Right Arm Pain In A Collegiate Softball Shortstop

Abstract

HISTORY: 18 year old right hand dominant female college softball shortstop complaining of right elbow pain x 5 months. She describes paresthesias from elbow to hand, along with notable weakness in the hand. Pain worsens with overhead activity, improves with resting arm at her side. Hx of subluxation of right shoulder several years earlier. PHYSICAL EXAMINATION: Right Shoulder: Inspection: prominence winging of scapulae b/l, + scapular dyskinesia b/l. ROM: Flexion:180, Extension:60, Adduction:nl, Abduction:180, Ext rot:90, Internal rot:T10. Palpation: AC/SC/Clavicle:non TTP. MSK Strength: Supraspinatus:5/5, Infraspinatus:5/5, Subscapularis:5/5. Special test:Jobe’s test:Neg, Hawkins-Kennedy test:Neg, Speeds test:+, Biceps tendon:+TTP, Cross chest Adduction:Neg, Obrien’s test:Neg, Neer’s test:Neg, Tinel’s test: Neg, Scapular Function: Severe dysfunction of right scapula, + profound winging b/l, Rt>Lt, + wall push up test. Roos:+, Adson’s:+ recurrence of symtpoms. DIFFERENTIAL DIAGNOSIS: Thoracic Outlet Syndrome, Long Thoracic nerve palsy, Cervical Radiculopathy, Myofascial pain syndrome, Shoulder impingement syndrome, Cubital tunnel syndrome, Scapular dyskinesia TEST AND RESULTS: A/P Xray C-spine: unremarkable, no abnormalities of alignment seen or cervical ribs noted. EMG: All nerve conduction velocities, terminal latencies, and amplitudes were wnl’s, with the exception of very mild slowing of all nerve conduction velocity across the ulnar groove with no loss of amplitude. The right serratus anterior revealed silence at rest with normal motor units and it is recruitment when samples at the rivet insertion. When sampled at the origin while the pt intentionally caused scapular winging, this also revealed silence at rest with no volitional activity. FINAL WORKING DIAGNOSIS: Thoracic outlet syndrome secondary to scapular dyskinesia, with congenital denervation vs. absence of serratus anterior muscle. TREATMENT AND OUTCOMES: 1.Referral to formal PT for rotator cuff/scapular strengthening and stabilization exercises. Office f/up in 4 wks, pt is struggling to return to collegiate softball play at a high level. Pt continues to have numbness and tingling in right hand. Pt continues physical therapy.