Schnibbe HD, Blair KK, Blair DF:
Wenatchee High School, Wenatchee, Washington
Background:
A16-year-old right hand dominant male baseball pitcher irritated his
right shoulder in a baseball game in April 2004. He has been playing baseball six to seven months out of
every year since he was 10 years old.
While pitching in this complete 7-inning game, he felt strong. Later that evening, pain and soreness
began to set in. It was not unusual
to be sore after a game; however, when he tried to practice the next day, his
shoulder felt unusually weak. About a week after the game, he sought a medical
evaluation. He was treated with
two extended courses of physical therapy.
When attempting to return to play, his symptoms were so severe that he
could not function, even as a designated hitter. On a subsequent orthopedic evaluation, the athlete
complained of anterolateral shoulder painÑparticularly with abduction and
external rotation. Physical examination
revealed passive ROM of: flexion-180 degrees; abduction-175 degrees; external
rotation at 90 degrees of abduction-115 degrees. Patient had mild pain with impingement testing and palpation
of the biceps tendon at the groove.
Patient exhibited a positive OÕBrien test. He also demonstrated mildly positive Speed, Apprehension,
and Crank tests. Cross adduction,
Sulcus sign, and Yergason tests were all negative. Neurological tests proved negative. Pulses were 2+. Differential Diagnosis: Bicipital tendinitis,
rotator cuff impingement syndrome, internal shoulder impingement, SLAP
(Superior Labrum Anterior to Posterior) lesion, Buford Complex, uni- vs.
multi-directional shoulder instability. Treatment:
MRI results confirmed a large
paralabral cyst of the anterior superior with a possible superior labral tear,
although the results were not completely conclusive. Arthroscopic surgery was
performed on January 10, 2005, with the following findings: a labrum tear
extending from the 11:00 to approximately the 4:00 oÕclock position consistent
with a Type 5 SLAP lesion (Type 2 with a Bankart lesion). A small
partial-thickness undersurface rotator cuff tear of <10 % thickness,
involving the anterior fibers of the supraspinatus tendon was also noted. Significant subacromial bursitis
necessitated a subacromial bursectomy. Immediate post-op rehabilitation
protocol for a shoulder was instituted. Passive ROM was limited to 90 degrees
of flexion and external rotation was limited to neutral. During the first 4-6 weeks, the patient
progressed with an active strengthening and progressive throwing program, which
started 4 months post-op. He returned to sports activity six months post-op as
a wide receiver in football and will return to pitching this baseball season (Spring
2006). Uniqueness:
This is a type 5 SLAP lesion, which is unique since it includes the
components of anterior instability seen in a Bankart lesion, as well as
microinstability found in a superior labral tear. It is a cause of pain in the overhead position competitive
athlete that combines both anterior and superior labral tears without a
traumatic event, causing the shoulder to be unstable. Maffet and Gartsman first described this injury in 1995 and
it has only recently been treated surgically entirely through arthroscopic
techniques.
Conclusion: Although a Type 5 SLAP lesion is relatively rare, athletic health care practitioners must consider
it as a cause of shoulder pain in the highly competitive athlete who uses
overhead motions that demonstrates internal impingement and microinstability of
the shoulder.
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