Shoulder Pain-Weight Lifting

Abstract

HISTORY: 22yo male recreational weightlifter and triathlete p/w several month h/o progressive L shoulder pain of insidious onset. He reported weakness in his shoulder, particularly with weight training, and described intermittent numbness and paresthesias radiating from the shoulder into the forearm and hand. He denied swelling or discoloration of the LUE. PMH: (+)RLE DVT with PE, approx. 1 year earlier, after immobilization in CAM walker following RLE injury. Extensive hypercoagulability work-up was (−). Meds: coumadin 5 mg daily, ASA 81 mg daily. (+)rare ETOH use. (−) tobacco/recreational drug/anabolic steroid use. FH: (−) thromboembolic/neurologic disease. ROS: no constitutional sx. PHYSICAL EXAMINATION: Gen: healthy-appearing, muscular, young male. No LUE edema/discoloration. L shoulder: no atrophy/deformity, (+)full ROM, (+)pain with shoulder elevation >130°, (+)Hawkin's test, (−)apprehension test. RUE strength 5/5, including RTC. Sensation intact to soft touch/pinprick. Reflexes +2 symmetric. Normal pulses LUE. (−)Spurling's maneuver, (−)Adson's test, (−)Roos test, (−) costoclavicular maneuver. DIFFERENTIAL DIAGNOSIS: Shoulder impingement syndrome Cervical radiculopathy Thoracic outlet syndrome Upper extremity deep vein thrombosis Brachial plexopathy TEST AND RESULTS: Shoulder MRI: small fluid collection in subdeltoid bursa and subcoracoid region, small effusion in glenohumeral joint, small subcortical cysts in posterior humeral head laterally. Os acromiale present. LUE EMG/NCS: abnormal insertional activity, denervation potentials and membrane instability c/w with active C6 radiculopathy. C-spine x-rays: normal C-spine MRI: normal Brachial plexus MRI: thrombosis of L subclavian vein with inflammation of nearby brachial plexus in cervical vascular and subclavicular regions. FINAL WORKING DIAGNOSIS: C6 radiculopathy secondary to subclavian vein thrombosis TREATMENT AND OUTCOMES: Given duration of sx, pt not considered candidate for thrombolytic tx. INRs in preceding months had been in 2.0-2.4 range. Hematology consultant who had been involved with pt's prior care for DVT/PE. advised increasing coumadin dosing to achieve INR in 2.5-3.0 range. Pt referred for surgical evaluation for consideration of thoracic outlet decompression.