Massive Rotator Cuff Injury in Youth Athletes - Case Study Example

?Case Study Report on Rotator Cuff Injury Introduction Injuries pertaining to rotator cuff are the most common cause of shoulder pain in individuals of any age group (Malanga, 2012). The injury can range from reversible acute tendinitis to massive tears involving the subscapularis, supraspinatus and infraspinatus. While in younger individuals there is a definite history of trauma, in older individuals there may not be an obvious history preceding the onset of symptoms. Management and course of the condition is complex and varies from individual to individual based on age, physical activity needs and cause of injury. In this case study report, rotator cuff injury in a young athlete will be discussed. The report is based on a case study that was published earlier. Case Report 16 year old male fell on the left shoulder and sustained injury while attempting to score a touchdown while playing baseball. As the patient dove towards the end-zone, the left upper extremity got outstretched. After landing, another player tackled him from behind and caused contact injury to posterior aspect of left shoulder. The young athlete sustained severe pain of the left shoulder immediately and stopped playing. He could not elevate the left limb. X-ray of the left shoulder done on the next day was suggestive of subluxation of humerus with no obvious fracture. Four days following the injury, the patient had a guarded posture with diffuse tenderness all over the shoulder. Active range of movement was restricted and passive range of movement was unrestricted at the left shoulder joint. Rotator cuff strength was 2/5 with limited instability evaluation. MRI done was suggestive of posterior subluxation of the head of the humerus with accumulation of hemorrhage and edema in the glenohumeral joint. There were also full thickness tears of the tendons of the infraspinatus and supraspinatus from their insertion points and also full thickness tear of the subscapularis. There was medial subluxation of the long head of the biceps tendon and full thickness tear of teres minor tendon. In view of four tendon involvement, the patient was taken up for surgery, 7 days after the injury. Initially arthroscopic evaluation of labrus and biceps tendon was done. The evaluation demonstrated severe hemorrhage and edema at the glenohumeral joint. There was distinct instability of the biceps tendon along with extensive injury of the rotator cuff. The glenoid labrum was found to be intact and there was no posterior labral disruption. The surgeon debrided the edges of the tendon and hemorrhage was removed. The biceps was subsequently released. Following arthroscopy, open surgery was performed. A combination of anterior and posterior approach was undertaken to gain complete access to the injury. Repair of upper teres minor tendons and infraspinatus was accomplished. Thereafter, scapularis tendon repair was performed. All the wounds were irrigated thoroughly and then closed. He was sent home on an external rotation sling with arm in neutral position. 2 weeks after the surgery, sutures were removed and the patient was put on external sling with arm in neutral position. The range of movements and strength improved. Forward flexion and abduction, internal rotation and external rotation were comparable to contralateral side. The rotator cuff was intact throughout strength testing. Elbow range of movements was initiated along with pendulum exercises. The patient was reviewed after 4 weeks of surgery. Radiographs revealed concentric reduction of the glenohumeral joint. At this juncture, physical therapy was initiated to improve passive range of movements. At 8 weeks, the patient sustained another injury due to motor vehicle accident. He had injury to the shoulder joint. Repeat MRI was not suggestive of any injury to rotator cuff, instead showed concentric reduction in glenohumeral joint. There was no instability. 5 months following surgery, range of movements was comparable to contralateral side and the motor cuff was intact throughout strength testing. The patient returned to baseball with no recurrence in symptoms. He returned to football after a year, again with no return of symptoms. Discussion Injuries pertaining to rotator cuff are the most common cause of shoulder pain in individuals of any age group. The injury can range from reversible acute tendinitis to massive tears involving the subscapularis, supraspinatus and infraspinatus (Turman et al, 2010). Diagnosis is mainly through history taking, physical examination and imaging studies in the form of radiography and magnetic resonance imaging. While in younger individuals there is a definite history of trauma, in older individuals there may not be an obvious history preceding the onset of symptoms. Plain radiography is a useful tool to evaluate and diagnose rotator cuff injury. The injury can be further evaluated using magnetic resonance imaging. Initial treatment must involve rest, application of cold fomentation and pain killers like NSAID or acetaminophen (Mantone et al, 2000). The patient must be asked to sleep with a pillow between the arm and the trunk for decreasing tension on the supraspinatus tendon and also to prevent compromise of blood flow. Surgery and arthroscopy are done based on MRI evaluation, clinical findings and clinical improvement (Marx et al, 2009, Williams et al, 2004). Physical therapy involves exercises to restore range of movements at shoulder joint, normalization of the strength of muscles and stabilization of the joint. Some of the exercises for restoration of range of movements at shoulder joint include wall walking, Codman pendulum exercises, stick exercises and towel exercises. For strengthening of the rotator cuff, rowing, shoulder shrugs and certain isolate exercises help the patient. Proprioception training is very important because it helps restrain the neurological control of the muscles that have been strengthened. In the rehabilitation phase, advanced proprioceptive training is very essential to teach the muscles relearn previous activities. Prevention is mainly through avoiding direct injuries to shoulder joint. Athletes, who are as risk of injuries must be trained to avoid such injuries. Conclusion Rotator cuff injuries are common in athletes. Diagnosis is made mainly based on elaborate clinical history taking, detailed physical examination and radiography of the concerned part. Confirmatory diagnosis is mainly through magnetic resonance imaging. Initial treatment involves rest and sling application. Arthroscopy and surgery may be performed based on clinical findings and MRI evaluation. Rehabilitation plays a crucial role in return to normal life, especially among athletes References Malanga, G.A. (2012). Rotator cuff injury treatment & management. Retrieved on 14th April, 2013 from http://emedicine.medscape.com/article/92814-treatment#a1156 Mantone, J.K., Burkhead, W.Z. Jr, Noonan, J. Jr (2000). Non-operative treatment of rotator cuff tears. Orthop Clin North Am., 31(2), 295-311. Marx, R.G., Koulouvaris, P., Chu, S.K., Levy, B.A. (2009). Indications for surgery in clinical outcome studies of rotator cuff repair. Clin Orthop Relat Res., 467(2), 450-6. Turman, K.A., Anderson, M.W., and Miller, M.D. (2010). Massive rotator cuff tear in an adolescent athlete: A case report. Sports Health, 2 (1), 5- 54. Williams, G.R. Jr., Rockwood, C.A. Jr., Bigliani, L.U., Iannotti, J.P., Stanwood, W. (2004). Rotator cuff tears: why do we repair them? J Bone Joint Surg Am., 86-A (12), 2764-76. Read More