Shoulder Pain- Weightlifter

Abstract

TITLE: Winged scapula in a recreational weight-lifter after inguinal hernia repair. HISTORY: A 34 yo male R handed recreational weight-lifter presents with 5 months of R shoulder and upper extremity pain. He notes that his scapula "pops out". There is no history of injury or trauma to the R shoulder. Five months prior, the patient underwent an uncomplicated laparoscopic bilateral inguinal hernia repair. 1 1/2 days after the hernia repair, he noted the onset of severe pain in his right shoulder. He reports deep shoulder pain with radiation to elbow and forearm. He went to an ER. EKG, cardiac enzymes and abdominal CT were all normal. He then went to an orthopedist who performed a corticosteroid injection for a presumptive diagnosis of posterior cuff tendonitis; this gave him no relief. PHYSICAL EXAMINATION: The patient is a well developed, male in NAD. Height 5-ft. 9 ½", and weight 188 lbs. Cervical spine exam reveals normal lordosis and full ROM without pain. No tenderness or atrophy of the cervical musculature. Decrease in active ROM of the R shoulder: forward elevation is restricted to 80°, abduction 80°, external rotation 45°. Passive ROM is not restricted. No pain elicited with palpation of the AC joint or cross-over test. No tenderness present in the subacromial space. Yergason's, drop arm, impingement and lift-off testing negative. Supraspinatus test of the R shoulder reveals significant pain and weakness, as did resisted external rotation. The right scapula reveals prominent winging. Neuro exam shows 5/5 strength throughout except for the right supraspinatus which was 4/5. Sensation and DTRs unremarkable. Pulses 2+. DIFFERENTIAL DIAGNOSIS: 1. Brachial neuritis (Parsonage-Turner Syndrome) 2. Posterior cuff tendonitis secondary to weight lifting 3. Intra-operative complication with referred pain from irritation of the diaphragm 4. Brachial plexopathy TESTS AND RESULTS: X-ray of right shoulder was unremarkable. Patient refused EMG/NCV testing. FINAL DIAGNOSIS: Long thoracic nerve palsy (Parsonage-Turner Syndrome) with the hernia repair as the inciting event. Suprascapular nerve palsy involvement suspected as well. TREATMENT AND OUTCOMES: Analgesia Avoidance of weight-lifting in acute phase Referral to PT Three year F/U reveals persistent winging - this athlete switched to running/cycling exercise.