Case Report

Push-ups may be hazardous to your health: an atraumatic etiology for bilateral Shoulder dislocation

Abstract

A 23-year-old man presented to the emergency depart- ment (ED) complaining of right shoulder pain. His symptoms began suddenly while exercising at home. The patient had been doing push-ups, and after completing approximately 100 repetitions, he felt his right shoulder give way and collapsed into a prone position. He had difficulty getting up from the floor and eventually called out to his friend for assistance. The patient’s friend was able to lift him from the floor. He experienced bilateral shoulder pain (albeit the right being much greater than the left) and noted that he had never had these symptoms before.

Upon arrival in the ED, he noted that his right shoulder had started to swell, and he had marked immobility and pain in the right shoulder region. Physical examination revealed a very fit and muscular young man in moderate distress with an obvious deformity of the right shoulder displaying the anterior fullness and square contour typically associated with Anterior shoulder dislocation. He was unable to mobilize his right shoulder and supported his right upper extremity with his left hand. The remainder of the examination results were benign, including the absence of any gross sensory deficits. Radiography of the right shoulder revealed anterior disloca- tion without evidence of fracture (Fig. 1). The dislocation was reduced using the modified Hennepin maneuver, and the patient tolerated the procedure well with the aid of fentanyl and midazolam.

After reduction, while his right shoulder was being immobilized, the patient noted an increasing discomfort in his left shoulder. Closer examination of the left side revealed decreased mobility about the Shoulder joint but no obvious deformity. Radiography of the left side revealed anterior dislocation of the Glenohumeral joint (Fig. 2). The patient was given additional sedation, and the second dislocation was reduced without complication. After the procedure, the patient was placed in bilateral shoulder immobilizers and referred to an orthopedic clinic. He was immobilized for

6 weeks and started on shoulder mobilization exercises.

Gradually, his range of motion improved, and he recovered complete mobility in both shoulders by 12 weeks postinjury. Although much rarer than unilateral shoulder disloca- tions, there have been several case reports of bilateral shoulder dislocation. Most reports regarding bilateral shoulder dislocation are in the context of a traumatic injury. A Dutch team reported a case of bilateral (1 anterior and 1 posterior) dislocation as a result of a motor vehicle crash [1]. A case of bilateral anterior dislocation reported in the European literature is also related to Motor vehicle trauma, although in this case, the second dislocation occurred several minutes after the first [2]. Lower energy mechanisms have also been reported to cause bilateral dislocations. One case report includes bilateral anterior glenohumeral disloca- tions in an Elderly woman after domestic assault [3]. Another author reports bilateral anterior dislocation after a fall from a ladder [4]. Finally, a soccer player sustained bilateral posterior Shoulder dislocations after falling during a

game [5].

Seizures have also been reported as a cause of bilateral shoulder dislocations, with one author reporting a case of anterior-posterior dislocation as the initial presentation of a brain tumor [6]. Recurrent bilateral shoulder dislocations have been observed after seizures secondary to nocturnal hypoglycemic episodes in a young diabetic male [7]. Other

Fig. 1 Radiography of the right shoulder revealing anterior dislocation without evidence of fracture.

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Fig. 2 Radiography of the left side revealing anterior dislocation of the glenohumeral joint.

types of maximal muscular contraction have been shown to cause bilateral shoulder dislocation, as in the case of an elderly woman with dyskinesia resulting from Parkinson disease treatment [8].

Several weight-training accidents have been reported as the etiology of bilateral shoulder dislocation. Maffulli and Mikhail [9] report the case of a weight lifter sustaining bilateral anterior shoulder dislocations while performing a “pull-over” bench maneuver. Another case involved a weight trainer performing a standard bench-press exercise [10]. In both of these cases, the weight bench presumably acted as a fulcrum to force the humeral head out of position under the load of the exercise weights.

The case we have presented is unique in that the mechanism was atraumatic, did not involve a single maximal muscular contraction, and occurred without the additional stress of weights or other exercise equipment. After fatiguing his muscles to the point of failure, our patient collapsed from the push-up position with his body weight supported primarily by his adducted, flexed upper extremities. It is probable that his right shoulder dislocated at this point, caught under his body and hyperflexed by his other arm. The left shoulder disloca- tion may have occurred simultaneously or perhaps sometime after the collapse. The patient was significantly

distracted by the pain in his right shoulder, and although he noted pain when he was lifted from the ground, he did not report left-sided pain until the right-sided dislocation was reduced. This case presents an unusual mechanism for an unusual injury and highlights the importance of a thorough physical examination, avoiding early closure, and frequent patient reevaluation throughout the course of treatment.

F. Alexander de la Fuente MD Providence-Everett Medical Center North Sound Emergency Medicine

Everett, WA, USA

Christopher Hoyte MD Department of Emergency Medicine Cook County-Stroger Hospital

Illinois Poison Center, Chicago, IL 60612, USA

Sean M. Bryant MD Department of Emergency Medicine Cook County-Stroger Hospital

Illinois Poison Center, Chicago, IL 60612, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2007.07.019

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