Shoulder Pain In An Adolescent Due To Fly Fishing

Abstract

HISTORY: A previously healthy 14 year old male presented to our clinic for a second opinion about pain in his right, dominant arm. He had no previous problems with his shoulder until 4 months prior to seeing us. At that time he and his Father had gone fly fishing in Canada. He used standard fly fishing rod and tackle and they fished 10 hours per day for 3 days in a row. He never had an injury to his shoulder, but the last day he began to have soreness in his right anterior shoulder which worsened over the next few days. He saw an orthopedic surgeon who took radiographs and an MRI of the shoulder but failed to come up with a diagnosis. The pain was worsened with abduction or reaching across his body. He had no parasthesias or neck pain. He was in good health with no systemic illnesses. Low doses of ibuprofen did not resolve his pain. PHYSICAL EXAMINATION: He was in no acute distress with no atrophy or deformity. He had full range of motion except for a loss of 5 spinal levels of internal rotation up the back. He had pain with resisted internal rotation but no weakness. His strength testing otherwise was normal and without pain. He had a negative lift off test but he had pain with a resisted lift off test. He had a positive Neer impingement sign, Hawkins impingement sign, shrug sign, active compression test and Whipple test. He was tender along his lesser tuberosity area but not when palpating the biceps tendon 4 to 5 centimeters distal to the acromion. His sensory examination was normal and he had a negative anterior and posterior apprehension tests. DIFFERENTIAL DIAGNOSIS: Rotator cuff inflammation Biceps tendonitis Superior labrum anterior posterior lesion (SLAP) Occult instability Epiphyseal irritation similar to Little League Shoulder TEST AND RESULTS: Plain radiographs of the shoulder: Anterior-posterior views negative, Axillary radiograph of shoulder: avulsion fracture lesser tuberosity, MRI: edema around fragment lesser tuberosity FINAL WORKING DIAGNOSIS: Subscapularis tendon avulsion injury lesser tuberosity TREATMENT AND OUTCOMES: Restricted throwing or abduction-ER motions, bench press, Allowed to do sports which did not cause pain, Radiographic follow up showed no change in fragment, He returned to all sports with no symptoms 4 months later