Case Study: Throwing Shoulder Injury in a College Baseball Player

Patient Profile:
Tyler, a 19-year-old right-handed college baseball pitcher, presents with a three-month history of gradually worsening right shoulder pain. He reports the pain began during the middle of the season after several games with increased pitch counts. The pain is localized to the posterior and superior aspects of his shoulder, particularly during the late cocking phase of throwing. He experiences occasional sharp pain and a feeling of "catching" deep within the shoulder when he throws. He also reports reduced velocity and control of his pitches. Resting for a few days provided temporary relief, but the pain returned when he resumed throwing. He has no prior history of significant shoulder injuries.

Tyler denies any numbness or tingling in his arm but describes general weakness and fatigue in his shoulder by the end of games. His goal is to get back to peak performance before the next season.

Physical Exam Findings:

• Inspection: No visible deformities or muscle atrophy.
• Palpation: Tenderness to palpation over the posterior shoulder, particularly along the infraspinatus and teres minor muscles.
• Range of Motion (ROM): Glenohumeral internal rotation deficit (GIRD) with limited internal rotation compared to the left shoulder. External rotation is slightly increased.
• Strength: 4/5 in external rotation and internal rotation of the right shoulder. Scapular dyskinesis observed during abduction.
• Special Tests:
  • Jobe’s Relocation Test: Positive
  • Anterior Apprehension Test: Positive
  • O’Brien’s Test: Positive (pain at the shoulder, especially in the deep posterior aspect)
  • Crank Test: Positive
  • Neer and Hawkins-Kennedy Tests: Negative

Imaging:
X-rays are normal. MRI shows a posterior superior labral tear (SLAP lesion) and mild glenohumeral internal rotation deficit (GIRD).

Questions for Case Assessment:

Using this information, please answer these questions:

1. Based on Tyler’s history, physical exam, and imaging findings, what is the most likely diagnosis? Which shoulder structures are affected in this injury?
   Explain the significance of the positive special tests and MRI findings, and describe the shoulder structures involved in a SLAP lesion.
    
2. What is the role of the glenohumeral internal rotation deficit (GIRD) in Tyler’s injury, and how might it contribute to his shoulder pain?
   Discuss the pathophysiology of GIRD in throwing athletes and its relationship to labral injuries or shoulder instability.
    
3. What is your initial management plan for Tyler, considering his desire to return to competitive pitching?
   Outline conservative treatment options, including physical therapy exercises, pain management, and any throwing modifications. Include criteria for a safe return to throwing.
    
4. When would surgical intervention be indicated for Tyler’s shoulder injury, and what procedures might be recommended?
   Discuss the indications for surgery in a SLAP lesion and the types of surgical procedures commonly performed for throwing athletes, such as arthroscopic labral repair. Describe the post-surgical rehabilitation timeline and expected outcomes.