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

2. Vanderbilt Sports Medicine History 18-year-old right-hand-dominant high school student who playsfootball 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. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine 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 aroundthe posterior aspect of his shoulder TTP over the posterior aspect of his shoulder with pain out ofproportion 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. Vanderbilt Sports Medicine Questions

6. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine Shoulder XRays

9. Vanderbilt Sports Medicine MRI

10. Vanderbilt Sports Medicine Diagnosis and Treatment Admission Diagnosis – Myositis of Subscapularis and Infraspinatuscomplicated 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. Vanderbilt Sports Medicine Treatment Initial blood cultures grew MRSA Hospital Day 4 – Transferred to the ICU for hypoxic respiratory distress

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

13. Vanderbilt Sports Medicine Chest CT Multiple, bilateral cavitary nodules consistent with septic emboli

14. Vanderbilt Sports Medicine Treatment Transthoracic echocardiogram – No infective endocarditis

15. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine 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. Vanderbilt Sports Medicine Questions or Comments

21. Vanderbilt Sports Medicine Thank You