Shoulder dislocations are fairly common injuries in the active teenager. Most shoulder dislocations occur as a result of a traumatic injury. Some dislocations should be reduced -- or put back into place -- in an emergency room, but some will spontaneously reduce on their own. Other forms of shoulder instability, though,  involve a shoulder that will dislocate with minimal trauma; a small number of children can voluntarily dislocate their own shoulders.

This brief post will focus on the traumatic shoulder dislocation. Most dislocations result from a fall on an outstretched arm. The child will be in obvious pain and will not be able to move the shoulder without increasing the pain. Numbness or tingling will be present in certain situations, but this will usually resolve itself spontaneously. If you take your junior athlete to the local emergency room, an xray will verify that the shoulder is dislocated and the ER staff will put the shoulder back into place.

Should the arm then be placed in a sling? If so, what type of sling? Does it matter?

Recent scientific literature reveals that if your child's arm is immobilized in 20 or 30 degrees of external rotation for a period of 3 weeks, then the risk of re-dislocation or recurrence diminishes dramatically. Because surgery is frequently necessary for a recurrent dislocator, that translates into a lesser chance that junior will require surgery to "repair" or stabilize the shoulder.

The sports medicine world used to be very aggressive (surgically) in managing a first-time traumatic dislocator. The pendulum has clearly started to swing to a much less aggressive non-operative form of initial management. Consensus opinion in the academic community is that a first-time dislocator -- if seen within the first three days after a dislocation -- should be placed in a brace that will externally rotate the arm 20 or so degrees. That brace is worn day and night for nearly three weeks. A course of physical therapy should follow, to rehabilitate the rotator cuff muscles, which collectively serve as the dynamic stabilizers of the shoulder joint.

If physical examination reveals persistent instability, or if a second dislocation occurs, then surgery is usually the recommended course of action ... in most circumstances.

If the exam is normal, then your child can return to sports ... sometimes nearly 9 months later. The risk of recurrent dislocation in this situation is a bit over 50 percent -- and nearly half that if you followed the external rotation splinting program.

Any questions?

In time, most overhead athletes will experience shoulder pain. In the pediatric populations, the younger the child and the more aggressive the pursuit, the more likely there is to be an episode of shoulder pain. We're not just talking about pitchers -- we're talking about pitchers, volleyball players, swimmers, track and field participants, and gymnasts.

Unlike their adult counterparts, children rarely suffer from a rotator cuff problem. At this age, the injuries we typically see are stress fractures or stress reactions of the growth plate and chronic repetitive stress injuries to the ligaments around the shoulder, leading to instability. Instability can be very subtle. The shoulder doesn't need to dislocate for instability to be present. Subtle instability, which leads to subluxation of the joint, can lead to pain that is often misinterpreted by the untrained observer to be a rotator cuff strain. Gross instability, where the shoulder dislocates, is usually associated with a significant traumatic event or a unique form of instability known as multi-directinal instability, where all the ligaments around the shoulder are loose. Most chronic repetitive stress related episodes of instability are not associated with labral tears. The ligaments have simply stretched out.

As you observe your junior athletes ... if they appear to be suffering every time they use their shoulder, it may be time to visit an orthopedist. Many children will recover uneventfully from many overuse shoulder injuries, IF the injured athlete is examined and treated by an appropriately trained professional within a reasonable period of time.

Children in general, and especially young girls, are suffering ACL tears and injuries at an increasing frequency. In these cases, parents are faced with a very difficult decision. Without an ACL the likelihood that your child can participate in sports involving cutting, pivoting, and twisting is very low.

In the adult population the solution is surgical reconstruction of the Anterior Cruciate ligament. In the pediatric population, the solution is also an ACL reconstruction, but the risks associated with an ACL reconstruction in children with open growth plates are potentially far more significant. This frequently places the parents in a difficult situation.

During an ACL reconstruction, we drill small tunnels to accommodate the new ligament graft. Those tunnels and the graft will cross the growth plate. Because of this, there is a risk of causing growth plate arrest -- leaving the leg short, or partial arrest -- causing the leg to grow at an unusual angle.

These complications are manageable with modern reconstructive techniques, and hundreds of children every year have their ACLs reconstructed without complications. You should thoroughly review the options available with your orthopedist and be sure that he or she has had significant experience with reconstructing ligaments in the pediatric population.

Even though parents and coaches are cautioned to not allow their kids pitch or throw too much, many children will be on the mound this spring throwing 100+ pitches every week. If you insist on taking this risk, or even if you just want your child in optimal shape for baseball season, make sure your child's arm and body are ready for the task.

Between 75 percent and 80 percent of the strength or momentum of a pitching motion comes from BELOW the bellybutton. A successful and strong pitch comes from the unwinding of an entire kinetic chain. Your child must possess phenomenal CORE strength and balance in order to coil and release through the pelvis and hips. The more power and control your CORE and lower body have, the less force your shoulder will need to generate -- and the less the rotator cuff will need to function to make up for the loss of control associated with loss of balance.

Squats, lunges, rotational exercises, CORE strengthening, and balance and agility training need to be performed for months leading into the season to put your child in the best shape possible to adapt to the needs of an overhead sport. Shoulder and cuff exercises are important too ... but focus on your CORE , abs, pelvis, and legs first.

And limit that pitch count ... 50 max per week, and no junk until you are over 16!!!!

For years I have been telling parents to minimize the amount of time their children spend pitching and instead concentrate on teaching the basics  and the finer points of being a team player. Baseball is a complex sport, and it takes years to master the nuances of the game. To a teenager, pitching presents itself as the most sought-after position because of the role associated with being the pitcher -- the team leader.

Teenagers do not need to pitch to learn the game, participate in the game, or have fun playing the game of baseball. Pitching is one of the most demanding activities we can put our body through. Many injuries can occur ... physically and emotionally. Our elbow accelerates at 3000 degrees per second and the stress on the shoulder is enormous. Our children have open growth plates, which are very plastic and very sensitive to the forces that pitching places on them. The growth plate will respond quite unfavorably if asked to do too much of a difficult activity. 

This Cat Scan shows a loose fragment of bone from a process known as OCD, which is related to chronic stress from pitching.

Many professional coaches and some of the finest trainers for children will also stress that pitching is not appropriate for children under 16. Even over 16, a child's growing skeletal system will suffer significantly if pushed past the breaking point.

What is the breaking point? Good question. In some kids that might be 50 pitches a week. In some in might only be 25 ... we just don't know, and we often don't find out until it is too late and a season-ending injury has occurred.

Bottom line:  let your children enjoy themselves and thrive by being a productive member of a wonderful team sport. They do not need to be perceived as the "leader" and should not be allowed to pitch more than 50 pitches per week! There will be time to perfect their pitching motion/strength and their form as they become older and their bodies can handle the stress.