0:02

<v ->I'll show some different cases.

0:04

The first case is 22-year-old woman,

0:07

presenting with increased intense pain in the shoulder.

0:11

Bilateral pain, started two weeks ago

0:18

during CrossFit competition.

0:21

I don't know if you know what is CrossFit.

0:24

Have you heard about it?

0:25

<v ->I think they do different things

0:28

'cause they're involved in different sports.

0:30

<v ->Exact, they put a lot of,

0:32

they use functional movements

0:35

associate with weightlifting.

0:37

<v ->Yeah, I don't do that.

0:38

I do no CrossFit.

0:41

<v ->It's very nice, but you know,

0:44

some recent studies show that

0:46

75% of the participants

0:49

have injury in this sport.

0:51

<v ->Ah, okay.

0:52

<v ->This is very nice for us.

0:54

'Cause we make a lot of MRIs here in Brazil.

0:56

In Brazil, it's very, very common practice.

1:01

Let's go, let's return to the case.

1:03

After the injury, she stopped her exercise

1:06

and applied ice and rest.

1:09

And during following days, she felt continuous pain,

1:13

bilateral in the area of anterior shoulder.

1:18

She put the hand like in the subscapularis muscle,

1:23

in front of the shoulder.

1:25

The physical examination was very inconclusive,

1:28

but the clinical suspicion was anterointernal impingement.

1:33

The guy suspect an injury of the glenoid labrum,

1:36

anterior glenoid labrum in the subscapularis tendon.

1:40

She did an x-ray and MRI of both shoulders.

1:43

Let me show the x-ray.

1:46

The x-ray is completely normal.

1:48

We can look the images.

1:51

There's a normal bone structures.

1:53

There is no lines of fractures.

1:55

There is no different things.

1:58

That's completely normal.

2:00

And we take a look in the MRI.

2:04

On the right side,

2:07

divide here in different.

2:10

Let's go to see different sequence, in different planes.

2:15

Okay, this is the T2 fat suppression,

2:18

the T1, and axial T2 and sagittal T2 image.

2:25

In this image, it's very easy to see,

2:30

an area of edema.

2:32

It is a bone edema.

2:34

Look like the channel enlargement, the vessels.

2:39

But in T1 image is very easy to see, a fracture,

2:43

a line of fracture at the surgical neck of the humerus.

2:52

What are you seeing besides the, this fracture?

2:55

There's something different in this case.

2:58

I don't know if the attendants

3:01

have see the case in the packs,

3:03

but we can see a different thing.

3:06

If you look, you can see an edema

3:10

of the subscapularis muscle

3:12

with scattered pattern

3:15

suggesting overload injury.

3:18

It look like a DOMS,

3:21

delayed onset muscle soreness,

3:24

due to physical exercises.

3:27

She had overload signs in the bone and in the muscle.

3:32

This is the right side.

3:33

This is a very uncommon place for a stress fracture.

3:38

It's really very uncommon.

3:40

I have saw some cases in the acromion,

3:42

some cases in the glenoid and the coracoid process.

3:48

But in this area, is really uncommon.

3:52

It's more uncommon when you see the other side.

3:56

The other side,

3:57

let me put the image of the other side.

4:01

You see exact the same stuff, the same thing.

4:06

She had a, edema.

4:09

In this left side, we cannot see very well

4:15

the line of fracture but we see the edema

4:18

and this pattern that you saw

4:20

that you talk, talk about it.

4:22

It's a polka dot sign.

4:26

It look like the channel is enlarge.

4:28

The vessels is enlarge.

4:29

That is, as you can see here.

4:32

And she's still feeling pain.

4:35

She did the rest and some physiotherapy.

4:40

And she came back about three months,

4:45

to do another MRI for both sides.

4:48

And the another MRI, we can see the complete resolution

4:53

of the fracture and the edema in the both side.

4:58

This is only to show an evolution of this case,

5:01

a very interesting case.

5:02

And we cannot even try to see where is the line of fracture.

5:08

It's very hard to see

5:10

the residual fracture in these images.

5:15

And if you look for the subscapularis muscle,

5:20

it's normal.

5:21

There is no more edema or no more signs of DOMS

5:26

in the subscapularis muscle.

5:29

It's an unusual case.

5:30

It's interesting, but a very unusual case.