Shoulder Pain in a Swimmer

Abstract

HISTORY: A 17 year old male, right hand dominant, competitive swimmer presented to clinic with a 2 week history of right shoulder pain. Initial pain was associated with coughing secondary to an upper respiratory infection and localized to the right upper trapezius and scapula. Several days later, he playfully lifted a heavy friend, felt more pain in the same area, and dropped his friend due to severe pain. Pain occasionally radiated down posterior arm. Exacerbating factors included overhead activities including swimming, shoulder abduction, cross body reaching, deep breathing and coughing. Past history included possible right shoulder dislocation in fifth or sixth grade, when shoulder “popped in and out”. PHYSICAL EXAM: Peripheral pulses intact, normal capillary refill. Breathing unlabored; pain with deep breathing. Strength, reflexes, and sensation normal. No evidence of atrophy, scapular winging, or swelling. No obvious tenderness to palpation. Full active shoulder range of motion with pain at terminal arc of forward flexion and abduction. No glenohumeral internal rotation deficit. Pain with horizontal cross-body adduction, Neer’s maneuver and resisted shoulder external rotation. DIFFERENTIAL DIAGNOSIS: 1. Rotator cuff injury 2. Shoulder impingement 3. Labral tear 4. Myofascial pain 5. Cervical strain or radiculopathy 6. Brachial plexitis/Parsonage turner 7. Spontaneous pneumothorax 8. Rib injury TEST AND RESULTS: Shoulder radiograph - Complete transverse fracture right 1st rib with associated soft tissue swelling. - Flattening of greater tuberosity of right humerus posterolaterally suspicious for a Hill-Sachs fracture. Slight deformity of tuberosity on external rotation view raises possibility of fracture. FINAL/WORKING DIAGNOSIS: Right first rib fracture TREATMENT AND OUTCOMES: 1. Initial treatment: No swimming. Encouraged rest, analgesia with Tylenol and avoidance of overhead activities and activities that caused pain including lifting. 2. Return visit 5 weeks after initial pain onset: Right rib radiograph showed a slightly comminuted and displaced fracture of the lateral aspect of the right 1st rib. On physical exam, full non-painful range of motion and strength of shoulder. 3. At 6 weeks, he gradually re-introduced upper body activity. 4. Returned successfully to competitive swimming.