case_study_2-_rotator_cuff

Document Sample
case_study_2-_rotator_cuff Powered By Docstoc
					Personal Data

        In this case study, a 21 year-old male in his senior year injured his left shoulder while

throwing a pitch in a baseball game. Upon evaluation, the athlete was thought to have sustained

an injury to the rotator cuff, with emphasis on the teres minor. The rotator cuff is actually made

up of four muscles and tendons—the supraspinatus, the infraspinatus, the teres minor, and the

subscapularis. (Figure 1) The four rotator cuff muscle tendons combine to form a broad,

conjoined tendon called the rotator cuff tendon and insert into the humeral head. Rotator cuff

injuries are a common occurrence among baseball players, especially pitchers—as this athlete

happened to be.

Chief Complaint

        During a game, the athlete felt discomfort in his left shoulder while throwing a pitch. As

his throwing arm went from the deceleration phase, which is essentially the arm positioned at 90

degrees of abduction and internally rotated, into the follow through phase, he described a sharp

pain immediately on his posterior shoulder. (Figure 2) The athlete described a pop being heard at

the time of injury. Soon after, his pain scale was said to be a 6 out of 10, with 10 being the worst

pain he has ever experienced. He described the location of the pain to be on the posterior aspect

of his shoulder. The athlete had no previous history of rotator cuff injuries or any other shoulder

problems, as the examiner noted that his pitching arm was obviously his dominant limb.

However, the athlete said to be experiencing sensations of tingling and numbness into his

anterolateral shoulder and down his arm. He explained that he took some Advil soon after his

injury occurred to help with the pain. Nonetheless, he was not able to continue to play in the

game after his injury occurred.

Result of Physical Examination

        As the assessment of the athlete began, he was observed to be carrying his injured arm

close to his abdomen and appeared to be in some pain, evident of his facial expressions.

However, there were no signs of swelling, ecchymosis, or deformities. While also observing his
shoulder, there seemed to be no signs of infection, cuts, scars, or any abnormalities when

compared bilaterally; but a tingling and numbness sensation was described into the athlete‟s

anterior and lateral shoulder and down his arm. The examiner then began to palpate the entire

shoulder and surrounding surfaces of the injured and non-injured side. The examiner‟s main

objective was to compare bilaterally, noting any signs of pain with movements, and feeling for

any possible crepitus or abnormal landmarks. The examiner began palpating the bony structures

of the involved upper extremity, noting any pain. These structures consisted of the spine of

scapula, acromion process, acromioclavicular joint, humeral head, greater tuberosity, lesser

tuberosity, bicipital groove, coracoid process, and the clavicle. The only structures that were

reported positive for pain were the acromion process and the greater tuberosity. Next, the soft

tissue structures were then palpated to examine the structural integrity and inspect any possible

ligamentous damage or muscular strains. These structures consisted of the supraspinatus,

infraspinatus, teres minor, subscapularis, upper trapezius, latissimus dorsi, deltoid, long head of

the biceps, and triceps brachii. The only structures that exhibited pain upon palpation were the

teres minor and the deltoid, also noting point tenderness on the entire posterior shoulder.

        The athlete was then taken through active, passive, and resistive range of motion test‟s to

determine the athlete‟s strength and detect any possible deficits to the upper extremity. As for

active and passive range of motion, the athlete described pain with shoulder abduction, shoulder

flexion, and with all overhead motions. These motions were reported to be at 4 out of 5 by the

examiner, describing weakness with all motions. This confirmed the athlete‟s willingness to

move his injured area was „good‟. However, when the athlete was instructed to perform active

range of motion for internal and external rotation at both 0 and 90 degrees, he experienced no

pain. Then the examiner proceeded to perform the same motions (internal and external rotation at

0 and 90 degrees) passively and resistively, which resulted in pain and weakness for the athlete.

Lastly, the athlete described pain with resistive shoulder abduction.
        The examiner continued the assessment with manual muscle testing. The structures that

were tested consisted of the supraspinatus, teres minor/infraspinatus, biceps brachii, rhomboids,

trapezius muscle group, triceps brachii, and latissimus dorsi. The examiner noted pain and

weakness with the teres minor and shoulder abduction motions. Next, the patient‟s neurological

symptoms were recorded as he described tingling and numbness into his anterolateral shoulder, at

the C5 dermatome area. Hereafter, special tests were performed on the athletes shoulder,

comparing bilaterally. The first test was for the teres minor (patient‟s arm at 90 degrees

abduction and actively go into external rotation as AT applies resistance), which tested positive

for pain. Right after, the Drop Arm test was performed, testing positive for pain and inability to

slowly lower his injured arm. Next the examiner performed impingement tests, which included

Hawkins-Kennedy test and Crossover impingement, but both were negative. After that,

O‟Brien‟s test and Empty Can were performed, both testing negative as well. Lastly, the Anterior

Apprehension test was performed to rule out any anterior glenohumeral instabilities and this test

was negative upon completion.

