Casey Bass: Today on Clubhouse Gas, I am going to go and see Dr. Marshall. We've got to do something about this shoulder pain; stay tuned. We are lucky enough to be joined by friend of the show, and the Director of Sports Medicine here at Children's Healthcare of Atlanta, David Marshall and his son Grant. Guys thanks for joining us. Dr. David Marshall: Thanks for having us back. Casey Bass: Today I want to talk about something that I have never heard off until today. I have heard Little League Elbow, but not Little League Shoulder. What is Little League Shoulder? Dr. David Marshall: Well Little League Shoulder is another one of those pesky growth plate elements that seems to effect Little League baseball players between the ages of 8 and 13 when their growth plates are still open and it’s another one of those growth plate injuries rather than the elbow, the knee, the heel, this occurs at the top of the shoulder. Casey Bass: We'll use this good looking model; we have got here and show us exactly what's going on. Dr. David Marshall: Well in a nutshell there is a really two different types of growth plates we have in our body. One growth plate is called an Apophysis and that’s the growth plate that serves as an anchor points for muscles and tendons. So the Little League Elbow, Osgood Slaughters disease, Sever’s disease, other growth plate problems in the knee are called Epiphyseal; where this growth plate is little more important, it is called an Epiphysis, and that growth plate is made up of a cartilage bar that is found at the ends of all of our long bones in our body. And those growth plates are very important, because what they will do is lay down layer after, layer after, layer of new bone and that’s what allows our bones to grow in length. So if we injure those growth plates we have to be concerned about the bone prematurely stopping growth. Casey Bass: So where you told us in a previous show that we could -- even with a little bit of pain the kid could go and play, they are not going to hurt themselves anymore, this might not be the case. Dr. David Marshall: Absolutely not in if kids have Little League Shoulder, if they have an injury to the growth plate at the top of the Humerus or the arm bone, then we really have to be little more aggressive, and much more careful to treating these kids. We recommend that they do not throw for a period of sometimes of six to eight weeks. I tell the kids this is like a broken arm. Now it's not like your arm broken half, that happens when you fall of the monkey bars, but in terms of the growth plate it is a fracture of that growth plate. Casey Bass: Well all we have got Grant we just want you show us exactly what it is that causes it. Dr. David Marshall: This is where it hurts. A lot of the older kids will complain of rotator cuff pain, the high school pitchers, the college pitchers, they will complain of pain more in the top of the shoulder, sometimes back behind the shoulder. But the young athletes that have Little League Shoulder they complain of pain more down at the top of the arm. So they will grab their arm, or they will point here, and that’s a very concerning complaint if they come in with that. What happens anatomically is the rotator cuff muscles from the back attach right above the growth plate, right about here. And when they throw that follow through phase of throwing there is an awful lot of traction or torque forcing the shoulder this way. So the momentum is going that way, the rotator cuff muscles are pulling that way, and that’s what sets up that traction force on the growth plate and over time that growth plate will actually separate and that’s the fracture what causes the pain. Casey Bass: So it is not actually the act of throwing, it is act of follow-through? Dr. David Marshall: Yes, it's the deceleration phase of throwing. When the kids -- when they are in that cocking phase, or acceleration they are much more likely to get pain in the elbow, but as you are coming