Shoulder overuse injury from archery: Naraen 1999

An 11-year-old boy came to the emergency department of a Nottinghamshire hospital with sudden, severe pain in the left shoulder, on his non-dominant side and so in his bow arm. During a competition, shooting a 28-pound bow, he had felt a click in the shoulder and immediately afterwards could no longer move the arm for the pain. Ten months earlier something similar but milder had happened, and it had settled with a few days' rest. The X-rays were read as normal and he was sent home with a diagnosis of an acromioclavicular joint sprain.

At review three days later the swelling had gone down and tenderness remained only over the coracoid process; on a second look at the X-rays the doctors noticed the growth plate still open at the base of the coracoid, and a bone scan two weeks later showed increased uptake at exactly that point. The diagnosis was revised to an overuse injury of the coracoid growth plate. After two weeks with the arm supported and a break from training, he went back to shooting at four months with a 24-pound bow; at six months he was pain-free and preparing for the summer season. The authors present it as the first overuse injury of the shoulder linked to archery reported in the literature.

It is a three-page case report. The account covers training history, physical examination, X-rays in two views and a bone scan. The boy had been shooting since April 1994: in summer two sessions a week of one to two hours, in winter one one-hour session, shooting up to fifty arrows an hour, with stretching exercises for the upper limbs; in summer he competed most Sundays, shooting up to twelve dozen arrows, 144, in a day. The diagnosis is clinical, supported by the bone scan; the authors also considered an avulsion of the coracoid and ruled it out after the scan. Treatment was conservative: the arm supported in a collar and cuff for two weeks, a pause in activity and a gradual return.

A single case cannot show how common this injury is or which young archers are most at risk. The link with archery is inferred from when the pain appeared, during a competition, and from the reported training load, not from any measurement of the shot. Technique, type of bow, draw length and arrow spine are not given, nor whether 28 pounds was the actual weight at the boy's draw length. That 24 pounds was "more appropriate for his age" is the authors' judgement, with no stated criterion. The diagnosis was made without MRI or CT, and follow-up ends at six months.

For anyone coaching children the case offers two concrete points. Sudden pain in the bow shoulder of a growing child may involve the growth plate, which can go unnoticed on standard X-rays: here the first reading called them normal. And a mild episode that cleared up on its own came ten months before the one that kept the boy out for four months.

The case also involves draw weight: an eleven-year-old competing with 28 pounds and up to 144 arrows in a day, who came back with 24. The study does not set a maximum draw weight by age or a number of arrows: it remains one example of a heavy load on a body that is still growing.