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Physical Therapist's Guide to Proximal Humeral Epiphysitis

Proximal humeral epiphysitis (PHE) is an injury to the shoulder of a throwing athlete who is still maturing physically. Although the injury is most commonly seen in young baseball players, the injury can occur in any child participating in repetitive overhead throwing activities. With an increased participation and sports specialization at a very early age, shoulder and elbow injuries in young athletes are common. Almost 10% of shoulder pain in pediatric patients can be attributed to athletic activities, such as throwing, and of these injuries, 26% are related to overuse and are preventable. As movement experts, physical therapists are uniquely qualified to analyze an athlete’s throwing mechanics, evaluate muscle strength and movement patterns, and develop exercises to return the athlete to pain-free sports participation.

Signs and Symptoms

With PHE, an athlete may experience:

  • Pain in the shoulder while throwing, or the day after a sporting event.
  • Swelling in the upper arm.
  • Increased shoulder pain associated with increased throwing.
  • Decreased speed, velocity, or ability to control the ball during pitching.
  • Restricted movement at the shoulder compared to the opposite side.
  • Difficulty lifting the arm.

How Is It Diagnosed?

A sports medicine or orthopedic physician makes a proper diagnosis of PHE by conducting a complete physical exam of the entire shoulder complex. X-rays of the athlete’s shoulder will show the widening of the growth plate. If conventional x-rays are negative, a physician might elect to order additional imaging studies, including an MRI.

If a child sees a physical therapist first, the physical therapist will ask:

  • How are you feeling (signs and symptoms)?
  • How long have you been experiencing your current symptoms? When do your symptoms typically occur?
  • What sport and position do you play, and how often do you play (practice and games) in a typical week/month/year?
  • If you are a pitcher, when is the last time you threw a ball? What types of pitches do you typically throw? How much rest do you get between throwing events?

A physical therapist takes this information and conducts a thorough physical exam to determine the root cause of the problem. The physical therapist examines the athlete’s shoulder and elbow range of motion, and tests the strength of the muscles around the shoulder blade, trunk, pelvis, and hip.

How Can a Physical Therapist Help?

The conditions caused by PHE, such as muscle weakness or lack of endurance, lack of range of motion, or poor throwing mechanics can all be addressed in physical therapy. The physical therapist will work with the young athlete to:

  • Improve muscle strength and endurance at the shoulder.
  • Normalize the shoulder's range of motion.
  • Increase the athlete’s trunk, pelvis, and hip muscle strength and stability to provide a firm foundation from which to throw.
  • Observe and correct pitching mechanics to reduce stress through the shoulder.
  • Establish a schedule for the year with a proper amount of participation and rest.
  • Establish a plan for a controlled progressive return to throwing, often called an interval throwing program, for a safe return to play.

The physical therapist will work with the athlete to develop an individualized treatment plan based on the initial evaluation and goals.

Can this Injury or Condition be Prevented?

No injury is ever completely preventable. However, there are some tangible steps that players, their parents, and coaches can take to reduce the risk of shoulder injury, including:

Pitch Count and Rest. Rest is the body’s way of healing itself. Taking days off from playing or practicing gives the body a chance to repair and remain healthy. Your physical therapist will provide a guide for the amount of pitching and rest periods required to maintain a pitcher's shoulder strength and health, based on age.

Body Mechanics. Young athletes should be supervised and monitored while participating in sports with repetitive overhead motions, like baseball and softball. Sports medicine professionals or coaches who are skilled in analyzing body mechanics should be consulted as soon as the athlete complains of any of the signs or symptoms mentioned above.

Movement Variety. It’s important as kids mature and develop that they are exposed to multiple sports and play multiple positions. Variety helps reduce the amount of repetitive stress placed on any 1 body region. Parents and coaches need to encourage this type of multisport participation. Although not fully substantiated, some research studies have suggested there might be a correlation between multisport participation and decreased injury risk.

