1. Group 4 David Folt, Stephen Smith, Valerie Allen, Amanda Foley

2.  A 17 year-old male student athlete  Chief complaint: complains of a “bad shoulder” Vital signs:  Blood Pressure: 125/75  Pulse:58 bpm  Rhythm:Regular  Temperature: 97.6 o F  Respiratory rate: 13 bpm  Height:6’0”  Weight:200 lbs.  General:No cutaneous sensory changes were found. No swelling or changes in perfusion were noted.  All other systems: Normal

3.  He was performing bench press without a spotter when his left upper limb and shoulder were pushed posteriorily past the bench by the shifting weight.  He states that he felt “an electric shock” inside his left shoulder.  When he was free from the weight bar and was able to stand up, he found that could not raise his left arm away from his body.  Following the incident he went home, took some “pain medicine”, and went to bed.  During the next several days he experienced pain and “stiffness”, especially in his chest and left upper limb.

4.  Left shoulder:  a decrease of muscular tone (firmness) on the posterior scapula  The glenohumeral joint allows a greater degree of manual movement Flexion/extension, medial/lateral rotation present but not smooth  Inability to voluntarily abduct the left arm from anatomical position to 90 degrees  Ability to maintain the position of 90 degree abduction if the limb is placed in that position

5.  1)Which bone(s) and or ligament(s), if any, have been directly damaged?

6.  Bones:  Probably none involved  Why?  Ligaments:  If any, fibrous joint capsule involved in glenohumeral joint  Heavily involved in glenohumeral stability, possible compromised stability

7.  The function of which muscle/tendon unit(s), if any, has been altered by this event? How has the function been altered?

8.  Possible muscles involved:  Supraspinatus Cannot abduct from anatomical position to 30 degrees  Infraspinatus Weakened lateral rotation Quick! What nerve innervates supra/infraspinatus?  Deltoid Possible strain, no innervations affected Clavicle  Deltoid tuberosity connection affected in the incident Flexion/Extension, lateral/medial rotation are not smooth movements  Pectoralis major Pain/stiffness, swelling in chest Hyperextension of muscle during the incident

9.  The function of which peripheral nerve(s), if any, has been altered by this event? How has the function been altered?

10. Nerves Involved:  Suprascapular  Supraspinatus and infraspinatus  Where does the suprascapular n. come from?  NOT axillary  Deltoid maintains functionality

11. How has nerve function been altered?  No sensory changes, therefore not severed  Other nerves that are continuous with the upper trunk are not affected (i.e. musculocutaneous, and he has no problems with anterior compartment muscles of arm)

12.  With a working assumption (hypothesis) that a tendon has been torn, when might the patient expect to have a return of function or elimination of symptoms related to his injury?

13.  Although we have not discussed the specific surgical techniques for repairing tendons, it is our understanding that the tendon will not regain original function unless appropriate medical interventions are used  Depending on the length of time the muscle remains inactive due to the injury, some sort of physical rehabilitation would be necessary

14.  If a nerve were injured (crushed), when might the patient expect to have a return of function or elimination of symptoms related to his injury?

15.  The patient would require conservative therapy consisting of rest, anti-inflammatory medication, and physical therapy designed to increase muscular tone and strength. (Safran MR: Nerve injury about the shoulder in athletes, part 1: Suprascapular nerve and axillary nerve. Am J Sports Med 2004;32:803.)  Surgical intervention is used if the initial non-invasive treatment is ineffective (Cummins, CA, Schneider DS. Peripheral Nerve Injuries in Baseball Players. Neurologic Clinics 2008; 26:1)