SEACSM Clinical Conference I Lt. Shoulder Pain Out of Proportion to the Stimulus

Vanderbilt Sports Medicine

SEACSM Clinical ConferenceI

Lt. Shoulder Pain Out of Proportion to the Stimulus

David G. Liddle, MDVanderbilt Sports Medicine

February 11, 2012


History• 18-year-old right-hand-dominant high school student who plays

football and baseball with left shoulder pain

• Began 2 months prior to presentation without specific injury– Football season had finished

– Not working out or doing anything differently

– Present intermittently since it began

• Able to snow ski in Gatlinburg without injury 10 days prior to eval

• No h/o prior shoulder injury


History• Pain worse over 4 days prior to presentation; particularly

around the posterior aspect of his shoulder• Pain at rest and worse with any movement • No paresthesias or vascular symptoms• No known fever but endorses a drenching sweat the night

before presenting to clinic• Naproxen, ice, and Lortab provide little relief• Only PMH is a recent Rt. Knee MRSA cellulitis; Tx w/ Bactrim• Otherwise healthy


Physical Exam• Appears fatigued, ill, & in obvious pain

• Holds his arm still at his side

• No warmth, erythema, or rash and no swelling in BUE

• PROM in any plane of motion causes significant pain around the posterior aspect of his shoulder

• TTP over the posterior aspect of his shoulder with pain out of proportion to the stimulus– No tenderness around the medial edge of the scapula

• Pain worst with resisted internal > external rotation – No pain with biceps strength testing

• Normal sensation and pulses


Questions


Differential Diagnoses


Data• Labs– CBC – WBC 18.4 w/ 88% PMN but o/w NL

– CMP – WNL x/ non-fasting glucose 130

– ESR – 48

– CRP – 264


Shoulder XRays


MRI


Diagnosis and Treatment• Admission Diagnosis– Myositis of Subscapularis and Infraspinatus

complicated by SIRS

• Management– Referred to ED for evaluation & admission

– Found febrile & septic; Started IVF and Abx• Obtained Blood Cx x 2 & started Vancomycin in ED

– Admit to Internal Medicine w/ Ortho Consult


Treatment• Initial blood cultures grew MRSA• Hospital Day 4– Transferred to the ICU for hypoxic respiratory

distress


Chest XRay


Chest CT


Treatment• Transthoracic echocardiogram – No infective endocarditis


Treatment


Repeat MRI


Treatment• Shoulder explored on HD7 given continued pain and

fever and increased inflammatory markers• Operative Report– “no purulent material”– “myositis that was swollen as a result of the fascial bands in

the subscapularis appearing to be walled off, but in fact there was no abscess.”

– “irrigated his shoulder” & “put in a gram of vancomycin to put on some local antibiotic coverage.”


Final Diagnoses• Lt. Subscapularis & Infraspinatus Myositis– No septic arthritis or osteomyelitis

• Sepsis with MRSA Bacteremia– No e/o endocarditis or infective thrombophlebitis

• TEE not obtained due to respiratory distress and likely no change in Abx therapy given no e/o IE on TTE and resolved bacteremia

– Presumed source from Rt. Knee furuncle/cellulitis

• Hypoxic respiratory distress• Septic pulmonary emboli


Outcome• Pain resolved by POD1• WBC peaked at 18 after initial improvement to 12; 16 at discharge• CRP 260 on admit, Peak 442, 260 prior to d/c• Respiratory distress & hypoxia resolved• Discharged on HD11 with PICC line to continue Vancomycin for a

total of 6 weeks – Changed to Bactrim for 2 weeks followed by MRSA decolonization therapy

• No pain and normal ROM in Orthopedic clinic on post-HD5• Chest XRay 6 weeks after admission showed near resolution of septic

emboli• Returned to play baseball that spring


Questions or Comments


Thank You

Documents

SEACSM Clinical Conference I Lt. Shoulder Pain Out of Proportion to the Stimulus