Working Diagnosis:
Acute, grade 2 (1 cm) posterior left sternoclavicular subluxation

Treatment:
Ice
Medications (NSAIDS, muscle relaxants)
Sling
Re-evaluation in 3 weeks
He was advised to seek reevaluation if with onset of new symptoms, such as
dyspnea, hoarseness, UE swelling, or UE numbness/tingling

Outcome:
On re-evaluation, the patient's "shifting movements" in his shoulder with overhead motion resolved. His left shoulder had full range of motion. Rehabilitation program was started. Estimated time to return to play was 16 weeks.

Author's Comments:
Mild-moderate sprains can return to play once pain has resolved and the athlete has full function (usually 2-4 weeks)
Anterior dislocations take a return-to-play time of 6-8 weeks
There is limited literature regarding posterior dislocations. It is more conservatively managed given the potential complications associated with a recurrent posterior dislocation. Case reports cite gradual return-to-play at around 16 weeks post-injury.

The typical presentation of posterior SC dislocations include:
Severe pain out of proportion to the exam, exacerbated by any arm movement, coughing, sneezing, or deep breathing

The patient may complain of hoarseness, dysphagia, dyspnea, numbness, and weakness or venous engorgement of the ipsilateral arm. Because of spasms in the neck muscles, the head may be tilted to injured side.

In our case, the patient had pain out of proportion to his exam and complained of shifting movements in his shoulder that was unprovoked. If this had been on the field, management of this, if with signs of dyspnea, numbness or weakness, would probably have included:
- Immediate ER, then OR with cardiothoracic surgery present
- Placing the patient supine with a bolster placed under the patient's thoracic spine to allow shoulder scapular retraction.

In order to reduce the posterior dislocation (usually done in the OR) the shoulder is abducted to 90 degrees, extended to 15 degrees, and traction on the arm is applied while anterior traction is applied on a sterile towel clip around the medial end of the clavicle to help dislodge the clavicle from its retrosternal location.

Editor's Comments:
This is an excellent case that illustrates a relatively common complaint (shoulder pain) that can be encountered at any football game, and leave a sports physician with a myriad of differentials at the beginning. Excessive pain and motion over the clavicle points towards specific differentials as illustrated above, but the physical exam is not suggestive of more common differentials, which makes this an interesting case. Posterior subluxation of the sternoclavicular joint is not a diagnosis that is considered initially in most athletes presenting with shoulder pain, and so, recognition is important, particularly when accompanied by dyspnea and/or signs or neurovascular compromise. Placement of the patient supine with a bolster placed under the patient's thoracic spine to allow shoulder scapular retraction also appears to be an important aspect of first responders immediate care on transport.

References:
Hollis J; Grangier C; Shiber JR. Posterior sternoclavicular dislocation. Journal of Emergency Medicine. 44(8):4, May 2008.

Judie Walton, Anastasios Paxinos, Anthony Tzannes, Mary Callanan, Kimberley Hayes, and George A. C. Murrell
The Unstable Shoulder in the Adolescent Athlete
American Journal of Sports Medicine. 30:758-767, September 2002.

Kirkley, Alexandra; Litchfield, Robert; Thain, Lisa; Spouge, Alison. Between Magnetic Resonance Imaging and Arthroscopic Evaluation of the Shoulder Joint in Primary Anterior Dislocation of the Shoulder. Clinical Journal of Sport Medicine. 13(3):148-151, May 2003.

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