Broadening the Shoulder Differential Diagnosis Anthony Luke MD, - PDF document

11/30/2017 Broadening the Shoulder Differential Diagnosis Anthony Luke MD, MPH, CAQ (Sport Med) Benioff Distinguished Professor in Sports Medicine Director, UCSF Human Performance Center University of California, San Francisco 12/3/2017 Disclosure  Founder, RunSafe™, RaceSafe™  Founder, SportZPeak Inc.  Sanofi, Investigator initiated grant 1

11/30/2017 Overview  Brachial Plexus injuries  Nerve Entrapment • Suprascapular nerve entrapment • Axillary nerve entrapment  Thoracic outlet syndrome  Arterial entrapments • Entrapment of the posterior circumflex humeral artery within the quadrilateral space  Paget Schroeder’s Disease / Effort Thrombosis Neurovascular “Bundle” 2

11/30/2017 Causes  Acquired  Positional • Surgery/scar tissue • Subluxation • Mass/Cyst • Traction  Infectious • Compression • Viral Neurogenic Problems  Look for occult onset of pain, weakness, numbness  May complain of decreased accuracy or compensation  Might follow acute trauma  Pain is often burning, can be severe  Check for dermatomal symptoms of pain, numbness or focal weakness  Look for specific muscle atrophy  Think compression or traction 6 3

11/30/2017 Tendon vs Internal Derangement Pain Tendon Pain Internal Derangement Pain  May be present at the start of an  Always present activity then “warm-up”  May be reproducible  Sore when the muscle is used  May have catching or giving way  Can be sore for > 24 hours or  Worse or same with activity longer  May have compensation  May occur in “compensation” Case  14 year old Pop warner football player  Made a tackle 1 day ago and had sharp pain  His arm went “dead” for 20 minutes  He still gets neck pain  He’s had a similar episode which he didn’t tell anyone about  His symptoms are 50% better but he’s still a bit sore 8 11/30/2017 4

11/30/2017 Burners / Stingers  Axial loading, hyperflexion, hyperextension or sudden rotation can cause injury to cervical spine and surrounding soft tissues Brachial Plexus  C5 to T1 nerve roots  Many variants 5

11/30/2017 Interscalene Region  Interscalene groove, the “envelope” provided by the scalene muscles and their investing fascia  Interscalene groove lies posterior to the clavicular head of the sternocleidomastoid muscle Supraclavicular Region  Scalene muscles descend to the first rib  Subclavian artery and the brachial plexus emerge from the interscalene groove, deep to the supraclavicular fossa, and course laterally and inferiorly to pass under the clavicle 6

11/30/2017 Infraclavicular Region  The vessels and brachial plexus enter the apex of the axilla through the cervicoaxillary canal, bounded by the first rib below and the clavicle above Don’t Forget about the Neck  Spurling’s test for cervical radiculopathy 7

11/30/2017 Cranial Nerve XI  Blow to the top of the shoulder  Atrophy trapezius Case  22 year old Div 2 volleyball player hitter  Has had 6 week pain with hitting  Her serve accuracy has been off  She gets tired with the arm  She has mild pain in the back of the shoulder with activity 16 11/30/2017 8

11/30/2017 Suprascapular Nerve Suprascapular Nerve Entrapment  May be due to repetitive stress and stretching of suprascapular nerve during overhead motions of serving and spiking  Seen in overhead athletes especially volleyball players  Isolated paralysis of the infraspinatus muscle  Loss of external rotation strength of shoulder  MRI may show a paralabral cyst in the spinoglenoid notch  Tx – Conservative, Address the underlying cause of compression, address labrum? Boykin RE et al. J Bone Joint Surg Am. 2010. 18 11/30/2017 9

