Shoulder Pain in a Weightlifter

Abstract

HISTORY: A 20-year-old male weightlifter presented as a new patient to a sports medicine clinic with left shoulder pain. Pain began five months prior while the patient was performing overhead presses with a 205 lb barbell. While pushing up into his 5th repetition, he felt a “shift” in his left shoulder. He did not have a significant amount of pain at the time. In the following weeks, he began to have more pain in the left shoulder and decreased his weight during overhead presses and chest presses due to pain and weakness. He tried taking two weeks off from lifting, but when he resumed he was unable to complete any overhead or chest work due to pain. The pain is focal over the anterior-lateral shoulder with no radiation. No numbness or tingling. He is unsure if his weakness is due to pain or a separate issue. PHYSICAL EXAMINATION: There was no bony abnormality or muscle atrophy. Patient had full active range of motion of the left shoulder in forward flexion and abduction, with mild pain at end range. Passively, he had 85 degrees of external rotation and 85 degrees of internal rotation with arm abducted to 90 degrees. There was tenderness to palpation along the distal clavicle and acromion, as well as over the supraspinatus, infraspinatus, teres minor/major, biceps, and anterior deltoid. Jobe’s test positive for pain and weakness. Positive cross-arm test. Negative Hawkin’s, Neer’s, O’brien’s, Speed’s, and Yergason’s. Pain with resisted external rotation and shoulder abduction. Strength was 5/5 at bilateral deltoid, biceps, triceps, wrist extensors, finger flexors, and finger abductors, but 4/5 during resisted left glenohumeral external rotation due to pain. DIFFERENTIAL DIAGNOSIS: 1) Glenohumeral subluxation 2) Rotator cuff tear 3) Labral tear 4) AJ joint sprain/separation 5) Clavicle fracture TESTS AND RESULTS: 1) XR Chest from ER visit for unrelated incident: Visualized left clavicle normal, shoulder not visualized. 2) MRI left shoulder without contrast: Nondisplaced fracture of the distal clavicle with associated bony edema of the clavicle and acromion at the AC joint with mild surrounding soft tissue edema. Low grade tendinosis of the infraspinatus and supraspinatus with suspicion for a tiny undersurface tear without retraction. 3) XR Clavicle: Clavicle is intact and negative for fracture. FINAL/WORKING DIAGNOSIS: Nondisplaced fracture of distal clavicle TREATMENT AND OUTCOMES: 1.Given no signs of fracture healing after 5 months, ordered laboratory work which revealed Vitamin D deficiency. Patient started on Vitamin D 1200mg and Calcium 800mg daily. 2. Activity modified to abstain from weight bearing exercises through the left upper extremity until next follow up visit.