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

SEACSM Clinical Conference I Lt. Shoulder Pain Out of Proportion to the Stimulus . David G. Liddle, MD Vanderbilt Sports Medicine February 11, 2012. History. 18-year-old right-hand-dominant high school student who plays football and baseball with left shoulder pain

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

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  1. SEACSM Clinical ConferenceILt. Shoulder Pain Out of Proportion to the Stimulus David G. Liddle, MD Vanderbilt Sports Medicine February 11, 2012

  2. 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

  3. 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

  4. 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

  5. Questions

  6. Differential Diagnoses • Septic Arthritis • Myositis • Brachial Plexopathy • Subacromial Bursitis • Shoulder Impingement Syndrome • Rotator Cuff Tendonopathy or Strain • Degenerative or Inflammatory Arthritis • Crystal Arthropathy • Adhesive Capsulitis

  7. Data • Labs • CBC – WBC 18.4 w/ 88% PMN but o/w NL • CMP – WNL x/ non-fasting glucose 130 • ESR – 48 • CRP – 264

  8. Shoulder XRays

  9. MRI

  10. 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

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

  12. Chest XRay • Multiple, bilateral, round airspace opacities consistent with septic emboli • Lateral view also showed bilateral, small pleural effusions

  13. Chest CT • Multiple, bilateral cavitary nodules consistent with septic emboli

  14. Treatment • Transthoracic echocardiogram – No infective endocarditis

  15. Treatment • Bilateral Upper Extremity Ultrasound • No septic thrombophlebitis • Blood cultures • Cleared by HD5 • Continued to fevers and increased pain • WBC and CRP also increased after initially improving • Prompted repeat MRI

  16. Repeat MRI • Marked interval increase of myositis • New large fluid collections suggestive of abscesses • New glenohumeral joint effusion and periarticular marrow edema • However, the fluid was uniform in color and lacked rim enhancement on T2 images

  17. 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.”

  18. 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

  19. 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

  20. Questions or Comments

  21. Thank You

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