Atypical Shoulder Pain In A Swimmer/rower

Abstract

HISTORY: A 16 year-old right hand dominant male who is a competitive rower and swimmer presents with 10 months of left shoulder pain that was first noticed after returning to competitive swimming after a 6-month hiatus. He describes the pain as atraumatic, intermittent, progressively worsening and a 3-9/10 anterior “ache”. His pain is noted in the pull phase in rowing, pushups, and pulling aspect of the freestyle stroke. Pain is associated with weakness and crepitus but no paresthesias. He has not been able to continue competitive rowing. Prior workup includes an unremarkable MRI. Previous treatments have included ice, heat, acupuncture, oral and topical NSAIDs, one month of rest and PT without resolution. PHYSICAL EXAMINATION: Muscular build with protracted shoulder position. Full AROM with pain at end range abduction and flexion. Tenderness to palpation over AC joint, subacromial space and bicep tendon area. Strength is 5/ 5 throughout, except trace weakness secondary to pain with external rotation. Positive Speeds, Hawkins, Obriens and Neers tests with palpable popping anteriorly with passive abduction and external rotation. Belly press, lift off and bear hug cause anterior pain. DIFFERENTIAL DIAGNOSIS: Labral pathology AC joint pathology Long head of the bicep tendonopathy RTC tendonopathy Subacromial bursitis/impingement Subcoracoid impingement Bony pathology such as stress fracture or tumor TEST AND RESULTS: MR Arthrogram: normal US: hypoechoic area of distal long head of the bicep tendon and cortical irregularity of the lesser tuberosity with tender sonopalpation. US guided biceps tendon sheath corticosteroid injection for diagnostic and therapeutic purposes resulted in temporary improvement. High resolution CT: 1.1 cm osteochondroma abutting the biceps tendon. TREATMENT AND OUTCOMES: Diagnostic arthroscopy and arthoscopic middle glenohumeral ligament repair with initial improvement. At 6 weeks he returned to completing 75% of his swim workouts and competed in a district rowing championship. However at the 9-month mark, his pain gradually returned to pre-surgical character, quality and intensity level. Orthopedic referral for tumor excision is pending. WORKING DIAGNOSIS: Symptomatic osteochondroma causing mechanical irritation of the bicep tendon and surrounding tissues.