Rotator Cuff Tear in a 12-Year-Old Baseball Pitcher: A Case Report

Abstract

Rotator cuff injury is common among baseball pitchers. The tremendous forces and torques repetitively generated at the shoulder during the throwing motion place it at risk for injury [1]. Adolescent baseball players commonly experience shoulder pain owing to issues not seen in the adult population. In the skeletally immature thrower, the physis is the weakest structural link in the kinetic chain and poorly tolerates the biomechanical stress of throwing [2]. Thus, injuries to the physis, such as Little League shoulder (or proximal humeral epiphysiolysis), occur frequently in young throwers. Rotator cuff injuries, however, are seen much less frequently in the adolescent athlete. Rotator cuff tears, in particular, are extremely uncommon in the pediatric population. A review of the literature yielded only 1 case of an atraumatic rotator cuff tear in anyone younger than 18 years; that case described a partial thickness tear in a 13-year-old baseball player [3]. A case of a near full-thickness tear of the supraspinatus tendon in a 12-year-old baseball pitcher is presented. CASE REPORT A right-handed 12-year-old starting baseball pitcher presented with 3-day history of acute superior and posterior shoulder pain in his dominant shoulder. He reported that he had injured it after pitching 2 ½ innings of Little League. At the time of injury, he denied hearing an audible snap or crack, or having local trauma. After the onset of pain he was unable to continue throwing and experienced swelling along the lateral aspect of his shoulder. Pain was exacerbated with overhead activity and range of motion. On further questioning it was revealed that he was participating in 2 Little Leagues simultaneously and pitching close to the maximum allowed innings in both leagues. He denied pitching curveballs. Neither league was informed that he was participating in another league. He denied a history of any trauma. Physical examination 3 days after injury revealed point tenderness just lateral to the acromion and along the upper trapezius. Range of motion of the shoulder was full; however, scapular dyskinesis was seen with shoulder abduction. He demonstrated normal strength in internal and external rotation, but had diminished strength in abduction as determined with the empty can test about the affected shoulder compared with the opposite extremity. Impingement signs including both Hawkins’ [4] and Neer’s [5] were negative, drop arm test was negative, Scarf test was negative, and anterior apprehension/relocation test was negative for signs of instability. The patient was advised to avoid all physical activities including overhead throwing until diagnostic workup was completed and he was seen for follow-up. Bilateral anteroposterior (AP) and lateral shoulder radiographs were obtained, which showed no bony pathology or widening of the physis. Because of the severity of his symptoms, a magnetic resonance image (MRI) was obtained (Figure 1) demonstrating a near full-thickness tear of the supraspinatus tendon. The patient was sent for consultation to an orthopedic specialist, who recommended confirming the MRI findings with a magnetic resonance (MR) arthrogram as it was thought unlikely that the patient had a rotator cuff tear considering his young age. The MR arthrogram demonstrated a partial-thickness tear of the supraspinatus tendon, and the orthopedic surgeon recommended nonoperative treatment considering the patient’s young age. The patient was treated nonoperatively with a physical therapy program that included core strengthening, scapular stabilization, and range of motion exercises. After completion of 4 weeks of physical therapy, the patient returned to playing recreational basketball without pain or limitation. On his return visit at 5 weeks, his physical examination was essentially normal with full and symmetric range of motion and