Case History:
The patient is a 45-year-old female gymnast, active and participating in
national and international competitions for veterans. As a child and
youth, she was actively competing on national level, outside the
national team. Around her thirties, the gymnastics were resumed for four
years before paused due to pregnancies, and again resumed at the age of
40, but on a veteran level with approximately five hours weekly
training. She is a medical doctor, healthy with no relevant prior
injuries, non-smoker, and does not use medication. Before the injury,
she exercised two or three times a week with gymnastics and sometimes
with running or cross-country skiing. Two years prior to the injury she
had chronic right shoulder pain radiating along the proximal dorsal part
of the right upper arm which worsened after training sessions.
The patient was injured in September 2020 while doing subsequent glide
kips in the uneven bars. She experienced a snap in the right shoulder
area after the third repetition of sudden pull of the shoulder when
hanging by her arms. She initially felt no pain but had a sense that
something was missing in the dorsal musculature and the feeling of
reduced function and swelling (Fig. 2). She did not cool down the area
with ice, nor did she need analgesics. She was referred to MRI with the
question of a possible tear of a tendon in the right shoulder area. The
referrer suggested a tear of the triceps, teres major, or subscapularis
muscles. Clinical testing was difficult to perform in the sub-acute
setting because of pain evolving in the area.
Imaging was performed as described below, but no specific therapy, like
guided physiotherapy, was performed, and no surgical attempts were made.
After the injury, the patient continued to exercise twice a week but
avoided sudden movements, the uneven bars, climbing the ropes, and
pull-ups.
After two weeks, an apparent abnormal contour of the right posterior
axillary fold was visible (Fig. 3a). However, she could do push-ups and
“cross handstand – roll forward” on the balance beam. When hanging by
her arms, she was hanging obliquely “like a banana” with her legs
deviating to the left in the coronal plane, probably due to compensation
for reduced strength on her injured right side (Fig. 4a).
She continued exercising mainly by doing cross country skiing three
hours a week and some basic strength exercises at home. She experienced
reduced strength in the right upper arm when poling during the diagonal
stride in cross country skiing (i.e., extending the right shoulder
against resistance). The pain subsided a few weeks after the injury, but
she experienced a stretching sensation in the area, for instance, when
doing pull-ups.
After three weeks, she could do a handspring entry onto the vault board
and handstand on the balance beam (Fig. 4b).
After three months, she was able to walk on her hands, as she could
before the injury.
After six months of non-operative treatment with continuous but
self-guided tailored exercises, she had no pain, nor did she experience
any asymmetric strength, and she could climb the ropes all the way to
the ceiling (>10 meters above the floor) (Fig. 5). However,
the stretching sensations in the injured area persisted, and a contour
change was visible when doing pull-ups, but otherwise, no noticeable
sequelae (Fig. 6a and b).