Shoulder Injury — Rugby, Tennis

Kenneth Vitale, Manhattan Wellness Medical Care (MWMC), New York, NY. e-mail: kvitale@nihonclinic.com HISTORY: A collegiate rugby player at age 19 shoulder tackled his opponent’s hip with immediate pain / instability requiring sling, but didn’t seek treatment. In his 20’s continued rugby however had progressive weakness / instability. Age 35: during baseball tournament had acute pain after throwing and couldn’t lift shoulder; only improved after complete rest. Age 47: during rugby match fell on arm injuring shoulder and wrist, requiring scapholunate ligament surgery and discontinuation of all sports. Age 50: he reattempted sports, tried overhead smash during tennis match and had sudden onset sharp pain / instability. No neck pain, radiating arm symptoms, or weakness. PHYSICAL EXAMINATION: Prominent AC joint, tenderness over AC joint and deltoid, positive Neer/Hawkins, cross-arm adduction, active compression, crank, painful arc, and give-way weakness during range of motion (ROM) testing. Negative Speed’s and biceps load test I&II. Normal neck and right arm neurovascular exam. DIFFERENTIAL DIAGNOSIS: 1. Glenohumeral joint dislocation / Bankart lesion with chronic instability. 2. Labral tear. 3. AC sprain/dislocation with chronic instability. 4. Osteolysis of lateral clavicle. 5. Rotator cuff tendinosis/tear. TEST AND RESULTS: MRI: moderate AC joint arthrosis, superior AC ligament thickening and fraying; mid/inferior anterior glenoid labrum fraying; mid/inferior glenoid rim cartilage thinning; superior labrum tear extending to biceps anchor; no rotator cuff signal abnormality. FINAL/WORKING DIAGNOSIS: 1. Type II SLAP lesion. 2. Mid/inferior anterior glenoid labral tear, glenoid rim cartilage thinning. 3. AC joint arthrosis. TREATMENT AND OUTCOMES: 1. Physical therapy: periscapular muscle strengthening, dynamic stabilization, scapular retraction / depression, scapular stability during ROM, posterior capsule stretching. 2. Currently in month 3, pain is decreasing but symptoms continue. 3. Difficult surgical decision: improving pain and he doesn’t want surgery, however tear is considerable and has multiple other pathologies. 4. Candidate for Platelet-rich Plasma? Prolotherapy? 5. Case highlights challenges treating a labral tear and achieving scapular stability while not aggravating AC pathology, and difficulties treating athletes who continue to play multiple sports despite injuries