Author: Kellen Gower, MD
Co Author #1: Ricardo Colberg, MD
Senior Editor: Mandeep Ghuman, MD, FAMSSM

Patient Presentation:
15 year-old female level 10 high school gymnast presented with one month history of progressive insidious right shoulder and neck pain.

History:
Patient described her pain as a moderate-to-severe aching, with intermittent dull and sharp stabbing pain in the right upper trunk/shoulder which started one month prior to presentation. It was worse with lifting and bodyweight exercises and improved with rest. She took acetaminophen as needed for pain. She denied swelling, numbness,tingling, or radicular symptoms down the arm, and any recent injuries or inciting events. She had been very active with gymnastics over the last 6-12 months and saw a chiropractor for adjustments 3 weeks prior due to suspected myofascial pain. She was initially referred to the clinic for trigger point injections for presumed trapezius muscle spasms. She denied any prior fractures, medications, or previous surgeries.

Physical Exam:
General: 4ft 11in and 85 lbs
Musculoskeletal:
Right Shoulder exam revealed no atrophy or deformity. Severe tenderness noted posterior-inferior to proximal clavicle. No crepitation. Range of motion was Abduction 160 degrees, forward flexion 180 degrees, extension 50 degrees, external rotation 75 degrees, internal rotation 85 degrees. No instability. Strength was abduction 5/5, forward flexion 5/5, internal rotation 5/5, external rotation 5/5. Negative impingement sign, cross-arm test, O Briens test, Speeds test, drop-arm test and empty can test.
Trunk/Neck: Severe tenderness to palpation over the right posterior first rib region, no other focal tenderness. FROM at cervical neck, (-) Spurlings
Neurovascular: Sensation grossly normal bilateral upper extremities. 2+ radial pulses,

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