        Since the athlete injured his throwing arm and could not continue in the game, he did not

perform any functional tests such as throwing, or any overhead motions due to pain. However, it

was noted that he could still swing a bat and did not experience any symptoms.

Results of Medical History

        After the athlete‟s thorough evaluation of his injured shoulder, it was decided that an

MRI should be taken just to make sure there had not been any partial-thickness tears or further

damage. He was advised to receive an MRI but failed to get the images taken, based on his

personal standpoint. The athletic training staff, along with the medical doctor‟s examination,

both agreed that it was not as serious as suspecting but just to be careful an MRI would rule out

any mishaps that can not be seen from the external view.
Diagnosis

        After the complete injury evaluation of the athlete‟s upper extremity, my diagnosis would

be a Grade II rotator cuff strain, specifically to the teres minor. The teres minor and infraspinatus

externally rotate the humerus and provide some assistance during horizontal abduction. In

addition, the eccentric contractions of these two muscles decelerate the humerus at the end of

overhead throwing motions. (1) My support behind this impression of having a rotator cuff strain

would be based on the various signs/symptoms that were discovered during the injury report. In

the history/observation portion, the athlete describing a pop in his posterior shoulder while

entering the deceleration phase at maximal internal rotation is a key indicator of a rotator cuff

injury. His strength and lack of swelling was a positive sign that there was not any sort of tear but

an MRI would be ideal for confirmation. During palpation, the point tenderness directly over the

rotator cuff, especially the teres minor and it‟s insertion on the greater tuberosity provided

support of my diagnosis. Furthermore, the positive special tests for pain with the teres minor

involvement as well as the Drop Arm test assisted my rationale on determining this pathology.

Treatment and Clinical Course

        After the diagnosis, the athletic training staff as well as the athlete worked in unison to

propose a rehabilitation program that would be most efficient and allow for the quickest recovery

time and the athlete to return to play. The athlete began his rehabilitation the same day as his

injury. His treatment started with ultrasound with a corticosteroid, followed by ice and pre-

modulated electric muscle stimulation. He then was advised to rest and was placed on Ibuprofen

for three times per day to help with the pain. The athlete was injured on a Thursday and began

rehabilitation strengthening and flexibility exercises on Friday. He started without weights and

light resistance and progressed to weighted exercises on Monday. The purpose of the exercises is

to strengthen the scapular muscles and the surrounding musculature as well as intensive

stretching to increase flexibility. The athlete began his workout by performing internal and

external rotation with the thera-band at 0 and 90 degrees. After, he used 4lb dumbbells and
performed the Phillies series workout, which consists of motions that make up a T, W, Y, and I

shape. To execute this workout, the patient is prone hanging over the edge of the table and

retracts his scapula then moves in the desired motion (either flexion, abduction, internal or

external rotation); the patient is to hold in contraction for 1 second and come down slow, to

concentrate on the eccentric contraction. Next the athlete did seated rows with 120lbs, while

doing a superset of retractions with the same weight. After that, he performed seated chest press

with 120lbs, while doing a superset of retractions with the same weight once again. For the next

exercise the patient used his body weight and performed dips followed with a superset of

depressions. After that, the patient moved to the thera-band and performed upright rows followed

by a superset of shoulder shrugs. Then the patient began performing a sport-specific exercise as

he went through his throwing motion very slowly, concentrating on the eccentric contraction,

doing negatives with the thera-band. Lastly, the patient performed D1 and D2 patterns with the

thera-band.

