NECK INJURY-FOOTBALL

Abstract

HISTORY a 18 year old senior high school football running back presented to clinic 1 month after injury for evaluation of right shoulder and neck pain. During the post season all star game, the patient struck an opposing player with his right shoulder, while on kick off return. He had immediate sensation of pain and numbness in the right shoulder. There was no instability at the time of injury as documented per the trainer. The patient continued play for the rest of the game. At the time of evaluation he had pain around the AC joint and right trapezius. He had no complaints of weakness or numbness. He complained of ongoing neck stiffness upon awakening and pain was exacerbated by overhead activities. The patient has had previous history of multiple burners associated with numbness. PHYSICAL EXAMINATION Examination, one month after injury, revealed asymmetry and wasting of the deltoid and supraspinatus muscles on the right side. There was also mild tenderness with palpation over the upper trapezius muscle, greater tuberosity, and biceps tendon. Active range of motion (ROM) of the shoulder was limited in forward flexion and abduction to 90 degrees and internal rotation to L2/L3 level. The patient had pain with passive ROM in internal and external rotation as well as abduction. Strength was decreased at 4/5 for forward flexion, abduction, internal rotation, and external rotation. The patient had a positive sulcus sign bilaterally with negative apprehension/relocation test. Provocative testing for impingement was negative. Spurling's test was also negative. Active C-spine ROM was normal. DIFFERENTIAL DIAGNOSIS Brachial plexopathy invoving upper trunk C5-C6 Axillary nerve injury Herniated nucleus pulposis (HNP) at C4-C5 Foraminal encroachment Cervical stenosis Cervical fracture Cervical instability TESTS AND RESULTS Anteroposterior (AP), Y, and Axillary shoulder radiographs: -no bony abnormalities Plain radiographs of cervical spine in flexion and extension: -no bony abnormalities or indications of ligamentous instability Electromyelographic (EMG) with Sensory Nerve Conduction (SNC) analysis of right upper extremity:-Right thumb sensory study revealed normal peak latency and amplitude in the median portion and borderline peak latency and amplitude in the radial portion. -Monopolar needle EMG revealed abnormal spontaneous activity in the right infraspinatus and deltoid muscles with evidence of reinervation in the same muscles and in the right serratus anterior.-Overall impressions reveals electrodiagnostic evidence of a severe acute on chronic right partial axonotmetic injury involving the right upper trunk versus C6 nerve root involvement. Magnetic Resonance Imaging (MRI) of cervical spine:-No evidence of herniated nucleus pulposis or spinal stenosis.-Minimal, if any bony foraminal narrowing at C5-C6 level or elsewhere. FINAL WORKING DIAGNOSIS Acute on chronic brachial plexus injury. TREATMENT AND OUTCOMES Nonsteroidal anti-inflammatories as needed for pain. Strengthening and ROM exercises thru physical therapy. At return visit 3.5 months after initial visit, the patient had full ROM of the shoulder with no decrements in strength. Cervical range of motion was normal. The patients only complaints were of mild muscle tenderness over the right trapezius. There was still evidence of right sided trapezius and deltoid wasting. He had experienced one episode of right arm numbness, lasting one day, after bench pressing. He was advised to continue activites as tolerated to pain but to avoid activities such as bench and military press. He will continue strength training and be re-evaluated in 3 additional months. Repeat EMG/SNC in 6 months from first exam to evaluate recovery.