Right Shoulder And Back Pain - Long Distance Runner

Abstract

HISTORY: A 20-year-old college cross country athlete who runs 55 miles per week presents to the ED complaining of a 3 day history of right sided shoulder and back pain. The pain gradually started in the right posterior shoulder and progressed to the right flank. The quality of the pain is described as sharp and stabbing in nature. She denied any traumatic injury. The pain is exacerbated by exercise and deep inspirations. The pain has woken her up from sleep several times. When she tries to run she experiences painful posterior shoulder and back spasm and is unable to tolerate exercise. She also notes a mild exertional dyspnea. She denies motor weakness, bowel or bladder incontinence, abdominal pain, fever, hemoptysis, costo-vertebral angle tenderness or parasthesias. Her current medications include a daily oral contraceptive pill. She denies smoking or alcohol abuse. PHYSICAL EXAMINATION: Vital signs including pulse oximetry on room air are unremarkable. No JVD or cervical spine tenderness. Respiratory exam reveals diminished breath sounds throughout the right lower lobe. She has moderate paraspinal tenderness in the right mid-back. No cyanotic signs are evident in the upper and lower extremities. Homan's sign is negative. Neuro exam reveals no motor or sensory dysfunction. DIFFERENTIAL DIAGNOSIS Rotater cuff tendinitis Subacromial bursitis Neoplasm Fracture (shoulder / rib) Kidney stones or pyelonephritis TESTS AND RESULTS D-Dimer - 1630 EKG: Deep S wave in lead I, Prominent Q wave in lead III, inverted T wave in lead III Chest radiographs -A hazy opacification within the posterior right costophrenic angle suggestive of pulmonary infiltrate. Lumbar spine radiograph - No fracture CT Angiography (Chest) - Large intraluminal thrombus involving the inferior branches of the right pulmonary artery. Lower extremity venous doppler: Negative for DVT Hypercoagulable workup negative FINAL/WORKING DIAGNOSIS: Acute right pulmonary embolism TREATMENT AND OUTCOMES Anticoagulation with Lovenox and Coumadin Percocet as needed for pain. Aerobic activity was not recommended for 1-2 weeks until patient's pain completely subsides without the aid of analgesics Return to running will only be allowed after she is able to tolerate various forms of other light aerobic activity without pain or dyspnea.