Atypical Nontraumatic Shoulder Pain In A Baseball Player

Abstract

HISTORY:15 year old male high school baseball player with past medical history of asthma, who presented with right shoulder pain. Pain started after swinging in a baseball tournament, with no specific trauma. Pain was located posterior. He was able to continue playing baseball, however pain persisted. Initially he tried heat, ice and ibuprofen with no improvement. Pain progressively worsened over the week with walking, deep breathing and coughing. Additional symptoms included radiation into his neck and shallow breathing. He pursued evaluation at the Emergency Department. His vitals were stable with mild tachypnea, saturating 100% on room air and pulse of 72. Right first rib fracture was noted on CXR. He was discharged with ibuprofen and referral to Sports Medicine. PHYSICAL EXAMINATION: Vital signs stable. Respiratory exam clear to auscultation with good air movement throughout and no distress. Cervical exam with full range of motion and strength in flexion, extension, side bending and rotation with mild pain with resistant right-side bending. Right shoulder exam showed no obvious deformities, swelling or bruising. Tenderness over right supra and infraclavicular areas. Hypertonic scalene and trapezius muscles on the right. Range of motion demonstrated glenohumeral internal rotation deficiency with internal rotation of 20 degrees and external rotation of 110. DIFFERENTIAL DIAGNOSIS: Clavicle fracture. Pneumothorax. Scalene muscle strain. Scapula fracture. SC or AC separation. TEST AND RESULTS: CXR 2 views demonstrated a transverse fracture of the first rib on the right with minimal displacement DIAGNOSIS: Right first rib fracture TREATMENT AND OUTCOMES: 1. Repeat imaging at 3 weeks post injury showed minimal callous formation 2. Advised strict rest with non-weight bearing of the right upper extremity until repeat imaging 3. Physical therapy for glenohumeral internal rotation deficiency found on evaluation. Including aggressive stretching and strengthening exercises for 4-6 weeks. 4. Re-evaluation at 7 weeks post injury showed no tenderness with palpation. 5. Repeat imaging at 7 weeks post injury finally showed callous formation. 6. Return to play with no restrictions at 7 weeks post injury after repeat x-rays showed callus formation, no tenderness with palpation, and full strength and range of motion.