The initial treatment of little league shoulder is rest and activity modification, typically including 3 months of rest before starting with a gradual return to throwing (Table 1). The protocol regarding return to throwing has been provided by the US Baseball Medical & Safety Advisory Committee (Table 2). Initially, the protocol involves light tossing with a gradual increase in distance and velocity. If symptoms return during any point in the throwing program, the athlete should initiate an additional period of rest with further assessment of symptoms through clinical and radiographic evaluation (Osbahr et al. 2010). If the patient remains asymptomatic during the throwing program, he or she may return to play. A previous report (Carson and Gasser 1998) demonstrated that 21 of 23 patients (91 %) were able to return to baseball at an average of 3 months (range: 1 month to 1 year) with asymptomatic shoulders. There are rarely any growth disturbances or length discrepancies secondary to little league shoulder.

Prevention of little league shoulder is the most important factor for clinicians treating this condition. Pitch count limits and proper throwing mechanics are key components identified to prevent little league shoulder (USA Baseball Medical and Safety Advisory Committee (2008)).

A detailed history and physical exam is critical in the diagnosis of shoulder instability. The athlete will typically complain of: pain, difficulty with overhead activities, feeling of the shoulder moving or popping, an inability to participate in sports, or episodes of “dead arm” in which the athlete loses control of the arm transiently. The history should include hand dominance, activity level, duration of symptoms, and previous treatments. It should be noted if a traumatic event occurred prior to the symptoms. Specific questions include: Did the initial event require reduction? How many episodes of instability have there been, and how many have required a reduction? What position was the arm in when the symptoms began? Complaints of pain or apprehension with the arm abducted and externally rotated suggest anterior instability, while symptoms that occur with the arm flexed, adducted, and internally rotated suggest posterior instability.

The physical exam should include a comparison to the contralateral limb as a control. Inspection is made of the shoulder girdle for atrophy of the trapezius, infraspinatus, supraspinatus, teres minor, and deltoid. Palpation over the anterior and posterior glenohumeral joint line, acromioclavicular joint, clavicle, and biceps tendon should be performed, with the presence of any tenderness documented. Active and passive range of motion in all six planes of the scapula should be performed, although most patients with instability will have full motion. Strength testing of the rotator cuff and periscapular musculature is also documented. Signs of generalized laxity include elbow hyperextension and the ability to reach the forearm with the abducted thumb (Fig. 4a, b).

The shoulder is then examined for stability with specific examination maneuvers:

Standard shoulder radiographs should be performed for athletes with concern for instability. Anteroposterior and axillary radiographs are used to determine any translation of the humerus on the glenoid (Fig. 9a, b). A West Point axillary view may be used to assess for a bony Bankart lesion or anteroinferior glenoid deficiency. The Stryker notch view may be used to identify a Hill-Sachs lesion.

Computed tomography (CT) scans are typically not used for cases of shoulder instability. However, they may be obtained to assess bony deficiency of the glenoid or humerus prior to a planned surgical procedure or if the patient has failed a prior surgical procedure.

Magnetic resonance imaging (MRI) with or without contrast is used to evaluate the articular cartilage, labrum, and rotator cuff of athletes with instability (Fig. 10). MRI is helpful in patients that have failed conservative management of glenohumeral instability or are possible surgical candidates as the MRI can be helpful for preoperative planning.

The major instability patterns are anterior and multidirectional. Historically, instability is characterized as either traumatic unilateral instability or atraumatic multidirectional instability.

Currently there are no specific outcome tools available for shoulder instability.

A complete discussion of the risks of the surgery should occur with the patient and his/her family including: infection, injury to nerves or blood vessels, stiffness, recurrence, and pain (Table 6). A complete neurovascular exam should be documented prior to the procedure. Radiographs and an MRI should be obtained and reviewed prior to surgery to determine any bony deficiencies that may need to be addressed, as well as the size and location of the Bankart lesion. An exam under anesthesia should be performed with special attention paid to the range of motion, laxity testing, and presence of a sulcus sign.

An OSI flattop table is used with the patient in a supine position. An alternative is to use a regular OR table and have the patient in a beach chair position. For adolescent patients, a radiolucent arm board may be used. The surgeon should be positioned in the axilla of the patient.

Initially the patient is kept in the sling at all times except for showering and performing Codman’s exercises (Table 8). Initial exercises are for wrist and elbow range of motion four times per day. At the 1-week postoperative visit, the wound is examined. At 4 weeks postoperatively, the sling is discontinued. Passive range of motion is begun at 4 weeks postoperatively with forward elevation allowed to 90° and external rotation to 15°. This is gradually increased over the next 4 weeks, with an increase in active range of motion begun. Week 12 is the time when noncontact activities are allowed and overhead throwers can begin light throwing exercises. Return to sports is typically between 3 and 6 months, with no contact sports allowed until at least 6 months postoperatively.

Good outcomes of surgically repaired recurrent traumatic shoulder instability have been reported with a redislocation rate of only 3.5 % of patients treated operatively (Rowe et al. 1978). Current literature reports an incidence of recurrent instability after Bankart repair between 1.5 % and 9 % (Galatz et al. 2008). The literature (Wirth et al. 1996) supports 93 % good or excellent results at an average follow-up of 5 years, with a high degree of patient satisfaction and marked improvement in ratings for pain, strength, stability, and function. Another report (Thomas and Matsen 1989) also described follow-up at an average of 5 years and found that 97 % of results were good or excellent. Open repair for recurrent shoulder instability in athletes has very good results. Researchers (Pagnani and Dome 2002) performed the operation on 58 football players and had no recurrent dislocations with excellent functional outcomes. Complications of surgical treatment of recurrent traumatic shoulder instability include: recurrence, loss of motion, subscapularis rupture, and problems related to the hardware. Recurrence is reported between 1.5 % and 9 % in the current literature. Loss of motion is typically seen in older patients and not in the adolescent age group.

Patients with multidirectional instability are treated with formal physical therapy including: strengthening of the rotator cuff muscles and deltoid along with treatment of any scapular dyskinesia that may be present. These patients may need long-term therapy (greater than 1 or 2 years) before symptoms are improved. Rarely is surgical intervention necessary.

Any patient with recurrent traumatic shoulder instability is treated with physical therapy and strengthening for at least 6 months. If after 6 months of physical therapy and strengthening the patient is still having symptomatic dislocation episodes, then a consideration for surgical intervention is made. Risks of the surgery are discussed. If the patient agrees to surgical intervention, an open Bankart repair as described above is performed.