Pain guide · Shoulder pain
Little League shoulder is a stress injury of the growth plate near the top of the upper arm bone, caused by the twisting force of repeated throwing. It mostly affects pitchers, at an average age of about 13, and shows as pain on the outside of the upper arm when throwing, often with slower or wilder throws. It needs weeks to months off throwing, and almost all children get back to their sport.
This guide is for young players, parents and coaches. It covers the warning signs, how it is diagnosed and why a widened growth plate on an X-ray is common even without pain, how long the rest usually lasts, how to keep fit meanwhile, and a staged plan with 3D demos back to throwing, within the pitch counts and rest days on our baseball and softball page.
Exercise is for pain that has been checked or is clearly mild and settling.
Throwing twists the upper arm bone hard. In a growing child, the growth plate near the top of the bone takes the strain, and growth cartilage copes less well with twisting than with pulling. Repeated twisting damages it, a bit like a slow stress fracture through the growth plate, and the classic sign is a widened growth plate on the throwing side.
It mostly affects boys, at an average age of about 13. In 95 children aged 8 to 16 at one children's hospital, 86% were pitchers, 8% catchers and 3% tennis players; only 2 were girls, and there were more cases every year. In 101 Japanese players, 99 were boys, and across 23 studies (266 children) the average age was 12.8, from 7 to 17. It can also happen in swimming, gymnastics, volleyball and tennis.
The main sign is pain at the top and outside of the upper arm when throwing, which may build over months, often with a drop in speed or control. In the 95 children, all had pain with overhead sport; 13% had elbow pain too, 10% tiredness or weakness, 8% catching or clunking, and 30% a throwing shoulder that was stiffer turning inwards.
Up to 70% are tender over the top and outside of the arm bone. In 101 Japanese players, pain when the arm was turned outwards against resistance was present in 94%, so clinicians use that test too.
X-rays of both shoulders, with the arm turned in and out, usually confirm it: the growth plate is wider on the throwing side, sometimes with fragments or changes in the bone nearby. Magnetic resonance imaging (MRI) is rarely needed, but helps if the X-rays look normal and the doctor still suspects it, or if another problem is possible.
A widened growth plate is common without pain. In 79 young players, it was wider on the throwing side across the group, and X-ray changes were seen in 55% of the 53 who had never had shoulder symptoms. On MRI, 12 of 23 Little League players without symptoms (52%) had findings in the throwing shoulder, including growth plate swelling or widening in 5. In a season-long study, 61% of 23 players had findings in the throwing shoulder, and 81% of those picked for all-star teams.
So the X-ray is read alongside the symptoms and the examination. Recovery is judged by symptoms: only one recent study waited for the X-ray to look normal before a return.
With rest, most recover fully. Across 23 studies, 94% returned to sport and 92.5% to their previous level, surgery wasn't used, 18.7% had symptoms again after returning, and 1 child's growth plate closed early. Rarely, a weakened growth plate breaks: X-rays showed a fracture through it in 2 of the 266 children.
In a small study, 10 high-school players who had had it reported more shoulder pain (80%) and elbow pain (70%) than 22 who hadn't (9% and 32%), and had more twist in the upper arm bone.
A 2006 review advises an average of 3 months off throwing. Across 23 studies, the recommended rest ran from 1 month to 1 year, most often 4 months, and advice has moved from long, complete rest towards shorter rest and a graded return guided by symptoms.
In recent series, symptoms settled at an average of 2.6 months and children were back in competition at 4.2 months (95 children), and 95% of 87 players were fully back at an average of 2.8 months. These are case series; no trial has compared rest periods, and the clinician sets the time for each child.
In 87 Japanese players, a longer delay between first seeing a doctor and stopping throwing went with worse results at 2 months, and poorer shoulder flexibility with a less complete return. This is one series, but it fits the advice to stop at the first sign of pain.
Source 9
In a Japanese series, return to sport took 8.8 weeks when throwing waited until turning the arm outwards against resistance was pain-free, against 12.7 weeks when players went back before that for team reasons. This is one small, non-randomised comparison from one surgeon (14 against 11 players), so it is a pointer, not proof.
Source 1
Symptoms came back in 7% of 95 children and 25% of 87 players in two series, in 18.7% across 23 studies, and in 6 of 17 in a 5-year telephone survey. Players who had had it reported more shoulder and elbow pain later in one small study. That is one more reason to keep to pitch counts, rest days and months off after a return.
Pitching with a tired or sore arm, on consecutive days or for several teams went with more arm injuries in large surveys and reviews. In US high schools, rules requiring rest between pitching days and daily caps of 105 pitches or fewer went with far fewer shoulder and elbow injuries, and a 9-exercise warm-up cut shoulder and elbow injuries in a trial of 237 players aged 9 to 11.
These studies cover young throwers' arm injuries in general, not Little League shoulder alone, so we borrow them for prevention.
