An eleven-year-old, right-hand-dominant, avid baseball player presented to our clinic with pain in the right shoulder. While he had no history of a single traumatic event or dislocation, the symptoms had developed over the previous three months with overhead throwing. He complained of diffuse soreness and weakness of the right shoulder precipitated by throwing and occasionally during batting practice. He was evaluated by his pediatrician, who diagnosed a Little League shoulder syndrome secondary to overuse and recommended a four-week period of rest with cessation of overhead sports. While the rest reduced the pain somewhat, the symptoms immediately recurred with his return to baseball and then precluded his completion of the season.
He presented to our office as a normal-appearing adolescent in no apparent distress. Clinical examination revealed no gross atrophy of the deltoid, trapezius, or rotator cuff musculature with symmetric scapulothoracic motion and no evidence of scapular winging. The cervical spine and glenohumeral joint demonstrated full, painless active and passive range of motion. The right upper extremity was neurovascularly intact. The acromioclavicular joint, sternoclavicular joint, and biceps tendon were not tender to palpation. A stability examination of the shoulder revealed no sulcus sign and 1+ anterior and posterior translation of the humeral head without apprehension. Rotator cuff strength testing revealed mild to moderate (grade 4 of 5) weakness of the right infraspinatus and supraspinatus muscles compared with the unaffected left side. The results of the lift-off and belly-press tests were normal. The active compression test and resisted supination external rotation test reproduced the symptoms in the right shoulder. On the basis of his examination and a concern for occult labral pathology, radiographs were made and a magnetic resonance imaging scan of the right shoulder was acquired.
True anteroposterior, scapular-Y, and axillary radiographs of the right shoulder were within normal limits. No proximal humeral epiphysiolysis, distal clavicle osteolysis, or occult acromioclavicular injuries were appreciated. The magnetic resonance imaging scan of the right shoulder revealed a chronic type-II superior labral tear with an associated large, multiloculated paralabral cyst superior to the spinoglenoid notch (Figs. 1-A, 1-B, and 1-C). No denervation edema or infraspinatus atrophy was appreciated. However, an electromyogram of the right upper extremity demonstrated evidence of suprascapular nerve compression with fibrillation potentials and positive sharp waves consistent with an early denervation of the infraspinatus muscle.
The nature of the diagnosis was reviewed with the family. Given the refractory symptoms and the suprascapular neuropathy, arthroscopic treatment was pursued. An examination with the patient under anesthesia revealed a full glenohumeral range of motion with no evidence of occult anterior or posterior instability. Arthroscopy confirmed a large type-II superior labral anterior-to-posterior (SLAP) lesion. There was frank detachment of the superior labral-biceps complex with exposed bone beyond the superior articular margin of the glenoid and superior fraying of the labral undersurface, demonstrating detachment of the labrum from its insertion (Fig. 2). No sign of internal impingement or pathology on the articular side of the rotator cuff was seen. With probing, the superior aspect of the labrum and the biceps anchor could be subluxated into the glenohumeral articulation. The stalk of the paralabral cyst was identified superior to the origin of the long head of the biceps and was opened with use of a radiofrequency probe. The cyst and its multiloculated subcompartments were thoroughly decompressed under direct vision (Figs. 3-A and 3-B). The anterosuperior margin of the glenoid was freshened and decorticated with use of a 3.5-mm shaver device. Anatomic arthroscopic repair of the superior labral complex to the glenoid margin was performed with use of two absorbable suture anchors, with one placed anterior and one placed posterior to the long head of the biceps origin (Fig. 4).
The patient had an uncomplicated postoperative course and was discharged on the day of surgery. He was managed with immobilization of the shoulder in a sling for three weeks, but elbow and wrist range-of-motion exercises were commenced immediately. Controlled range-of-motion exercises, avoiding positions of extreme abduction or external rotation, were subsequently initiated. Resisted strengthening exercises were added at three months postoperatively, followed by a formal throwing program at four months after full, painless range of motion had been achieved. He was allowed to return to competitive sports at six months postoperatively and was pain-free and without any complaints. Although electromyography was not repeated postoperatively, he had regained full supraspinatus and infraspinatus strength on physical examination at the time of the final follow-up twelve months after surgery.