Prescribed Rest. If an athlete develops PHE, the athlete will need to rest from the overhead activity for 4 to 6 weeks to ensure that the bone heals properly. A physical therapist can work with the athlete to provide alternative ways to remain active during the rehab process. Afterwards, the athlete will be able to work with a physical therapist to complete a gradual return to a throwing program. Rest periods will vary from injury to injury and patient to patient; your physical therapist will prescribe rest periods to address the young athlete's individual condition and goals.

Real Life Experiences

Cade is a 12-year-old pitcher who just completed a successful season with his school's baseball team. While pitching a win during the third game of the season, Cade started to feel pain in his right shoulder that increased near the end of the game. His pain got worse with each game. Cade's father noticed his son's pitching velocity slowed as each game progressed. He iced Cade's shoulder after each game, but as soon as the season ended, he decided Cade needed to see a physical therapist.

Cade’s physical therapist asked about his medical history and his current symptoms. He found that the muscles that control the position of Cade's shoulder blade were much weaker on his right side than on his left side. He also recorded less shoulder range of motion on Cade's right side compared to his left side. An x-ray confirmed a diagnosis of proximal humeral epiphysitis.

Cade's physical therapist educated Cade and his family about the importance of taking adequate rest periods between sport activities. And due to Cade's current condition, he said Cade needed to take the entire summer off to rest and recover, and not play baseball while he was being treated.

Cade reluctantly agreed, and worked with his physical therapist to strengthen the muscles around his shoulder blade, trunk, pelvis, and hips, and regain his range of motion at his right shoulder. Cade was also given specific exercises to perform at home to supplement his physical therapy sessions. Although he missed playing baseball, Cade found he enjoyed all the new exercises he was learning.

After several weeks of physical therapy, Cade did not have any pain in his right shoulder. He reported that his muscles were feeling stronger throughout his whole body.

Once Cade was cleared by his physician, Cade’s physical therapist guided him through a gradual return to a throwing program. He worked with the pitching coach to ensure Cade was using proper mechanics as he began throwing again.

When the new school year began, Cade decided to sign up for the track team to continue to build his lower body strength and endurance. His physical therapist approved the fact that he was adding another sport to his training routine.

When baseball season came around, Cade was able to return to pitching (and catching)—pain free. His dad was amazed at how fast he rounded the bases when he got a hit!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat proximal humeral epiphysitis. However, you may want to consider:

  • A physical therapist who is experienced in treating people with proximal humeral epiphysitis. Some physical therapists have advanced practice skills, with a pediatric sports medicine focus.
  • A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have proximal humeral epiphysitis.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of proximal humeral epiphysitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Difiori JP, Benjamin HJ, Brenner J, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med. 2014;24(1):3–20. Article Summary in PubMed.

Rice SG, Congeni JA; Council on Sports Medicine and Fitness. Baseball and softball. Pediatrics. 2012;129(3):e842–e856. Free Article.

Hill DE, Andrews JR. Stopping sports injuries in young athletes. Clin Sports Med. 2011;30(4):841–849. Article Summary in PubMed.

Osbahr DC, Kim HJ, Dugas JR. Little league shoulder. Curr Opin Pediatr. 2010;22(1):35–40. Article Summary in PubMed.

Fortenbaugh D, Fleisig GS, Andrews JR. Baseball pitching biomechanics in relation to injury risk and performance. Sports Health. 2009;1(4):314–320. Free Article.

Lawson BR, Comstock RD, Smith GA. Baseball-related injuries to children treated in hospital emergency departments in the United States, 1994-2006. Pediatrics. 2009;123(6):e1028–e1034. Article Summary in PubMed.

Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries. Am Fam Physician. 2006;73(6):1014–1022. Free Article.

Lyman S, Fleisig 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(4):463–468. Article Summary in PubMed.

Little League Baseball. Regular season pitching rules – baseball. Accessed December 18, 2014.

USA Baseball Medical and Safety Advisory Committee. Youth baseball pitching injuries. . Accessed December 18, 2014.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Burke Wilson, PT, DPT, CSCS.  Reviewed by the editorial board.

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