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Abstract

CASE HISTORY: The patient was a 21-year old right-handed collegiate female volleyball player who presented with chronic shoulder pain in her dominant shoulder, which began approximately five years ago. Her previous assessment and treatment included x-rays and MRI imaging, several joint injections, and daily rehabilitation in an attempt to manage her symptoms. Unfortunately, her shoulder problems persisted. Four years after the onset of her pain, she underwent surgery as it was deemed necessary, due to her consistent pain and functional limitations. PHYSICAL EXAM: The patient reported sharp pain (7/10) during overhead activities. Strength was 3+/5 on flexion and abduction, 4/5 on internal rotation, 3/5 external rotation. Positive Empty Can Test for pain and weakness. Negative Sulcus Sign Test. DIFFERENTIAL DIAGNOSIS: Anterior shoulder instability; rotator cuff tear; impingement syndrome; labral tear. TESTS & RESULTS: MRI revealed a partial rotator cuff tear and the presence of a large loose body in shoulder joint. Clinical testing indicated instability and symptoms of impingement. FINAL DIAGNOSIS: Anterior shoulder instability with impingement syndrome, partial rotator cuff tear, and a 5mm intra-articular loose body. DISCUSSION: Shoulder injuries are common among overhead athletes, with labral tears and instability presenting significant challenges. Without early diagnostic imaging, extended rehabilitation may be insufficient. In this case, the athlete completed nearly four years of daily corrective exercises before undergoing diagnostic imagining. Once the imaging showed injuries that required surgical intervention, surgery was performed. However, post-operative rehabilitation only regained strength and range of motion; it did not alleviate pain. Ultimately, the athlete only achieved pain relief when she stopped all activity, including rehabilitation, for six months. This case study highlights the complexity of treating shoulder instability and the importance of rest when pain does not subside after traditional treatments. OUTCOME OF THE CASE: Arthroscopy of the right shoulder was performed. The procedure included glenoid labral repair with Arthrex anchors, acromioplasty, extensive debridement of the labrum and rotator cuff, and loose body removal. The patient engaged in post-operative rehabilitation and progressively regained strength in shoulder function. However, she still experienced pain. RETURN TO ACTIVITY: After discontinuing rehabilitation for an extended amount of time, she was able to slowly return to activity. She was able to participate in practices and games without pain in her final collegiate season.

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