Arm Injury-Baseball

Abstract

HISTORY: A 19 year-old male baseball pitcher presented with a complaint of right lateral arm and shoulder pain of one-year duration. He reported that initially he was able to pitch without much discomfort, but would develop soreness in the region of the triceps and biceps the following day. He began to notice an ache in his right shoulder while pitching several months later. Although he denied shoulder weakness, he did report an incident in which he developed severe transient weakness of right index finger extension following a game. PHYSICAL EXAM: Mild tenderness was present in the deltoid and posterior arm. There was full range of motion, but 4/5 strength in the deltoids, biceps, supraspinatus and external rotators. Muscle stretch reflexes were 2+ at the triceps and brachioradialis, but 1+ at the biceps. Sensation was intact throughout the upper extremity. Provocative maneuvers for labral and rotator cuff pathology were negative. DIFFERENTIAL DIAGNOSIS: Brachial Plexopathy Suprascapular Neuropathy Thoracic Outlet Syndrome Vascular Insufficiency/Vascular Thoracic Outlet Cervical Radiculopathy Radial Neuritis TESTS AND RESULTS: Shoulder X-ray Series: No fracture or cortex abnormality Shoulder MRI: Normal without any labral or rotator cuff pathology High Resolution MRI of brachial plexus, thoracic outlet and radial nerve: Normal Three Phase Bone Scan within 24hrs of pitching: No abnormalities NCS/EMG: 1+ fibs in the extensor indices proprius, otherwise normal study Surgical Exploration: Radial nerve entrapment due to an anomalous tendon on the lateral head of triceps FINAL WORKING DIAGNOSIS: Radial neuritis due to an anomalous tendon on the lateral head of triceps causing kinking of the radial nerve with flexion. TREATMENT AND OUTCOMES: He underwent a radial nerve neurolysis and excision of the anomalous tendon. He made gradual improvement in upper extremity strengthening and began throwing two weeks post surgery. Unfortunately he did not return to collegiate pitching this season due to a spontaneous pneumothorax requiring surgical management. A few months later, he returned to Fall practice.