Shoulder Instability - Collegiate Diver

Abstract

HISTORY The patient was an 18 year old collegiate diver who had insidious onset of shoulder pain during the fall of his freshman year. This pain was associated with swimming and not with diving. One day in practice he was diving and when he hit the water and his shoulder sustained an axial load, driving his shoulder posteriorly. He felt his shoulder slide out of the socket and spontaneously reduce. He stopped diving that day but could not return despite a month's rest. He continued to have shoulder pain with activity but no sense of instability. He did not have parasthesias, neck pain or weakness. He was in good health with no history of connective tissue disorders. PHYSICAL EXAMINATION He had no atrophy or deformity of his shoulders. He had full range of motion but had a painful are. His strength was normal except pain with resisted external rotation with his arm at the side. He had a positive Neer and Hawkins impingement sign. He had pain with posterior apprehension testing which he reported to be deep in his posterior shoulder. He had a grade 2 sulcus sign which did not reproduce his symptoms. His posterior drawer revealed a posterior subluxation which produced pain only. He had a positive active compression test. He was otherwise entirely neurologically intact for sensation, motor and reflexes. DIFFERENTIAL DIAGNOSIS Posterior subluxation Superior labrum (SLAP) lesion Rotator cuff tear Rotator cuff tendonitis Strain of posterior capsule of shoulder TEST AND RESULTS Plain radiographs (AP in internal and external rotation, axillary views): reverse bony Bankart lesion MRI shoulder: Reverse Bankart lesion FINAL WORKING DIAGNOSIS Posterior traumatic instability shoulder TREATMENT AND OUTCOMES Patient had failed non-operative rehabilitation for 5 months Diagnostic arthroscopy revealed posterior labrum detachment (reverse Bankart) Open posterior capsular shift with posterior bony Bankart External rotation brace for 6 weeks Progressive rehabilitation program Return to diving over 9 months