Left Shoulder Pain - Football

Abstract

HISTORY: A 13 year old football player reported the insidious onset of left shoulder pain over a three month period. The pain began after lifting weights and slowly worsened. It was described as aching and located over the posterior shoulder. The pain was made worse by rotating and abducting the arm and improved with rest. The pain radiated to the upper arm. The patient reported one episode of numbness and tingling in his left arm. He denied any persistence of these symptoms and reported no subjective weakness. PHYSICAL EXAMINATION: Exam of the left shoulder revealed limited active flexion, abduction, and external rotation at the extremes of range of motion secondary to pain. Rotator cuff strength testing on the left revealed weakness and pain throughout, particularly with external rotation. There was also 2+ anterior and posterior instability noted with a positive apprehension and relocation test. The patient was neurovascularly intact to his bilateral upper extremities. There was no supraclavicular or axillary lymphadenopathy. The exam was otherwise normal. DIFFERENTIAL DIAGNOSIS: 1. Rotator cuff strain/tendinitis 2. Shoulder instability/subluxation 3. Scapular dysfunction 4. Bony lesion of the scapula TESTS AND RESULTS: Left shoulder radiographs: -Permeative lesion in the scapular body that extended from the base of the supraspinatus fossa inferiorly to within 3.5 cm of the inferior angle of the scapula. The lesion had ill-defined boundaries and a wide zone of transition. Left scapula MRI with and without contrast: -Lesion in scapula redemonstrated. In greatest dimension, it measured 2.8 cm by 3.2 cm by 5.6 cm with a soft tissue mass extending into the infraspinatus and teres minor. Overall appearance of the lesion was most concerning for an aggressive etiology such as Ewing’s sarcoma or osteosarcoma, though other bony tumors remained in the differential. CT guided biopsy: -Pathology was consistent with eosinophilic granuloma (Langerhan’s cell histiocytosis). FINAL/WORKING DIAGNOSIS: Localized eosinophilic granuloma of the left scapula TREATMENT AND OUTCOMES: 1. Patient is currently undergoing treatment at a tertiary care center (awaiting updated records). 2. Patient is being held out of football currently.