A Weak And Painful Shoulder In A Professional Volleyball Player

ABSTRACT: HISTORY: A 29-year old professional volleyball player, without history of recent trauma, surgical procedures, infections, complained of a dull ache in the right lateral base of the neck, exacerbated by digital pressure on the region and associated with episodes of vagal reaction (asthenia, dizziness, nausea) after training sessions and cold air exposure. After 3 days, the athlete exhibited deficiency of right scapula adduction, mild limitation of scapula elevation, right shoulder weakness, mild pain in the right lateral base of the neck, radiated to the right shoulder, without sensitivity deficits. PHYSICAL EXAMINATION: Physical exam revealed an asymmetrical neckline with drooping of the affected shoulder, lateral displacement and minimal winging of the right scapula, that was displaced laterally, rotating downward and outward. Winging disappeared during forward flexion of the arm. A moderate pain on the right neck base persisted for about 20 days. Both deep reflexes and strength of upper right limb were normal, and no contractures were present. The athlete complained of weakness in abduction of right arm and inability of scapula adduction, but he could shrug the shoulders, elevate forward the right arm and move the neck in any direction. After 1 week hypotrophy of superior trapezius was evident. DIFFERENTIAL DIAGNOSIS: -paralysis of the rhomboid and serratus anterior muscles; -herniated nucleus pulposus of cervical disks; -progressive neuromuscular disease; -scapular osteochondroma; -herpes zoster infection; -thoracic outlet syndrome; -suprascapular nerve injury. TEST AND RESULTS: Magnetic resonance imaging of cervical spine and shoulder: - no signs of mass lesions nor disk disease; - signs of infraspinatus chronic tendinopathy and acromioclavicular arthrosis. EMG right upper limb: -denervation in the upper, middle and lower components of the right trapezius muscle, due to axonotmesis of spinal accessory nerve. Blood tests: - protein profile and complete blood count were normal; Varicella-Zoster and Herpes virus IgM antibodies were negative. FINAL/WORKING DIAGNOSIS: Idiopathic spinal accessory nerve palsy. TREATMENT AND OUTCOMES: - Rest from playing volleyball for 3 months - Formal physical therapy. - Neurocognitive Rehabilitation - Transition to sport specific movements and return to play