Download Shoulder Injury

Shoulder Injury – Paratriathlon
AAPM&R Annual Meeting
October 1, 2015
Cheri A. Blauwet, MD
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA
History
• Chief Complaint
– Left shoulder pain
• History of Present Illness
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34 yo right hand dominant female triathlete with h/o spina bifida
Training for Ironman World Championships in 6 weeks
Left shoulder pain progressive for 2 months, prohibiting training
Currently training 15 hours/week, combination of swimming,
handcycling, wheelchair racing
History, cont’d
• Three components of paratriathlon
– Swimming  painful
– Handcycling (equivalent to the bike)  painful
– Wheelchair racing (equivalent to the run)  not painful
Painful
Painful
Not painful
History, cont’d
• Pain Description
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Left anterior shoulder, “deep”
Radiates to medial elbow when severe
Average 3/10, flares to 9/10
Worse: handcycling, swimming, transfers
Better: ice, naprosyn
Episodic pain at rest, no pain at night
History, cont’d
• Shoulder History
– Primary wheelchair user since 6 years old
– Played competitive wheelchair basketball in college (10 years ago)
– Started triathlons in 2012 – competed in 2 prior Ironmans
• 2012 – minimal L shoulder pain, no intervention
• 2013 – L shoulder pain recurred, required PT and subacromial steroid
injection  able to compete
• 2014 – L shoulder pain beginning 2 months prior, progressive  patient
requesting further work-up
– Continues with PT exercises on her own 2-3x/week
Past Medical and Surgical History
• Spina bifida leading to L1-2 neurologic level of injury
– Can ambulate but slowly, uses wheelchair for efficiency
• Tethered cord release in youth
• Club foot repair in youth
• Ureteral re-implantation in youth
Functional and Social History
• Functional History
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Independent with manual wheelchair use
Independent with transfers and all ADLs
Lives independently, travels internationally
Lives in high rise condo, elevator building
Works full-time at a non-profit
• Social History
– No tobacco use, 2-3 alcoholic drinks/week, single
Physical Examination
• Inspection: Left scapula resting in protracted position, increased
medial winging with active FF/abduction (negative lateral scapular
slide test)
• ROM: Active IR to T3 on right compared to T6 on left (with pain);
otherwise normal
• Palpation: Tenderness over left proximal biceps tendon and
supraspinatus insertion on greater tuberosity
• Neurovascular: Normal
Physical Examination
• Special Tests (focus on left):
– Spurling’s negative bilaterally
– Positive Neer’s, positive Kennedy-Hawkins
– Positive empty can (pain, no weakness), full strength to resisted
IR/ER bilaterally, negative belly press bilaterally
– Positive Obrien’s, positive dynamic labral shear (with palpable
click), negative sulcus sign, negative apprehension/relocation
– Positive Speed’s, negative Yergason’s, negative bear hug
– Negative cross-arm adduction
Differential Diagnosis
• Shoulder Soft Tissue
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• Cervical/Plexus
Subacromial/subdeltoid bursitis
– Cervical radiculitis
Scapulothoracic dyskinesis
– Brachial neuritis
Biceps tenosynovitis/tendinopathy
– Thoracic outlet syndrome
Rotator cuff tendinopathy
Rotator cuff tear (partial)
• Other
AC joint osteoarthritis
– Neoplasm
Glenohumeral labral tear
– Occult fracture
Glenohumeral osteoarthritis (early)
Questions?
Narrowed Differential Diagnosis
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Supraspinatus partial tear
Supraspinatus tendinopathy
Biceps tendinopathy
Glenohumeral labral tear
Cervical radiculitis
Diagnostic Tests
• Left shoulder musculoskeletal ultrasound obtained in office
– Focused study – used as extension of physical exam
• Left shoulder MR arthrogram for evaluation of labrum
Ultrasound Proximal Biceps Tendon
Tendinopathic changes most severe as tendon becomes intra-articular
Long axis
Short axis
Ultrasound Supraspinatus Tendon
Tendinopathic changes and partial articular sided tear
MRI Coronal Oblique T2 Fat Sat
MRI Coronal Oblique T2 Fat Sat
MRI Coronal Oblique T2 Fat Sat
Moderate to severe intra-articular long head of biceps tendinosis
MRI Coronal Oblique T2 Fat Sat
MRI Coronal Oblique T2 Fat Sat
Moderate to severe supraspinatus tendinosis, partial tear articular surface, anterior fibers
MRI Glenoid Labrum
Superior labral tear from anterior to posterior, extending from superior 12
o’clock position to the posterior 10 o’clock position
Axial T1 DESS
(dual echo steady state)
Coronal Oblique T2 Fat Sat
Final Diagnosis
• Left superior glenohumeral labral tear from anterior to
posterior
• Supraspinatus tendinopathy with partial tear
• Long head biceps tendinopathy, intra-articular portion
Final Diagnosis
• Left superior glenohumeral labral tear from anterior to
posterior
• Supraspinatus tendinopathy with partial tear
• Long head biceps tendinopathy, intra-articular portion
Goal: Ironman triathlon in 6 week’s time
Initial Treatment
• Left glenohumeral joint steroid injection under US guidance
• Single injection treats pain due to:
– Glenohumeral labral pathology
– Articular sided tear of the
supraspinatus
– Proximal biceps tendinosis
(Clark, JBJS Am 1992)
• Referral to PT to re-establish home exercise program
Follow-Up
• At 2-week follow-up  90% relief
of pain
• Ramped back up to full training load
within the following 2 weeks
• Completed the swim and bike
portions of the Ironman, not limited
by pain
What’s Next?
• Athletes who utilize their shoulders for mobility AND sport
participation require a unique approach
– Heightened focus on conservative management and injury prevention
• Functional implications of shoulder arthroscopy:
Before Surgery
After Surgery (for ~ 6 months)
Manual wheelchair
Power wheelchair
Independent in transfers
Requires full assist
Independent with ADLs
Requires assist for dressing/bathing
Traveling, working
Limited to home-based activities
Next Steps
• Athlete given information regarding obtaining a surgical
opinion and advised to establish care
• Continues with an aggressive rehabilitation program –
currently without pain on a daily basis
• Plans to decrease the intensity of endurance events in
attempt to maintain shoulder function longitudinally
and prolong length of time until arthroscopy is required
Discussion
Thank You
• Colleagues participating in this symposium
• Colleagues and mentors at Spaulding Rehabilitation
Hospital/Brigham and Women’s Hospital