        After the first week of rehabilitation, he stopped receiving ultrasound with the

corticosteroid and began combo, which is ultrasound with simultaneous electric muscle

stimulation. The intensity of the ultrasound was set to 1.0 and the frequency at 1mhg. As for

electric stimulation, it was set on Hivolt and continuous, with the intensity at 18. He was then

started on a throwing program about a week after his initial injury. As his rehabilitation

progressed, the athlete threw his first bullpen 2 weeks after his initial injury at about 70 percent of

his maximal strength, throwing 25 pitches. Three days later he threw his second bullpen at about

90 percent of his maximal strength and simulated a real game, throwing 40 pitches. The next day

he took off, proceeded to throw light for two days after and prepared for his first start in a game

since his injury. The athlete started in his first game 21 days after his initial injury. He was only

able to pitch for two innings until his shoulder began tightening up and he was relieved.

Criteria for Return
          The athletic training staff along with a primary physician set guidelines that the athlete

must meet in order to return to play. A throwing program was designed to introduce added loads

to an athlete‟s arm in a safe progression and to develop the necessary strength and skills to begin

throwing competitively again. This program consisted of completion of a rigorous twelve level

training course. (Figure 3) During the course of a week, they are to throw two days in a row and

then rest for one; then throw two days in a row and rest for two. The athlete must be able to throw

with comfort or they are not allowed to continue that session. Also they must successfully throw

at any level of the program for two times without discomfort before advancing to the next level.

Discussion

          Rotator cuff injury can be caused by a number of factors. It can be a result of an acute

traumatic force, impingement syndrome, reduction of the coracoacromial arch, a loose anterior

capsule and a tight posterior capsule, repetitive overhead motions/eccentric forces, rotator cuff

muscle weakness, or scapular dyskinesis. (2) Therefore it is of high importance to recognize

rotator cuff injuries and discover the root of where the problem exists so the patient can

rehabilitate accordingly. Acute strains may be initially overlooked, with the symptoms attributed

to other, more common causes, such as rotator cuff contusion or brachial plexus neuropraxia

(“stinger” or “burner”). If undiagnosed, the strain may progress to a tear and cause further

problems. Therefore, rotator cuff injuries must not be overlooked in shoulder injuries, especially

with throwing athletes, and included in the differential diagnosis for acute shoulder injuries. (3)

Conclusions

          Rotator cuff injuries are very common in baseball players, especially pitchers, or in any

sport with repetitive overhead motions. Many signs/symptoms that present with rotator cuff

strains can mimic a number of shoulder pathologies. Therefore, a full systematic evaluation must

be conducted to determine the proper diagnosis. Rotator cuff strains can be rehabilitated rather

quickly but returning to play too soon can place an athlete at an increased risk of a tear or further

injury.
Figure 1 (4)




Figure 2 (5)
Level               Minimal # of        Throws/Feet         Throws/Feet         Throws/Feet
                    Sessions
One                 2                   25/25               25/60               -------------------
Two                 2                   25/25               50/60               -------------------
Three               2                   25/25               75/60               -------------------
Four                2                   25/25               50/60               25/90
Five                2                   25/25               50/60               25/120
Six                 2                   25/25               50/60               25/150
Seven               2                   25/25               50/60               25/180
Eight               2                   25/25               50/60               25/210
Nine                2                   25/25               50/70               25/240
Ten                 2                   25/25               50/80               25/240
Eleven              2                   25/25               50/90               25/240


Figure 3 (6)

                                           References

   1) McConville, OR, and Iannotti, JP: Partial-thickness tears of the rotator cuff: Evaluation

         and management. The Journal of the American Academy of Orthopedic Surgeons, 7:32,

         1999.

   2) Joseph JBM Myers, Kevin KGL Laudner, Maria MRP Pasquale, James JPB Bradley,

         Scott SML Lephart . Glenohumeral Range of Motion Deficits and Posterior Shoulder

         Tightness in Throwers with Pathologic Internal Impingement. The American Journal of

         Sports Medicine, Volume 34, Number 3 (March 2006), pp. 385-391

   3) Lee LDK Kaplan, David DCF Flanigan, John JN Norwig, Patrick PJ Jost, James JB

         Bradley. Prevalence and Variance of Shoulder Injuries in Elite Collegiate Football

         Players. The American Journal of Sports Medicine, Volume 33, Number 8 (December

         2005), pp. 1142-1146

   4) http://www.safepitching4youth.com/?page_id=253

   5) http://www.google.com/imgres?imgurl=http://cdn.bleacherreport.net/images_root

         /slides/photos/000/479/621/81311972_display_image

   6) Rowan University Athletic Training; Chuck Whedon, MS, ATC, CSCS; Colleen Grugan,

         MS, ATC

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:6
posted:11/7/2011
language:English
pages:8