Sternoclavicular Stress Lesions In An Adolescent Gymnast

Abstract

HISTORY: A 13 year old level 7 gymnast presented with a three week history of insidious onset of pain in the proximal clavicular area of his left, non-dominant shoulder. He had no pain at rest or at night. He had recently added a new maneuver to his routine on the parallel bars. Radiographs were normal but further study with CT scanning was performed. The clavicle healed over time. About 5 months after the initial injury he felt a pop in his sternoclavicular (SC) joint area while doing a routine on the parallel bars. He had immediate onset of pain and swelling and could not continue. He again sought an evaluation to determine the nature of this injury. He had been in good health with no previous history of shoulder problems, systemic health problems, previous fracture or tumors. PHYSICAL EXAMINATION: Upon physical examination the patient appeared younger than his stated age but was otherwise normal in appearance. He had no atrophy but did have swelling at his right SC joint area. The swollen area on the right was firm, not mobile and nontender. His cervical spine examination was normal with no limitations of motion. He had full range of motion and strength in both shoulders. He was neurologically intact for sensation, motor and reflexes for both upper extremities. He had normal vascularity to both upper extremities with normal pulses and capillary refill. No provocative maneuvers could reproduce his pain. DIFFERENTIAL DIAGNOSIS: Fracture proximal clavicle Stress lesion proximal clavicle Tumor proximal clavicle Systemic arthritis both SC joints Congenital abnormality both SC joints TEST AND RESULTS: Left shoulder: Plain radiographs normal MRI suggests proximal humerus lesion Blood studies normal including rheumatoid screen and small cell tumor screen Right shoulder: Plain radiographs suggest possible abnormality proximal humerus CT scanning suggests that nonunion of physeal stress lesion FINAL WORKING DIAGNOSIS: Healed physeal stress fracture left proximal clavicle Nonunion physeal stress fracture right proximal clavicle TREATMENT AND OUTCOMES: Left physeal injury curtailed gymnastics for a month and no subsequent symptoms Right physeal injury returned to gymnastics with no limitations; follow up CT scan one year later showed continued nonunion at two years after injury