Virginia Research Day 2022

Medical Resident Research Case Reports

12 A Deep Plunge Into Shoulder Weakness In A Collegiate Diver

Chella Bhagyam, DO; Courtney Botskin, OMS II; Mary Mitchell, DO Corresponding author: cbhagyam@vcom.vt.edu

VCOM Virginia Virginia Polytechnic Institute

HPI: 22-year-old Division 1 diver presented with left shoulder pain and weakness noted first about 2 weeks prior. While doing resistant band exercises he noticed some weakness with external rotation and pain from his shoulder blade radiating to his humeral head. There was no inciting incident, and no history of injury to his shoulder or neck. He denied having any significant pain at rest. He was able to do all of his ADLs and was not limited at diving practice. He had not taken any medications for the pain. He denied numbness or tingling of his upper extremity. Physical Exam: Upper extremity: Muscle wasting to L infraspinatus. Surrounding shoulder muscles well developed. Tenderness to palpation of infraspinatus and inferior portion of supraspinatus on the left. Active ROM full in flexion, extension, abduction, internal rotation, limited in external rotation (30degrees). Passive ROM full in all planes. Right UE normal. Neuro: Sensation intact. Left muscle strength 4/5 in L external rotation, 5/5 in other major muscle groups of UE. Right UE muscle strength 5/5 in major muscle groups.

Imaging/ Work Up: MRI arthrogram left shoulder: Prominent type II SLAP tear. Small paralabral cyst. There is suggestion of a small perilabral cyst extending toward the spinoglenoid notch. Questionable minimal denervation edema of infraspinatus and teres minor muscle bellies without significant atrophy. EMG:Minimal electrophysiologic evidence suggestive of a left suprascapular nerve entrapment likely at the spinoglenoid notch. Final working diagnosis: Left isolated infraspinatus weakness due to cyst compression of the suprascapular nerve at the spinoglenoid notch. Asymptomatic SLAP tear. shoulder pain. Due to the unique path of this nerve, there are many possible causes for entrapment. However, the vague presenting symptoms often make it difficult to diagnose until more significant muscle wasting has occurred. Anatomic areas particularly at risk for compression include the suprascapular notch, for which there are 6 anatomic variations, and Discussion: Suprascapular nerve compression is an uncommon cause of

the spinoglenoid notch. Transverse scapular ligament ossification, retracted rotator cuff tears, cysts, and nerve traction are additional reasons for injury. Treatment depends on cause and extent of nerve injury determined by EMG. Common treatments include conservative rest and rehab, suprascapular notch release, surgical repair of rotator cuff or labrum, US guided injection or aspiration. Prognosis depends on extent of nerve damage and muscle atrophy. Outcome: Since EMG only revealed minimal changes, conservative approach was taken. Patient was in physical therapy from first appointment throughout work up. Upon follow up with ortho after EMG he reported doing well and feeling improvement in strength with physical therapy targeted at strengthening infraspinatus, E- stim and other therapies. If improvement does not continue, there has been discussion about US guided cyst aspiration. RTP: He currently has no restrictions for diving and is progressing through physical therapy.

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