Shoulder pain in a baseball pitcher

Abstract

HISTORY: A 15 yo right handed male baseball player presents with a one month history of right anterior shoulder pain following an injury from running into a fence while playing baseball. At initial impact, he had mild pain which later evolved significantly while he was pitching. He now notes sharp pain in the anterior right shoulder exacerbated by shoulder abduction, extension, batting practice, and pitching. He denies any sensation of shoulder instability and reports relief of pain with rest. He denies any prior evaluation or prior shoulder or upper extremity problems or injuries. He is in the 10th grade and plays Varsity level baseball and hockey. Past medical, surgical, and family history are unremarkable. PHYSICAL EXAM: Inspection: mild hollowing of the right infraspinatous fossa. Palpation: tenderness at the proximal right biceps tendon and anterior labrum. ROM: right shoulder with full shoulder flexion and extension. Mild deficit of right shoulder internal rotation compared to the left. External rotation: Left 1200, right 1400. Internal rotation: Left 450, right 300. Motor, sensory exam, and DTR's all normal. Special tests: Hawkins, Neer, and empty can test all negative. O'Briens test is positive and Anterior slide test equivocally positive. Differential Diagnosis: Anterior Labral tear Labral Cyst Rotator cuff injury Focal Biceps tendinopathy Transient anterior shoulder dislocation Physeal injury Tests and Results: X-RAY: Performed in office revealed open growth plates and no obvious pathology. MRI: Performed 2 days post-evaluation with gadolinium: Mild tendinosis of the distal supraspinatus tendon without evidence of rotator cuff tear; Hill-Sachs deformity of the humeral head with subjacent marrow edema suggesting a subacute anterior dislocation; Heterogeneous signal in the region of the anterior-inferior labrum without definite MR evidence for a detached labral tear. All other aspects of the study were normal. FINAL/WORKING DIAGNOSIS: Hill-Sach deformity likely secondary to subacute anterior dislocation from impact with fence. TREATMENT AND OUTCOMES: Initial treatment with relative rest, strengthening of the RTC and scapular stabilizers followed by progressive return to throwing. This case is ongoing, final treatment and outcome to be fully discussed in presentation at conference.