Physiotherapy for movement and strength, including stretching the back of the shoulder when it was stiff, was standard care in the series, and better flexibility went with a pain-free return. One centre used a 1-month throwing programme before competition.
No trial has tested the exercises, and no throwing programme has been validated: published programmes are mostly versions of one old programme. The plan on this page is our suggestion, built from that consistent advice.
This rule is our editorial suggestion. No study has tested a pain rule for Little League shoulder, and no throwing programme has been validated, but professional advice for young throwers is consistent: go back only when pain-free, and stop when it hurts. If your child's clinician or coach has given you a programme, follow theirs.
Throwing: no pain at the top or outside of the upper arm during throwing, straight afterwards or the next morning. If it hurts, stop for the day and restart a step lower; if pain comes back each time throwing restarts, stop until the child has been checked again.
Before throwing restarts, the clinician can check that turning the arm outwards against resistance is pain-free. Stretches should give a stretch at the back of the shoulder, never pain at the top of the arm or a pinch at the front.
Start at the first stage. Each move opens a full guide with a 3D demo.
Stop throwing straight away: no pitching, catching or throwing practice. We suggest no serving or smashing in tennis or volleyball either, since the same growth plate takes the strain. Keep fit, and keep the shoulder moving within a pain-free range. If the throwing shoulder is stiff turning inwards, stretch it gently: better flexibility went with a pain-free return in one series.
3D demoShoulder CARs (controlled articular rotations)Beginner · No equipment3 slow circles each way, once a day · Stay in a pain-free range. The move page's dose
Easier: Arm circles · Harder: Sleeper stretch
3D demoCross-body shoulder stretchBeginner · No equipment3 holds of 30 s on the throwing side · Only if it is stiffer turning inwards. Editorial dose
Harder: Sleeper stretch
3D demoThoracic rotationBeginner · No equipment6 each side · The move page's dose
Easier: Side-lying open book · Harder: World's greatest stretch
3D demoBand rowBeginner · A band + An anchor point2 sets of 12 with a light band, elbows close to your sides · Pain-free at the top of the arm. Editorial dose
3D demoSingle-leg standBeginner · A wall3 holds of 30 s on each leg · Editorial dose
Easier: Tandem stance and heel-to-toe walk · Harder: Single-leg reach matrix
3D demoStationary cyclingBeginner · Cardio machine20 to 30 minutes, 3 times a week · Or running. Editorial dose
Harder: Air bike intervals
Move on when: No pain in daily use, no tenderness at the top of the arm, full shoulder movement, and the clinician finds turning the arm outwards against resistance pain-free.
2 to 3 sessions a week, light and slow, with no pain at the top of the arm. The doses are editorial, or our throwing arm strength workout's where the moves overlap.
3D demoStanding band external rotationBeginner · A band + An anchor point2 sets of 12 each arm, elbow by your side · Start once the resisted turning test is pain-free
Harder: Side-lying external rotation
3D demoBand internal rotationBeginner · A band + An anchor point2 sets of 12 each arm, elbow by your side · Editorial dose
Harder: Side-lying external rotation
3D demoSide-lying dumbbell external rotation (on a bench)Beginner · A dumbbell + A bench or box2 sets of 12 each arm, no weight at first, then a light dumbbell
Easier: Standing band external rotation · Harder: Incline reverse fly with external rotation
3D demoProne Y-T-W raisesBeginner · No equipment2 sets of 5 of each shape · Forehead on a towel
Easier: Wall angel · Harder: Bent-over reverse fly
3D demoScapular push-up (push-up plus)Beginner · No equipment2 sets of 10, on the knees first · Editorial dose
Easier: Dumbbell shoulder-blade punch · Harder: Pike push-up
3D demoSingle-leg Romanian deadliftAdvanced · A dumbbell2 sets of 8 each leg, no weight at first · Fingertips on a wall at first. Editorial dose
Easier: Dumbbell Romanian deadlift
Move on when: Pain-free, full movement, strength similar on both sides, and the clinician clears a return to throwing.
Follow the graded throwing steps in the notes below, with the baseball arm care warm-up first and strength work twice a week. In the studies, children were back in competition at an average of 2.8 to 4.2 months, and one centre used a 1-month throwing programme before competition. If your clinician or coach has a programme, follow theirs.
3D demoScaption raiseBeginner · A dumbbell2 sets of 10, a light weight, thumbs up, to shoulder height · Editorial dose
Easier: Band lateral raise · Harder: Smith machine upright row
3D demoMedicine-ball chest pushBeginner · Medicine ball2 sets of 5, light ball · Editorial dose
Harder: Two-hand overhead throw
3D demoTwo-hand overhead throwIntermediate · Medicine ball2 sets of 5, light ball · Editorial dose
Easier: Medicine-ball chest push · Harder: Lying one-arm overhead throw
3D demoLying one-arm overhead throwIntermediate · Medicine ball2 sets of 5 each arm, light ball · The throwing arm strength workout's dose
Easier: Two-hand overhead throw
3D demoHalf-kneeling Pallof pressBeginner · A band + An anchor point2 sets of 10 each side
Harder: Pallof press
Move on when: The throwing steps are complete with no pain at the top of the arm during, straight after or the next morning, and the clinician agrees. Then games and pitching within the daily limits and rest days, with at least 4 months a year off overhead throwing.
