Thoracic Pain - Tennis

Abstract

HISTORY: A 24-year old right-handed female former collegiate tennis player presented to clinic with a 2-year history of left sided periscapular pain. She developed symptoms while playing a competitive tennis match, and reports feeling a sharp pain around the left scapula after hitting a forehand volley with her right hand. The pain persisted after the match, even at rest. She denies any similar symptoms previously, no prior injuries to the shoulder, back or neck. She had months of physical therapy without any significant resolution. PHYSICAL EXAMINATION: Inspection of the thoracic spine revealed a prominence of the medial border of the left scapula. Thoracic extension was mildly limited and non-painful. The left scapula demonstrated delayed medial rotation when bringing arms down from an abducted position. Shoulder examination was notable for discomfort with left shoulder abduction that improved with scapular assist. There was tenderness to palpation along medial border of the left scapula. There was no cervical or thoracic spinous process or paraspinal tenderness to palpation. Cervical spine range of motion was full. Spurling’s was negative bilaterally. The shoulder examination was unremarkable. Strength, sensation and reflexes were normal in bilateral upper extremities. DIFFERENTIAL DIAGNOSIS: 1. Long thoracic neuropathy 2. Parsonage-Turner syndrome (idiopathic brachial plexopathy) 3. Neuromuscular control dysfunction causing scapular dyskinesis 4. Thoracic rib dysfunction 5. Thoracic discogenic pain or radicular pain 6. Cervical radiculopathy TEST AND RESULTS: EMG/Nerve Conduction Study: electrodiagnostic evidence of a left long thoracic neuropathy with features of early reinnervation and no evidence of ongoing denervation. MRI Thoracic Spine: normal FINAL WORKING DIAGNOSIS: Left long thoracic neuropathy TREATMENT AND OUTCOMES: 1. Physical therapy focused on neuromuscular control of the periscapular muscles to restore normal scapulohumeral rhythm 2. Trial of low-dose gabapentin for neuropathic pain 3. Activity as tolerated