Shoulder Injury - Recreational Alpine Skiing

Abstract

HISTORY: 54-year old female recreational alpine skier with history of left shoulder pain following a fall on hyperabducted outstretched arm after being hit from behind by another skier 3 days earlier. She noted immediate local pain of 8/10 on VAS and noticed a popping sound in the shoulder at injury. She was unable to lift her arm. PHYSICAL EXAMINATION: Edema was noted at the anterolateral shoulder, no gross deformity present. Palpation of soft tissues, tendon and bony structures revealed significant point tenderness at the greater tuberosity. Limited active ROM of 20 deg. in flexion, abduction and external rotation due to pain. Passive ROM was 80 degrees in flexion and abduction, 30 deg in ext. rotation. Resistive testing was weak and painful in flexion, abduction and ext. rotation. Due to significant pain complaints, further physical examination was suspended and clinician progressed to point-of-care ultrasound imaging of the shoulder complex. DIFFERENTIAL DIAGNOSIS: 1. Rotator Cuff Tear 2. Labral Tear/ Bankart Lesion 3. Proximal Humerus Fracture 4. Shoulder Sprain 5. Reduced Shoulder Dislocation TEST AND RESULTS: MSK Ultrasound Imaging of the shoulder complex revealed 10mm displacement of supraspinatus footprint of humerus in LAX. Patient was referred to orthopedic surgeon for further diagnostic imaging. XRI revealed displaced and comminuted greater tuberosity fracture. 3D CT also revealed acute greater tuberosity avulsion fracture with 9mm displacement. FINAL WORKING DIAGNOSIS: L shoulder displaced greater tuberosity fracture TREATMENT AND OUTCOMES: Patient underwent open ORIF of greater tuberosity fracture with two 6.5 PEEK anchors and parachute suturing. During procedure anterior/lateral rotator cuff tear was noted and repaired using high five sutures. Post surgical rehabilitation consisted of a modified RCR protocol: -Week 0-2: Brace immobilizer and PROM only in flexion to 90 deg. -Week 2-4: Brace continued. Progressed to PROM in all directions and pendulums in 4 weeks -Week 4-8: Progressive AAROM to AROM and gentle isometrics -Week 8-12: Progressed to RC strengthening and functional activities Patient outcomes were excellent with SPADI 4/100, full ROM in all directions, and only minor weakness in abduction/external rotation. Patient returned to full recreational athletic activities.