Unusual Cause of Shoulder Pain

Unusual Cause of Shoulder
James N. Robinson, M.D.
American Sports Medicine
 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
HPI continued
 Patient describes his pain as deep to his
 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
Past History
 PMHx: Asthma on Dulexa
 PSHx: None
 Social: Junior, HS football center
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
 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
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
Differential Diagnosis
Scapular fracture
Shoulder Contusion
Rib contusion/fracture
Rotator Cuff Impingement
Small Pneumothorax
Asthma Exacerbation
Pulmonary Embolism
Pulmonary Contusion
 Final Diagnosis: Right 1st Fracture
 Management
 Placed in Shoulder Immobilizer in slightly
 No contact
 Return in 2 weeks
2 week Follow Up
 Pain much improved and minimal in
 FROM of shoulder, slightly decreased
strength, mild tenderness to palpation of
 Sent to PT to work on ROM and strength of
shoulder and cervical
 Continue non-contact, but can condition
 Return in 2 weeks
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
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

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