1. Unusual Cause of Shoulder Pain James N. Robinson, M.D. American Sports Medicine Institute James N. Robinson, M.D. American Sports Medicine Institute

2. HPI  16 y/o Junior, Center Football player presents on Monday with Right shoulder and chest pain following Friday night football game  He doesn’t remember any one specific hit, but started having achy shoulder pain sometime in 3rd quarter  Pain continued to get worse and eventually kept patient out of game  The pain got so bad that he went to the ER that night and was told that he possibly had a rib fracture  16 y/o Junior, Center Football player presents on Monday with Right shoulder and chest pain following Friday night football game  He doesn’t remember any one specific hit, but started having achy shoulder pain sometime in 3rd quarter  Pain continued to get worse and eventually kept patient out of game  The pain got so bad that he went to the ER that night and was told that he possibly had a rib fracture

3. HPI continued  Patient describes his pain as deep to his scapula  Pain with Abduction of shoulder and with deep inspiration, but does not feel SOB  No pain with adduction and his pain is better with arm held across body  No pain previously  Pain was worst day after game and has continued through weekend  No numbness or weakness  Patient describes his pain as deep to his scapula  Pain with Abduction of shoulder and with deep inspiration, but does not feel SOB  No pain with adduction and his pain is better with arm held across body  No pain previously  Pain was worst day after game and has continued through weekend  No numbness or weakness

4. Past History  PMHx: Asthma on Dulexa  PSHx: None  Social: Junior, HS football center  PMHx: Asthma on Dulexa  PSHx: None  Social: Junior, HS football center

5. Physical Examination  6 ft, 215lb  Pt in obvious discomfort  No bruising noted  Tenderness to palpation of the scapula especially along medial border  No tenderness over AC, SC, clavicle, or glenohumeral joint line  6 ft, 215lb  Pt in obvious discomfort  No bruising noted  Tenderness to palpation of the scapula especially along medial border  No tenderness over AC, SC, clavicle, or glenohumeral joint line  Shoulder ROM: Flexion 150, abduction limited 95 due to pain, no pain with ER/IR  Weakness of supraspinatus with extreme discomfort  Weakness with ER, no weakness with IR  No increase anterior/posterior translation  Shoulder ROM: Flexion 150, abduction limited 95 due to pain, no pain with ER/IR  Weakness of supraspinatus with extreme discomfort  Weakness with ER, no weakness with IR  No increase anterior/posterior translation

6. PE continued  Respiratory: CTAB though pain with deep inspiration  Rib palpation on the right side does not reproduce pain, no cervical tenderness, or no tenderness over sternum  FROM of neck without pain  +2 distal pulses, good capillary refill  Respiratory: CTAB though pain with deep inspiration  Rib palpation on the right side does not reproduce pain, no cervical tenderness, or no tenderness over sternum  FROM of neck without pain  +2 distal pulses, good capillary refill

7. Questions

8. Differential Diagnosis  Scapular fracture  Shoulder Contusion  Rib contusion/fracture  Rotator Cuff Impingement  Small Pneumothorax  Asthma Exacerbation  Pulmonary Embolism  Pulmonary Contusion  Scapular fracture  Shoulder Contusion  Rib contusion/fracture  Rotator Cuff Impingement  Small Pneumothorax  Asthma Exacerbation  Pulmonary Embolism  Pulmonary Contusion

10. A&P  Final Diagnosis: Right 1st Fracture  Management  Placed in Shoulder Immobilizer in slightly adduction  No contact  Return in 2 weeks  Final Diagnosis: Right 1st Fracture  Management  Placed in Shoulder Immobilizer in slightly adduction  No contact  Return in 2 weeks

11. 2 week Follow Up  Pain much improved and minimal in immobilizer  FROM of shoulder, slightly decreased strength, mild tenderness to palpation of scapula  Sent to PT to work on ROM and strength of shoulder and cervical  Continue non-contact, but can condition  Return in 2 weeks  Pain much improved and minimal in immobilizer  FROM of shoulder, slightly decreased strength, mild tenderness to palpation of scapula  Sent to PT to work on ROM and strength of shoulder and cervical  Continue non-contact, but can condition  Return in 2 weeks

12. 4 week Follow up  Doing well, no pain  Asthma physician obtained bone density scan due to chronic steroid use which was normal  PE full motion and strength, no tenderness  XR showed slight callus  Patient allowed to start light contact and progress if no pain  Doing well, no pain  Asthma physician obtained bone density scan due to chronic steroid use which was normal  PE full motion and strength, no tenderness  XR showed slight callus  Patient allowed to start light contact and progress if no pain

13. Final Outcome  Patient return to full play at 5 weeks out from injury  He completed the rest of his football season (3 more weeks)  He has no residual pain or problems  Patient return to full play at 5 weeks out from injury  He completed the rest of his football season (3 more weeks)  He has no residual pain or problems