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Abstract

Background: A 21-year-old collegiate baseball player reported to the athletic training staff complaining of pain along the superior angle of the scapula, decreased shoulder range of motion, and transient numbness and tingling in the 4th and 5th digits of his right hand. Physical evaluation revealed substantial spasm and rigidity of the upper trapezius and scapular stabilizer musculature, along with myofascial adhesions in the rhomboids and levator scapulae, in addition to weakness with shoulder abduction and external rotation. All thoracic outlet syndrome testing yielded no positive tests. Thorough patient history revealed a history of shoulder arthroscopy the previous summer to address minor fraying of the rotator cuff after which the patient reported participating in minimal therapeutic exercise. At this time, the patient was advised to begin icing following every practice, along over the counter NSAIDs as directed. The patient was also instructed to begin therapeutic exercise on a daily basis with the athletic training staff. Differential Diagnosis: Scapular dyskinesis, scar tissue following improper rehabilitation of shoulder arthroscopy, general deconditioning of the shoulder musculature. Treatment: Day 1, patient began therapeutic exercises with the athletic training staff aimed at addressing scapular stabilizer weakness and decreased shoulder range of motion. During exercise, patient reported increased pain along the superior angle of the scapula when performing shoulder abduction with dumbbells. This exercise was discontinued at this time while the remainder of the therapeutic exercise program was continued. Day 2, patient reported that his shoulder and the surrounding musculature felt fatigued, but did not feel sore. Following re-evaluation, it was determined that the fatigue was a normal response to therapeutic exercise following deconditioning and exercise was continued. Day 5, patient began seeing the team chiropractor during regular weekly clinics. Evaluation from the team chiropractor confirmed both weakness and tightness of the shoulder musculature. At this time the patient was informed that they would be referred to the team physician if their symptoms worsened or did not significantly improve two weeks after the initial evaluation. Day 9, patient reported worsening symptoms during practice. Patient was then removed from team activities and scheduled to see the team physician. Day 10, upon evaluation, the team physician concurred with the evaluation of poor scapular stabilizer strength while also diagnosing the patient with poor postural stabilization of the cervical spine. Following the updated diagnosis, the patient’s therapeutic exercise plan was revised to address the new found weakness. Day 14, during treatment at the team chiropractor’s office cervical spine x-rays were obtained that revealed cervical kyphosis. With this new finding, patient began undergoing dry needling and cupping treatments in an attempt to address tight anterior musculature while continuing to address weakness. Day 21, patient continued current treatment plan, and presented with an increase in strength and range of motion. Throughout the remainder of the season, the patient continued treatment and rehabilitation plan and was able to participate in practices and competitions with minimal symptoms. Uniqueness: While cervical kyphosis is not a unique diagnosis in and of itself, the continued participation in competitive intercollegiate activity is noteworthy. Furthermore, patients suffering from cervical kyphosis often require surgical intervention to be able to maintain quality of life. In this case, the patient was able to continue with activities of daily living through the utilization of conservative measures. Conclusions: When treating a patient with an uncommon condition in their population, it is paramount that the clinician exhaust all resources to find proper treatment to address all associated pathologies. Should a clinician be treating a condition they are unfamiliar with, evaluation and re-evaluation of outcomes is crucial for an optimal prognosis.

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