No throwing programme has been validated. These steps follow the principles the sources share: pain-free first, short and easy before long and hard, and a step back for any pain. Read pain in the steps as pain at the top or outside of the upper arm. If your child's clinician or coach has a programme, use theirs instead.
These are the Pitch Smart guidelines from Major League Baseball and USA Baseball, and the UK youth league rules, and they match our baseball and softball page. They apply in full after Little League shoulder, all year and across every team. A 2023 review also advises at least 4 months a year off overhead throwing.
Tennis serves, volleyball spikes and swimming strokes load the same growth plate: it has been seen in tennis players and is listed in swimmers, gymnasts and volleyball players. We suggest pausing them while the shoulder is sore.
If the throwing shoulder is stiffer turning inwards, stretch it gently with the cross-body stretch; better flexibility went with a pain-free return. Use the sleeper stretch only if a clinician finds a clear loss of turning in, and never on a painful shoulder.
| Habit or position | Why it matters | Instead |
|---|---|---|
| Throwing through shoulder pain | Pitching with a sore or tired arm went with several times the odds of injury, and pain came back in up to a quarter of children after returning. | Stop for the day and follow the plan. |
| The sleeper stretch on a painful shoulder, or any stretch into pain | Skip the sleeper stretch with a painful or unstable shoulder; it is only for a clear loss of turning in. | The cross-body stretch, gently.Try: Cross-body shoulder stretch |
| Heavy resisted turning while the top of the arm is tender | Turning the arm against resistance is the test that brings the pain on (positive in 94% in one series). | Light band rotations, once the resisted test is pain-free.Try: Standing band external rotation |
| Hanging from a bar, or heavy overhead pressing, while it is sore | They load the shoulder at the end of its range (our reasoning). | Rows and other work with the elbows by your sides.Try: Band row |
| Serving, spiking or throwing in other sports during the rest | The same growth plate takes the strain. | Running, cycling, football or other sports without overhead throwing. |
A 12-minute arm care warm-up for baseball and softball, built on a Japanese youth programme: an arm massage, shoulder, forearm and hip stretches, and balance.
12 minBeginner9 movesA massage ball, A wallA 35-minute session for baseball and softball players: the five Shoulder Control exercises, rotator cuff and forearm work, medicine-ball throws and legs.
35 minIntermediate17 movesA dumbbell, A cable machineA 25-minute band routine for healthy shoulders: move the shoulder and upper back through their range, then strengthen the rotator cuff and shoulder blades.
25 minBeginner12 movesA wall, A bandA stress injury of the growth plate near the top of the upper arm bone, caused by the twisting force of repeated throwing. It is most common in boys of about 13 who pitch.
Usually weeks to months: an average of about 3 months in one review, and anywhere from 1 month to 1 year across studies. In recent series, children were back in competition at an average of 2.8 to 4.2 months. The clinician sets the time for your child.
From the story, tenderness at the top of the outer arm and pain when the arm turns outwards against resistance, usually confirmed by X-rays of both shoulders showing a wider growth plate on the throwing side. Widening also appears in players without pain, so the X-ray is read alongside the symptoms.
Yes: sports without throwing or overhead hitting, plus running, cycling and leg and trunk work. We suggest tennis serves and volleyball spikes wait too, because it has happened in tennis players.
Ask the clinician. We found no studies on batting with Little League shoulder, so we suggest waiting until daily life is pain-free and the clinician agrees.
When the pain has gone, the shoulder moves fully, and turning the arm outwards against resistance is pain-free; then a graded return to throwing. In one small comparison, waiting for that test to be pain-free went with a quicker return, but it wasn't a trial.
Very rarely: one child among 266 in a review had early closure of the growth plate. Stopping throwing quickly gives the best results.
Almost never. Surgery wasn't used for any of the 266 children in the review, and 92.5% returned to their previous level.
Yes, in 7% to 25% of children in single studies, on average about 6 to 8 months after returning. Players who had it reported more shoulder and elbow pain later in one small study, which is another reason to protect the arm.
No. It's a growth plate injury in children, while adult throwers' deep shoulder pain is covered in our SLAP tear guide (a tear of the rim of the socket) and our rotator cuff tear guide. Changes in the rotator cuff and the rim of the socket are common on MRI even in Little League players without pain.
Follow Pitch Smart's daily limits and rest days, take at least 4 months a year off throwing, play for one team at a time, and keep to the limits on pitchers also catching. Limits help but don't guarantee safety: playing one sport all year went with more shoulder MRI changes.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
