Bilateral Shoulder Pain - Baseball

Abstract

HISTORY: A 14-year-old right handed baseball player presents with two and a half years of insidious-onset bilateral shoulder pain. The pain is generalized in both shoulders, but worse anteriorly and in the right shoulder. He has continued to play year-round at an elite level, but he had to stop pitching due to pain. His shoulders “catch” and pain is exacerbated with rapid movements. PHYSICAL EXAM: Examination in clinic demonstrated tenderness of the anterior and posterior humeral head on the right and anterior humeral head on the left. Range of motion is limited in extension, internal rotation, and external rotation, and is full in flexion and abduction. Strength is full in all ranges of motion with pain in abduction, internal and external rotation. Hawkins, O’Brien’s, and Crank tests are positive for pain. He is distally neurovascularly intact. DIFFERENTIAL DIAGNOSIS: 1. Labral tear 2. Proximal Humeral Epiphysiolysis 3. Synovial Osteochondromatosis 4. Dysplasia Epiphysealis Hemimelica TEST AND RESULTS::Bilateral shoulder radiograph: Abnormal rounded ossific densities anterior to the right humeral head and metaphysis. Similar pattern of ossification anterior to the left humeral head,which is less well-defined than that seen in the right shoulder.Bilateral shoulder MR without contrast: Bilateral symmetric irregularly-shaped osteochondral fragments within the anterior glenohumeral joint spaces with evidence of erosions of the humeral head.Bilateral shoulder CT without contrast: Bony irregularity along the medial, proximal aspect of both humeri with clustered ossicles adjacent to the bony irregularity. No evidence of free intra-articular bodies. FINAL/WORKING DIAGNOSIS: Bilateral Synovial Osteochondromatosis of the Shoulders TREATMENT AND OUTCOMES: 1.Referred for a surgical consult, where non-operative treatment was recommended. 2.Started in physical therapy (PT). 3.Continued full participation in sports despite pain. 4.10-15% improvement after 3 months of PT. 5.Currently travelling for the winter baseball season and continuing PT at a distant site.