An uncommon shoulder injury.

A 21 year old male fell while water skiing one year before presentation. The impact with the water caused the right l arm to be forcefully hyperextended while fully elevated. Symptoms persisted for nearly a year despite a course of anti-inflammatory medication, and induded twinges of pain on reaching or elevating the arm. Early in the summer of the following year he tried to play softball, but found that throwing exacerbated his pain. Physical examination of the shoulder, including active, passive and resisted movements revealed only limitation of _' internal rotation of the arm (inability to put the hand between the scapulae as shown in Figure 1). Resisted (isometric) testing of isolated shoulder muscles revealed weakness and pain upon testing of latissimus dorsi during its prime motion of arm depression. The test is shown in Figure 2. There was full elevation and normal scapulohumeral movement. There was no painful arc on > B abduction. The acromioclavicular joint was normal. The capsule was stable and free. The pain caused by the resisted arm depression was generally posterior to the shoulder and axillary. Palpation of the latissimus dorsi and its tendon revealed marked l; _ tenderness near the insertion into the bicipital groove, and also just caudad at the junction of tendon and muscle belly. Deep cross-fibre friction massage was applied to these areas for one minute, as described by Cyriax'. Immediate Figure 1. Patient unable to place nght hand between re-testing now showed improved range of active movescapulae ment, plus increased power and less pain. The tender areas were then injected with a mixture of triamcinolone 40mg/ml in plain one per cent xylocaine. Amounts were two drops of triamcinolone in 1 ml xylocaine. The needle was inserted and partially withdrawn several times in an attempt to cover the whole of the tender areas. The injection is not into the tendon, but adjacent (Figure 3). This was followed by more cross-fibre massage. The patient was seen a week later, and had been able to play softball. Follow-up at six months showed no problem.