Shoulder Instability Induced By Bat Swing In A High School Baseball Player

HISTORY: A 17 year-old right-hand dominant (RHD) male baseball player presented to the clinic one week after a left shoulder injury while at batting practice. Patient was batting right handed when he felt a pop and pain in his left shoulder after a swing. The pain progressed with subsequent swings, where he experienced two more pops and worsening feelings of instability. He presented to a local emergency department due to the pain and instability, where he received X-Rays (unremarkable), a sling and ketorolac. Patient denied previous history of left shoulder injuries, continued to report subjective feelings of instability, and denied pain, weakness, or paresthesia. PHYSICAL EXAMINATION: Pertinent Negatives:Range of motion was normal in all planes. Manual muscle testing revealed full and symmetric strength bilaterally. Neurovascularly intact, no signs of muscle atrophy.Pertinent Positives:Tender to palpation at the proximal long head of Biceps tendon.Special Tests:Positive Crank test for mechanical symptoms posteriorly. O’Brien Compression, Apprehension, Speeds, and Empty Can tests were all negative. DIFFERENTIAL DIAGNOSIS:1. Rotator Cuff Tear2. Superior Labrum Anterior and Posterior (SLAP) Tear3. Posterior Subluxation TEST AND RESULTS: Three- view radiographs:- UnremarkableMagnetic Resonance (MR) Arthrogram:- Minimally depressed impaction fracture along the anteromedial aspect of the humeral head- Non-displaced posterior labral tear FINAL WORKING DIAGNOSIS: Impaction fracture of the humeral head secondary to posterior subluxation with posterior labral tear (aka Batter’s Shoulder) TREATMENT AND OUTCOMES: 1. Discussed surgical (Bankart repair) versus conservative management. Family opted for conservative management involving activity modification, physical therapy (PT) and home exercise program (HEP).2. Restricted from batting, catching, and heavy lifting for 6 weeks.3. Biweekly PT incorporating return to batting program (slow progression of batting motion exercises) and HEP focusing on posterior shoulder structure strengthening for 6 weeks. 4. Patient’s symptoms significantly improved with PT and HEP. Patient returned to live batting after 4 weeks of batting program (total 6 weeks of therapy).5. Patient without any recurrence of symptoms over 1 year status-post initial injury.