A 16-year-old right-hand-dominant high school quarterback sustained injury to the left shoulder while attempting to score a touchdown. The left upper extremity was outstretched overhead, with the ball, as the patient dove into the end zone. As the patient landed, he was tackled from behind by another player, with direct contact to the posterior aspect of the left shoulder. The patient had immediate severe pain in the left shoulder and was unable to continue play. He was evaluated locally the following day owing to continued pain and inability to elevate the upper extremity. Radiographs revealed posterior humeral subluxation but no fracture. An magnetic resonance imaging (MRI) scan was ordered, and he was referred to our institution for further evaluation and management.
Our initial evaluation, 4 days postinjury, revealed a guarded posture and diffuse tenderness throughout the shoulder. Although passive range of motion was unrestricted (though with significant discomfort), the patient displayed limited active range of motion of the shoulder. Rotator cuff strength testing revealed 2/5 strength on shoulder abduction (supraspinatus) and external rotation (infraspinatus) with a positive liftoff test (subscapularis). Instability evaluation was limited, secondary to patient discomfort and guarding; however, no discrete anterior instability was documented with load and shift or with abduction and external rotation. The humeral head was resting posterior but in a reduced position. Increased translation and pain were present with a posterior load and shift, but the shoulder was not able to be dislocated. Sulcus sign was negative. The patient was neurovascularly intact.
The MRI revealed marked posterior subluxation of the humeral head with a large accumulation of edema and hemorrhage in the glenohumeral joint. The MRI also revealed complete, full-thickness tears of the supraspinatus and infraspinatus tendons from their insertions; a complete, full-thickness tear of the subscapularis with medial subluxation of the long head of the biceps tendon; and a probable full-thickness tear of the teres minor tendon (Figure 1).
The patient was subsequently taken to the operating room 7 days postinjury. Given the 4-tendon involvement, an open-cuff repair was planned; however, arthroscopy was recommended to first assess the labrum and biceps tendon. An arthroscopic evaluation was therefore performed and so demonstrated the marked hemorrhage and edema in the glenohumeral joint (Figure 2). The extensive injury to the rotator cuff was confirmed, as was instability of the biceps tendon. Remarkably, the glenoid labrum was found to be intact throughout its perimeter with no posterior labral disruption. A debridement of the tendon edges and hemorrhage was completed, the biceps released, and the arthroscope removed in preparation for the open approach. The arthroscopic portion of the case was kept brief to prevent excessive swelling from hampering the open repair.
A combined anterior and posterior approach was selected owing to concern that a single extended approach may not allow complete access to the extremes of the rotator cuff for repair. The posterior approach was first performed. A longitudinal incision was created overlying the deltoid and centered on the posterior glenohumeral joint. The posterior arthroscopic portal was incorporated into the incision. The deltoid fascia was incised, and upon splitting the deltoid fibers, the posterior humeral articular surface was in direct visualization, confirming a complete avulsion of the infraspinatus tendon and disruption of the posterior capsule (Figure 3). Involvement of the teres minor was also documented. Two bioabsorbable anchors with a total of 4 suture sets passed in horizontal mattress configuration were used to accomplish a repair of the infraspinatus and upper teres minor tendons.
A deltopectoral approach was then performed. Upon development of the interval, it was readily evident that the subscapularis tendon had completely avulsed off of its insertion onto the lesser tuberosity and the biceps tendon had subluxed medially out of the bicipital groove. During superior retraction, access to the supraspinatus was achieved and the full-thickness tear was easily identified. A total of 3 additional double-loaded bioabsorbable anchors were placed to repair the supraspinatus and subscapularis. With each anchor, both sets of sutures were passed in horizontal mattress configuration. In all, 5 anchors and 10 suture sets were used to complete the rotator cuff repair. The excellent tendon quality and mobility and strong repair resulted in confidence with a single-row repair. A second row was not deemed to be necessary. A biceps tenodesis was also performed through the anterior approach with the use of a bioabsorbable tenodesis screw. All wounds were thoroughly irrigated and closed. The patient was placed into an external rotation sling with the arm in neutral.
At 2-week follow-up, sutures were removed and the patient was continued in the external rotation sling. Elbow range of motion and pendulum exercises were initiated. At 4-week follow-up, radiographs revealed a concentric reduction of the glenohumeral joint. Physical therapy was initiated for passive range of motion. At 8-week follow-up, the patient continued to show improvement but reported involvement in a motor vehicle accident 2 weeks beforehand (6 weeks following surgery) with transient increase in shoulder pain. Range of motion revealed forward flexion to 120  and external rotation to 20 . Due to the recent trauma, a repeat MRI was ordered. The MRI, eventually performed nearly 3 months postsurgery, revealed a concentrically reduced glenohumeral joint with no evidence of persistent or recurrent rotator cuff tear (Figure 4). Clinical follow-up at this time demonstrated continued improvements in motion with active forward flexion to 140  and external rotation comparable to the contralateral side at 60 . No instability was evident on clinical exam and the patient was without apprehension. At the last clinical follow-up, 5 months following surgery, the patient demonstrated 170  of active forward flexion and abduction, external and internal rotation comparable to the contralateral side, and an intact rotator cuff throughout to strength testing. At 6 months, the patient had returned to baseball with no recurrent symptoms, and 1 year following injury he has returned to football without complaint.