Shoulder Pain in a Youth Hockey Player

Abstract

HISTORY: A 14 year-old male hockey player presented for right shoulder pain. He checked an opponent with his left shoulder and developed right shoulder pain immediately. There were no associated neurovascular symptoms. The pain was sharp, and radiated down the lateral shoulder to the mid-arm with abduction. Outside shoulder radiographs were normal. PHYSICAL EXAMINATION: Athletic male resting with his right hand on his abdomen. Asymmetric depression of his right acromion with arms unsupported at his side. Right shoulder range of motion was slightly limited due to pain. He had tenderness just posterior to the distal mid-third of the clavicle diaphysis over the trapezius insertion. Neurologic and strength examination were normal. DIFFERENTIAL DIAGNOSIS: -Trapezius strain -Occult clavicle fracture -ACJ separation -Physeal injury -Brachial plexus injury -Rotator cuff injury -Labral tear TEST AND RESULTS: Diagnostic Ultrasound revealed an avulsion of the deep fibers of the trapezius from the clavicle, with ACJ sprain and distal clavicular hypermobility. Repeat radiographs demonstrated subtle periosteal lifting of the inferior clavicle near the avulsion visualized on sonographic evaluation indicative of a clavicular physeal injury. FINAL WORKING DIAGNOSIS: Grade 1 right ACJ separation with trapezius avulsion off of the clavicle and distal clavicular physeal injury. TREATMENT AND OUTCOMES: The patient was placed in a sling for comfort for 2 weeks. At the 3 week follow-up, he was about 95% of normal, repeat ultrasound demonstrated a small amount of distal clavicular callus formation. He was cleared to resume non-contact aerobic activity (e.g.skating) and gentle, non-painful shoulder isometrics. Re-evaluation at 6 weeks demonstrated full, pain-free shoulder range of motion, normal strength, and distal clavicular callus formation on radiographs. He was released to unrestricted activity.Figure