Shoulder Injury – Paratriathlon AAPM&R Annual Meeting October 1, 2015 Cheri A. Blauwet, MD Department of Physical Medicine and Rehabilitation, Harvard.

Shoulder Injury – Paratriathlon

AAPM&R Annual MeetingOctober 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 – 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 – 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– 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), positive increased laxity to lead and shift, negative sulcus sign, negative apprehension/relocation

– Positive Speed’s, negative Yergason’s, negative bear hug– Negative cross-arm adduction

Questions?

Differential Diagnosis

• Shoulder Soft Tissue– Subacromial/subdeltoid

bursitis– Scapulothoracic

dyskinesis– Biceps

tenosynovitis/tendinosis– Rotator cuff tendinosis– Rotator cuff tear

(partial)– AC joint osteoarthritis– Glenohumeral labral

tear– Glenohumeral

osteoarthritis (early)

• Cervical/Plexus– Cervical radiculitis– Parsonage-Turner

syndrome– Thoracic outlet

syndrome

• Other– Neoplasm– Occult fracture

Narrowed Differential Diagnosis

• Supraspinatus partial tear• Supraspinatus tendinosis• Biceps tendinosis• Glenohumeral labral tear• Cervical radicular pain

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 possible tear of most anterior fibers

Short axis

Loss of normal contour

Partial teararticular side

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 tendinosis with partial tear• Long head biceps tendinosis, intra-articular

portion

Final Diagnosis

• Left superior glenohumeral labral tear from anterior to posterior

• Supraspinatus tendinosis with partial tear• Long head biceps tendinosis, 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: – Articular sided tear of the supraspinatus– Proximal biceps tendinosis– Glenohumeral labral pathology

• Referral to PT to re-establish home exercise program

(Clark, JBJS Am 1992)

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