful site) ⁽⁵⁾ and his physical examination simulated a SLAP-type injury. However, back at baseline X-ray images, we could diagnose the presence of small ligament fracture and, theoretically, this would be enough for diagnosis. Nevertheless, we preferred to further study the case by means of other imagining tests, since that athlete’s clinic was a little different from usual for that pathology.

As reported in literature, this athlete did not present with any kind of complaint after three months of relative rest and after one year of follow-up. He is now playing normally, with no complaints or lost range of motion, although X-ray images of the affected shoulder still show a slight enlargement of the growth physis when compared to contralateral side.

The small ligament injury should be part of the differential diagnosis in young pitching athletes presenting with pain at dominant shoulder ^(2,4).

REFERENCES

Received in: 09/02/05; approved in: 12/07/05

Study conducted at the Department of Orthopaedics and Traumatology, ABC Medical College

• 1. Lyman S, Fleising GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002; 30: 463-8.
• 2. Adams JE. Bone injures in very young athletes. Clin Orthop. 1968; 58:129-39.
• 3. Micheli LJ. Overuse injuries in children's sports: the growth factor. Orthop Clin North Am. 1983; 14:337-57.
• 4. Albert MJ, Drvaric DM. Little league shoulder: case report. J Pediatr Orthop. 1990; 13: 779-81.
• 5. Carson WG, Gasser SI. Little leaguer's shoulder: a report of 23 cases. Am J Sports Med. 1998; 26:575-80.
• 6. Barnett LS. Little league shoulder syndrome: proximal humeral epiphyseolysis in adolescent baseball pitchers. J Bone Joint Surg Am. 1985; 67: 495-6.
• 7. Cahill BR, Tullos HS, Fain RH. Little league shoulder. J Sports Med. 1974; 2:150-3.
• 8. Axe MJ, Snyder-Mackler L, Konin JG, Strube MJ. Development of a distance-based interval throwing program for little league-aged athletes. Am J Sports Med. 1996; 24: 594-602.
• 9. Neer CS, Horwitz BS. Fractures of the proximal humeral epiphysial plate. Clin Orthop. 1965; 41:24-31.
• 10. Dameron TR, Reibel DB. Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg Am. 1969; 51:289-97.
• 11. Dale GG, Harris R. Prognosis of epiphysial separation. An experimental study. J Bone Joint Surg Br. 1958; 40:116-22.
• 12. Caine D, Roy S, Singer KM. Stress changes of the distal radial growth plate: a radiographic survey and review of the literature. Am J Sports Med. 1992; 20:290-8.

Publication Dates

• Publication in this collection
  21 July 2006
• Date of issue
  2006

History

• Accepted
  07 Dec 2005
• Received
  02 Sept 2005