A 15-year-old boy presents to your office with insidious onset of right shoulder pain for the past 3 months. He is right-handed and denies any injury; however, he does play baseball. He plays pitcher on 2 teams, and sometimes he plays catcher as well. On exam, he has no shoulder asymmetry and mild tenderness of the proximal humerus. He has normal range of motion and strength. You obtain the radiograph as shown below. What is the most likely diagnosis?

A Rotator cuff tear

 B Shoulder strain

 C Epiphysitis

 D Clavicle fracture

 E Growing pains

Answer. C

A high volume of repetitive activity can stress tissue, including the growth plate in a growing adolescent. The radiograph shows widening of the proximal humeral physis, which is consistent with epiphysitis, or bone edema and growth plate injury. Epiphysitis can also be found at the medial epicondyle of the elbow in baseball pitchers. Radiographs can be normal, so a history of high levels of repetitive activities and activity-related pain should raise suspicion for growth plate stress injury. Treatment is rest from painful activities including throwing. Adhering to pitch count recommendations and rules is an important part of preventing these injuries.

Rotator cuff tears are more common in adults and cannot be diagnosed based on radiographs. Shoulder strain or clavicle fracture would more likely present with an acute injury, and clavicle fracture would be evident on radiographs. Growing pains are a diagnosis of exclusion and more common in the lower extremity.

(Chapter 215: Injuries)

Question is from Rudolph's Pediatrics, 23e, Self-Assessment and Board Review (C) 2023 McGraw Hill.