Working Diagnosis:
Left shoulder reverse Bankart fracture with associated labral tear and Hill-Sachs lesion.
Right shoulder reverse Bankart fracture with associated posterior labral tear.

Treatment:
Initially conservative treatment included shoulder sling for comfort (2-wks), football position change, ice and NSAIDs as needed. After imaging results were reviewed with patient, surgical intervention was offerred. Physical therapy was also recommended for rotator cuff and anterior deltoid strengthening.

Outcome:
The patient declined both surgical intervention and physical therapy as the symptoms were not bothersome with activities of daily living and he has completed his football career.

Author's Comments:
Multiple attempts were made to contact the patient for further follow-up, but we have not been successful. At the time of print he was 9 months out since the last visit. The patient and his parents understand that he is at high risk for early-onset osteoarthritis due to his instability and bone abnormalities. It is unclear if he has some some degree of congenital multi-directional shoulder instability or truly his findings are a result of multiple traumatic injuries to each shoulder.

Editor's Comments:
This case is a good example of shoulder instability and the potential consequences. Usually patients with traumatic injuries present with unilateral symptoms. The patient in this case has bilateral symptoms which may point to an additional genetic component. Beightons criteria can be used to assess patients for ligamentous laxity. For patients with multidirectional instability, physical therapy is often the mainstay of treatment. However, in a patient with significant bone and cartilage abnormalities surgical intervention would be best for resolution of symptoms and best functional outcomes long-term.

References:
Bahu MJ, Trentacosta N, Vorys GC, et al. Multidirectional instability: evaluation and treatment options. Clin Sports Med. 2008;27:671-689.

Miniaci A, Codsi MJ. Thermal capsulorrhaphy for the treatment of shoulder instability. Am J Sports Med. 2006.

Caprise P, Sekiya J. Open and arthroscopic treatment of multidirectional instability of the shoulder. Arthroscopy: J Arthroscopic Related Surg. 2006;22:1126-1131.

Mahaffey BL, Smith PA. Shoulder instability in young athletes. Am Family Phys. 1999;2773-2782.

Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60:1-16.

Return To The Case Studies List.