1022 - It's Not Always Little League Shoulder – a Rare Case of Shoulder Pain in an Adolescent Baseball Athlete

Case Diagnosis: Lesser tuberosity avulsion fracture

Case Description: A 13yo RHD male baseball athlete with three-weeks of right shoulder pain describes a sharp onset of pain in his trail shoulder after a specific swing, and dull aching pain with throwing over the preceding several weeks. Physical examination demonstrated tenderness in the proximal humerus, GIRD, and pronounced pain in apprehension. Initial XR were interpreted with open proximal humeral physis with presumptive diagnosis of Little League Shoulder. Rest from baseball activities was prescribed with variable compliance. At 2-months the athlete demonstrated persisting symptoms. Subsequent MRI revealed an 11x8 mm avulsion fracture of the lesser tuberosity.

Discussions: Lesser tuberosity avulsion fractures are rare and may elude immediate diagnosis. Such fractures are typically attributed to falls with outstretched hands or externally rotated positions, but atraumatic injuries associated with overuse in skeletally immature athletes can occur. Given symptomatic overlap with more common conditions such as Little League Shoulder, these injuries require a high level of awareness for accurate diagnosis. In the current case, retrospective review of initial XR did demonstrate subtle presence of avulsion in the axillary view, later confirmed on MRI. This case demonstrates the importance of comprehensive physical exam, attention to subtleties in history, and the need for close follow-up in vulnerable adolescent athletes to ensure accurate diagnosis and successful outcomes. In the literature, both surgical, and non-operative treatment has been described.

Conclusions: The current case highlights the diagnostic challenge of lesser tuberosity avulsion fractures in young athletes. High index of suspicion and close follow-up is crucial, particularly in a young athlete with abrupt onset and atypical mechanism such as eccentric contraction of the subscapularis muscle, as seen in bat-on-ball contact during hitting in baseball. The current case suggests that early diagnostic testing in atypical presentations of Little League Shoulder may be helpful to ensure accurate diagnosis and management.