Posterior Shoulder Pain in a High School Football Lineman

Abstract

HISTORY: 16yo high school football lineman presented with right shoulder pain. He initially noticed moderate pain after squatting 350lbs and placing the weight back down. The pain was sharp and painful when turning his head to the left. He was evaluated at an urgent care facility and felt to have a muscular injury and placed on muscle relaxants and anti-inflammatories. His pain improved transiently. He then re-injured this area when he was in gym class running hurtles and brought his arms across his chest in the front of him. He states that he heard a pop in his shoulder and had excruciating pain, and presented to the sports medicine clinic for further evaluation. The pain was pleuritic and still localized to the posterior shoulder. PHYSICAL EXAMINATION: BMI 33.5RR 17O2 Sat 99% He appeared moderately uncomfortable. He had full motion at the neck with no tenderness of the cervical spine. Bending to the left was mildly painful. He had a negative Spurling’s maneuver. He had tenderness over the medial rhomboids, trapezius, and overlying the scapular body. He had no scapular winging. He had full range of motion at the shoulder and 5/5 rotator cuff strength. He had no AC tenderness or pain with cross arm adduction. His lung fields were clear to auscultation with good air movement throughout. DIFFERENTIAL DIAGNOSIS: 1. Strain or partial tear of scapular stabilizer 2. Snapping Scapula (scapulothoracic bursitis) 3. First Rib Fracture TEST AND RESULTS: Three views of the right shoulder (AP, scapular Y, and lateral axillary) -Nondisplaced, oblique fracture through mid-portion of the first right rib Two views of clavicles (AP and 15 degree cephalic) -Fracture confirmed; no pneumothorax is visualized FINAL WORKING DIAGNOSIS: 1st Rib Stress Fracture secondary to scalene and serratus anterior contraction TREATMENT AND OUTCOMES: 1. Patient was placed in sling and provided with narcotic analgesia; pendulum exercises were emphasized. 2. At three weeks, repeat XR showed minimal displacement of the fracture. His sling was discontinued and he was allowed to start back light weight training (30lbs max). Physical therapy was ordered. 3. At 7 weeks, he was pain free with normal strength and allowed to resume normal weight lifting. 4. At 3 month follow up, repeat XR showed some callus formation. He was allowed to resume contact sports, such as football.