Author: Caitlynn Croft, MD
Co Author #1: Jocelyn Mittner, MD
Co Author #2: Mark Keilbarth, MD
Senior Editor: Drew Duerson, MD
Editor: Emily Catalano, MD

Patient Presentation:
A healthy 16-year-old high school football player presented to a sports medicine clinic for follow-up after evaluation at an urgent care center for sharp right upper back pain following a football game. <br> <br>The patient reported that his pain worsened with cross-body movements and cervical rotation to the left. He also reported pain with deep inspiration. <br> <br>The pain developed gradually without a specific collision or identifiable inciting event. The patient played the safety position and recalled one head-on collision involving the crown of his helmet while making a tackle 4 days prior to presentation. However, he denied the immediate onset of pain following that event. <br> <br>He denied dyspnea, cough, fever, or other systemic symptoms. He also denied neurologic or vascular symptoms, including numbness, paresthesias, color change, or swelling of the upper extremities.

History:
The patient denied any prior history of trauma or injury involving the right shoulder. He had no prior surgical history involving the right shoulder, cervical spine, or thorax. <br> <br>His past medical, surgical, social, and immunization histories were otherwise unremarkable.

Physical Exam:
The patient was afebrile with stable vital signs. <br> <br>There was no swelling, deformity, or muscle atrophy of the shoulders, clavicles, or cervical spine. He was nontender to palpation over the cervical spinous processes, bilateral clavicles, biceps tendons, acromioclavicular joints, chest wall, or thoracic paraspinal musculature. <br> <br>The patient had full range of motion of the cervical spine, including flexion, extension, and rotation, as well as full shoulder flexion, extension, abduction, adduction, external rotation, and internal rotation. He was able to internally rotate to the level of T4. <br> <br>Distal pulses were palpable and symmetric, with a 2+ radial pulse. No swelling of the right upper extremity was noted. <br> <br>Strength was 5/5 throughout and symmetric bilaterally in all planes of shoulder motion. Sensation was intact throughout the C2-C8 dermatomes of the upper extremities. <br> <br>Provocative testing reproduced pain with right-arm cross-body adduction and left cervical rotation. The remainder of the cervical and shoulder examination was unremarkable.

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