Shoulder Injury - Water Polo

HISTORY: 15 yo RHD male with h/o hypermobility syndrome and 2 prior right shoulder dislocations presented with new right shoulder injury sustained during a water polo game. He reported a collision with another athlete when his arm was in a flexed, abducted, and externally rotated position. Right shoulder suffered anterior dislocation, but spontaneously reduced when arm was placed in sling. Pain located over lateral shoulder with radiation into lateral elbow. Pain described as an ache that worsened with attempts to abduct or externally rotate shoulder. ATC advised sling and modification of activity. PHYSICAL EXAMINATION: Positive Obrien’s, sulcus sign, and SLAPrehension test. Neurovascularly intact with strength preserved. DIFFERENTIAL DIAGNOSIS:1. Bankhart lesion2. Perthes lesion3. ALPSA 4. SLAP lesion 5. Subscapularis tear 6. GLAD lesion TEST/RESULTS: Xray: Small shallow Hill-Sachs deformity noted on posterior humeral head. MRI: demonstrates a Hill-Sachs deformity in the posterior humeral head and a deficient anterior inferior glenoid labrum with medially displaced labral ligamentous complex, suggestive of anterior labral periosteal sleeve avulsion (ALPSA). FINAL WORKING DIAGNOSIS: Anterior labral periosteal sleeve avulsion TREATMENT AND OUTCOMES: Evaluated in SM clinic, 6 days after collision injury. X-ray ordered/reviewed. MRI ordered for further evaluation given exam, recurrent shoulder instability, and x-ray findings. Advised conservative management, PT, and activity modification with overhead activities. MRI returned with positive Hill-Sachs deformity and ALPSA lesion. Referred to orthopedic surgeon for further eval and treatment. Treatment options discussed with parents. Parents opted for non-op treatment. Strength and stability were improving with PT. 2 mo later he experienced 4 additional episodes of shoulder dislocations, while at a camp, with low energy mechanisms. Repeat x-ray with no new bony abnormalities. They returned to the surgeon’s office to discuss surgical intervention. Right shoulder arthroscopy with labral repair was agreed upon and performed. Currently, he is doing well, undergoing physical therapy, with no further episodes of shoulder instability. Participating in non-competitive swimming. Expected to be able to RTP after 6 months with no restrictions.