Scapular Winging and Multi-Directional Shoulder Instability in a Collegiate Women’s Gymnast Abstract A 20-year-old Caucasian collegiate women’s gym- nast presented with a previous history of shoulder instability. A specialist in the uneven bars event, the gymnast required increased mobility to perform specific skills. The athlete presented with an inferior shoulder dislocation event after warming up at a competition. After clinical evaluation, the differential diagnoses included chronic subluxation, severe scapular winging, and multi-directional instability. The athlete underwent rehabilitation and diagnostic imaging which demonstrated labral tearing. An electromyography (EMG) test was performed which was normal. Continued physical therapy was performed. The patient had significant disability with daily activities and did not progress with a dedicated therapy program. Surgery was performed and the athlete demonstrated significant improvements in function but decided not to return to gymnastics. Introduction Shoulder injury occurrence is common in college sport participation. The National Collegiate Athletic Association (NCAA) works with college athletic trainers to monitor injury rates and occurrences in NCAA sports. This program is known as the Injury Surveillance Program (ISP) and started in 1982.10 Hootman et al. noted upper extremity injuries were around 20% of all injuries reported over 15 sports in 16 years. In the gymnastics injury surveillance report from 2014-2019, out of all injuries accounted for, 9.2% were shoulder injuries.9 Commonly noted shoulder pathologies in the sport of college gymnas- tics include rotator cuff tendinitis/tendinopathy, labral and biceps tendon pathology, instability/subluxation, multidirectional instability (MDI), and sprain/strain injuries.11 While most may not consider gymnastics when thinking of an upper extremity sport, the incidence of shoulder injuries is still prevalent. In women’s gymnastics, there is increased torque placed through the shoulder complex and arms in all events, including the uneven bars. Due to the repetitive nature of the sport, upper extremity injuries are typically from overuse. Circumferential labral lesions represent about 2.4% of all labral lesions, thus underlining the rarity of this clinical case report.5-6 A detailed history and clinical evaluation is important in the diagnosis of any injury. Overuse injuries can often be managed with rest, rehabilitation, and non-steroidal anti-inflammatory drugs (NSAIDs). If conservative treatment of an injury does not provide a patient with relief, then referral to an orthopedic physician for further evalua- tion and diagnostic imaging is warranted. This clinical case report provides evidence of a rare shoulder diagnosis in the athletic training and sports medicine worlds. Case Presentation A 20-year-old Caucasian collegiate women’s gym- nast presented with a previous history of shoulder instability. She noted that she had previously gone through general rehabilitation for her shoulder, but it had not helped much. At the time of evaluation, the patient was in the beginning of her junior season. The athletic trainer’s evaluation revealed severe scapular winging, multi-directional instability, and the patient could actively self-sublux her shoulder. (Figures 1 and 2). There was mild instability present on the contralateral side as well, but the patient had not experienced decreased function like the affected side. Key Points: 1. Multidirectional instability can lead to severe scapular winging 2. Conservative treatment may not work for chronic shoulder subluxation with multi-directional instability. 3. Circumferential labral tears are rare, but should be included in differential diagnoses. Mercedes A. Himmons, PhD, LAT, ATC, CES, PES, Anthony Eacuello, LAT, ATC, Eric Padegimas, MD and Jordan Gruskay, MD 18
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