SHOULDER INJURY - FOOTBALL

Abstract

HISTORY A 19-year-old right hand dominant college football player with known bilateral multi-directional instability but no prior subluxations or dislocations sustained a traumatic anterior-inferior right shoulder dislocation during a football game. While scrambling for a lose ball, he landed on the ball with his shoulder abducted and externally rotated, after which an opponent landed on the back of his shoulder. He heard a pop, accompanied by the dislocation. Attempted on-the-field reduction failed, and he was transported to a local emergency room. Pre-reduction x-rays were normal, and reduction required sedation and multiple medical personnel. He presented to our Sports Medicine Clinic 2 days later complaining of global right shoulder pain, inability to abduct or forward flex the shoulder and numbness over the lateral proximal arm. PHYSICAL EXAMINATION The right upper limb was slightly inferiorly subluxated without sulcus or step-off. The deltoid was slightly hypotonic and without fasciculations. Palpation revealed global anterior and lateral shoulder tenderness, but no clavicle tenderness. Active range of motion was 20° in flexion, 5° abduction and 30° extension. There was no visible or palpable contraction of the anterior, middle or posterior heads of the deltoid. Strength was otherwise intact throughout. A sensory deficit to light touch was noted over the lateral aspect of the proximal arm at the distal deltoid. Reflexes were normal. Apprehension was not tested. DIFFERENTIAL DIAGNOSIS Shoulder dislocation. Axillary neuropathy. Brachial plexopathy. Cervical radiculopathy. Rotator cuff injury. TESTS AND RESULTS Right shoulder radiographs AP IR & ER and axillary views – Suggestion of a Hill-Sachs lesion Right shoulder MRI -Confirms Hill-Sach's lesion with edema -Complex Bankart lesion -Intact rotator cuff Electrodiagnostic studies (at 3 weeks) – Absent right axillary compound muscle action potential – Fibrillation potentials and poor motor unit potential activation of all heads of the right deltoid with reduced recruitment -Normal needle examination of the right biceps, triceps, infraspinatus and teres minor. FINAL/WORKING DIAGNOSIS Traumatic unilateral anteroinferior shoulder dislocation with a severe axillary neuropathy. TREATMENT AND OUTCOME Anti-inflammatory and sling for analgesia and support. Physical therapy for scapulothoracic ROM, shoulder passive and active assisted range of motion and isometric exercises. Thera-Band exercises for internal and external rotation at 3 weeks, at which time the patient had 175° active shoulder elevation, 165° abduction and 75° passive external rotation before apprehension. There was still no perceptible voluntary contraction of the deltoid muscle. No return to play for remainder of season. Repeat MMT at 6 weeks reveals no palpable deltoid activity. Second opinion with orthopedic surgeon arranged.