How to read a complex doctor note on shoulder injury

Patient: Football player - started boxing classes

• Recurrent subtle instability episodes both shoulders & deep seated aching post exercise.

• Previous bilateral ACL reconstructions.

• Generally hypermobile on exam, tall, but no other features of Marfan's syndrome

• Load & Shift test both shoulders +ive ++ especially posterior glide.

• Dislikes Apprehension test.

• Subluxation on hard resisted Empty Can test.

• MRI - bilateral features of multi-directional instability,  but especially posterior instability - mild glenoid dysplasia, humeral head subluxation & posterior labral tearing & attenuation.

• Block of shoulder rehabilitation first to optimise control, strength & movement patterning - consider sensible surgical opinion if becomes more functionally disabling.

The football player who started boxing classes is experiencing recurrent subtle instability episodes in both shoulders and deep-seated aching post-exercise. They have a history of previous bilateral ACL reconstructions and are generally hypermobile on examination. The load and shift test for both shoulders is positive, especially for posterior glide. They also dislike the apprehension test and show subluxation on the hard resisted Empty Can test. MRI findings reveal bilateral features of multi-directional instability, with mild glenoid dysplasia, humeral head subluxation, and posterior labral tearing and attenuation. The initial approach is a block of shoulder rehabilitation to optimize control, strength, and movement patterning. If the condition becomes more functionally disabling, a surgical opinion may be considered.