When Diagnosis is Elusive

February 15, 2019

By Larry Cooper

Larry Cooper, MS, LAT, ATC, recently retired after 27 years as Head Athletic Trainer at Penn-Trafford High School in Harrison City, Pa., where he also taught health, physical education, and sports medicine classes. Since 2012, he has served as Chair of the NATA Secondary School Athletic Trainers’ Committee. Winner of a 2016 NATA Most Distinguished Athletic Trainer Award, 2015 T&C Most Valuable Athletic Trainer Award, and 2014 NATA Athletic Training Service Award, he was inducted into the Pennsylvania Athletic Trainers’ Society Hall of Fame in 2014. Cooper can be reached at: coopatc1@gmail.com.

 

There are times when we will be faced with an injury or illness that stumps us. We may not be sure about our own ability to evaluate it. Or we may not remember all of the special tests. Sometimes, we simply are missing an otherwise critical sign.

Hopefully nothing tragic happens because of our misstep, but it should be a wake-up call to do something different. To quote Michael Jackson: “Start with the man in the mirror.”

Start with yourself. Don't be looking at all the other things. Start with thinking about how you can be a better evaluator of injuries. Return to your college days, looking for all of the information that you can find on that particular injury.

My push to take a hard look in the mirror came about due to a wrestler with a perplexing injury. He had reduced grip strength and tingling, numbness, and weakness in his right arm/shoulder. It seemed to present itself three to four minutes into a match regardless of the level of competition.

We started looking at his match tapes and reviewing his techniques, conditioning, pre-match routine, and diet—just about every aspect of his daily routine. Nothing stood out, and I along with the coaches and the wrestler were getting frustrated. It seemed like I wasn’t able to help this athlete so it became personal to me.

When I wasn’t at school, I combed through books, read journals, searched online, and spoke with physicians and other athletic trainers. None of them were able to tease through and pinpoint the injury. There was no previous injury, no radiculopathy, no neck or shoulder pain, no vascular or neurological deficits that presented. As you can see, we thought we were covering all bases.

This was occurring over a period of approximately three weeks but it seemed like months. Finally, we asked for shoulder and neck x-rays to rule out a fracture or abnormality. The results of the X-ray proved to be just what we needed. It showed an extra first rib that was more than likely the culprit. This is called Neurogenic thoracic outlet syndrome.

Thoracic outlet syndrome can be a result of an extra first rib (cervical rib) or an old fracture of the clavicle (collarbone) that reduces the space for the vessels and nerves. Bony and soft tissue abnormalities are among the many other causes of TOS. The following may increase the risk of developing thoracic outlet syndrome:

  • Sleep disorders
  • Tumors or large lymph nodes in the upper chest or underarm area
  • Stress or depression
  • Participating in sports that involve repetitive arm or shoulder movement, such as baseball, swimming, golfing, volleyball
  • Repetitive injuries from carrying heavy shoulder loads
  • Injury to the neck or back (whiplash injury)
  • Poor posture
  • Weightlifting

After this injury I made sure that whenever I went to a conference or meeting I tried to attend as many presentations on shoulders that I could. My goal was to improve my clinical skills so that the same scenario would not present itself again in the future.

The incident was frustrating at first, but it reminded me of the importance of constant and never-ending improvement. It was also a case of adapt, overcome, and achieve, which allowed me to up the level of care I provide to our student-athletes.

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