An Unexpected Radiographic Finding in an Adolescent Boxing Athlete With Shoulder Pain

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Clin J Sport Med

Abstract

History: Patient is a 15 year old male boxing athlete who presented with complaint of right shoulder pain that had been ongoing for the past year, but had acutely worsened. His pain initially started after throwing a jab in a match one year prior and acutely worsened to the point where it was difficult for him to complete his training sessions. Pain was located to the posterior and lateral shoulder. Rated as a 6/10. Pain worse with reaching back behind his body and across his body. Pain improved with rest. Symptoms also associated with intermitted tingling over the lateral deltoid that occasionally traveled down to his right thumb lasting a few seconds. No prior shoulder surgeries, instability events, or other injuries. Physical Exam: Inspection: No appreciable asymmetry or atrophy Palpation: AC joint tenderness: negative, biceps tenderness: negative. Range of Motion: Flexion 170•, Abduction 160•, External Rotation at Side 50•, Posterior Internal Rotation T8, External Rotation at 90• of abduction 100•, Internal Rotation at 90• of abduction 45•. Muscle Strength: Internal Rotation 5/5, External Rotation 5/5, Forward Elevation 5/5. Special Tests: Speeds negative, Cross body negative, Hawkins and Neer negative, Bear hug negative, lift off negative, Obrien negative, Anterior load/shift negative, Apprehension/relocation produced posterior pain with end range external rotation, but no apprehension. Differential Diagnosis: 1. Internal impingement of the shoulder 2. Labral tear 3. Little league shoulder 4. Suprascapular nerve entrapment syndrome 5. Loose body Test Results: 4-View Bilateral Shoulder X-ray: No growth plate widening when compared to the left. Small rounded ossific body projecting over the inferior/medial aspect of the humeral head on the right, may be a joint body of unknown donor site. MRI: Chronic avulsion of the lesser tuberosity at the attachment of the subscapularis tendon. No rotator cuff tear. Blunting of the posterior labrum and cystic changes within the posterior humeral head suggestive of internal impingement. Final Diagnosis: Internal impingement of the shoulder with chronic avulsion of the lesser tuberosity. Discussion: Internal impingement of the shoulder is a relatively common diagnosis in overhead/throwing athletes that is often associated with a glenohumeral internal rotation deficit. Lesser tuberosity avulsion fractures, on the other hand, are of rare occurrence with an estimated incidence of 0.46 in 100,000 people. There have not been any documented cases of lesser tuberosity avulsion fractures jointly associated with internal impingement of the shoulder. It is unclear whether these 2 findings are related, however it is well documented in case reports that lesser tuberosity avulsion fractures often result in a decrease in internal rotation. Thus, it is possible this was a contributing factor. Outcome: The patient completed 6 weeks of physical therapy with complete resolution of his shoulder pain and glenohumeral internal rotation deficit. Due to his symptom resolution and lack of a functional deficit, surgical intervention was avoided. Follow-Up: After the completion of physical therapy, the patient was cleared to return to boxing without complication.

Volume

35

Issue

3

First Page

e36

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