A-20 Clinical Case Slide - Musculoskeletal: Neck and Back: MAY 27, 2009 9:30 AM - 11:30 AM: ROOM: 201
HISTORY: A 17 year old right hand dominant high-school baseball pitcher presented with a six month history of right medial scapula pain. The pain started with one fastball pitch at approximately 75% effort. He noted a shooting pain along his medial scapular border and was unable to continue pitching. After a week of rest, the patient noted shoulder stiffness and difficulty throwing. He continued to rest and underwent two secessions of physical therapy. He had been seen in the primary care setting and had two shoulder MRI's three months apart. The results of the first MRI were normal. Although the appearance was similar, the second MRI was reported as having a small partial tear of the distal infraspinatus tendon without retraction, and a small signal change in the anterior labrum which may represent an anatomic variant. At the time of his initial visit, he was throwing as a positional player but felt his symptoms would return if he tried to pitch.
PHYSICAL EXAMINATION: Mild tenderness at T4 without radicuolopathy, full neck range of motion. Neck extension reproduced right medial scapular pain and numbness in the middle digit of the right hand. Mild tenderness of the paravertebral musculature of T3-5 on the right. Normal scapulothoracic biomechanics. Shoulder exam was normal including special tests.
1. Cervical radiculopathy
2. Brachial plexopathy
3. Occult bone pathology
4. Intra-articular shoulder pathology
TESTS AND RESULTS: Triple Phase Bone Scan
focus of increased uptake along proximal first rib
Chest Computerized Tomography:
minimally displaced left anterior first rib fracture
Cervical Spine Radiographs
Magnetic Resonance Imaging
small partial tear of the distal infraspinatus without retraction, and a small anterior labral signal which may represent an anatomic variant
FINAL WORKING DIAGNOSIS: First rib stress fracture
TREATMENTS AND OUTCOMES:
1. Initial relative rest, only throwing as a positional player.
2. Continued physical therapy, scapular stabilization.
3. Sat out junior year of high school baseball.
4. Gradual return to pitching with heightened supervision from coach.
5. Able to pitch senior year of baseball, pain free.
6. Currently in college, not playing varsity sports. Pain free.