11/30/2017 Quadrilateral Space Syndrome  Teres major inferiorly, long head of triceps medially, teres minor posteriorly, subscapularis anteriorly, and surgical neck of humerus laterally  Fibrotic bands form as the result of trauma, muscular hypertrophy or mass/cyst  Dull, burning pain especially when in the late cocked position (abducted/externally rotated) of throwing  Tx – Conservative first (ART); then decompression McAdams, T., et al. Am J Sports Med 2007. Case  48 year old male competitive tennis player  Had 2 month history of burning pain in the shoulder during the winter tennis season  Has had gradual weakness and clicking around the scapula  He is getting pain with his serve  He notices wasting around the muscles around the shoulder  PMH – borderline diabetes, hypercholesterolemia 20 11/30/2017 10

11/30/2017 Brachial Neuritis (a.k.a. Parsonage-Turner syndrome)  Neuralgic amyotrophy  Immune system – mediated inflammatory reaction against nerve fibers of the brachial plexus  Viral? Immunization?  Lasts 6-12 months  Tx: Opiates, NSAIDS, and neuroleptics; TENS; PT Feinberg JH,HSS J. 2010 Herpes Zoster  Painful, blistering dermatomal rash in dermatomal distribution  Reactivated, the virus travels along the affected sensory nerve, causing neuronal damage  Prior to rash appearance, the frequent prodromal itching or pain  Lifetime risk 30%, > after 50 years of age  Rash resolves in several weeks  Tx: Antiviral drugs and analgesics 22 11/30/2017 11

11/30/2017 Winging  Long Thoracic Nerve • Serratus Anterior  Less common • Spinal Accessory Nerve (trapezius) • Dorsal Scapular Nerve (rhomboids)  Scapular Dyskinesis – MOST COMMON • Pain may alter mechanics or vice versa Scapulohumeral Rhythm  Ratio of Scapular to Humeral movement 60:120  Occurs via coupled movement of the scapular muscles  Through elevation, scapula upwardly rotates, posteriorly tilts and externally rotates 12

11/30/2017 Scapular Dyskinesis  Scapular dyskinesis is Treatment common as a pattern of  Strengthen dysfunction, more than  Train functionally neurogenic winging  Biofeedback  Use impingement signs to rule in shoulder problems  Tape  Rotator cuff strength tests help diagnose shoulder issues Calcific tendinosis  38 year old female with 1 day history of 10/10 pain, crying, asking for pain meds  Unable to lift the arm  No trauma  Works as nurse manager  PMH – Remote history of fibromyalgia; no hx of drug use 27 13

11/30/2017 Calcific Tendinosis  Severe acute pain in shoulder, often unwilling to move  X-ray may show calcium deposits; Ultrasound more sensitive than MRI  Tx: Can consider Ultrasound-guided percutaneous needle injection, aspiration and lavage or needling/fragmentation techniques  Prognosis for needle techniques vary with size and density (soft vs. hard)  70% improved after procedure, 91% at 1 month Bazzocchi A et al. Br J Radiol. 2016 Calcific Tendinosis  5 year follow shows subacromial injection results are the same as barbotage de Witte PB et al. Am J Sports Med, 2017 Surgery  If fail conservative treatment, consider arthroscopic removal of calcific deposits and tendon repair without acromioplasty  95.8% were able to return to sports; 91.3% returned to the same level Ranalletta M et al. Orthop J Sports Med. 2016 14

11/30/2017 Case  43 year old female yoga enthusiast  Works in office  Has had numbness in all 5 fingers worse on the R > L hand after typing over one hour. It gets bad enough she needs to stop her activities.  She has neck pain but feels it’s unrelated.  PMH – none 34 11/30/2017 Thoracic Outlet syndrome  Repetitive upper extremity use • shoulder, elbow, hand ‒ assembly line ‒ computer with mouse and phone  Poor posture  Reaching  Stress  Apical breathing 15

11/30/2017 Thoracic Outlet syndrome  Possible compression of the subclavian artery between the scalenes and any cervical rib  Compression of neurovascular symptoms in the upper extremity by the pectoralis minor  Neurogenic greater than vascular (lower plexus) Adson’s Test  Seated patient extends and turns head toward the tested shoulder  Shoulder is abducted and extended.  Subject inhales while the examiner palpates the ipsilateral radial pulse.  Positive findings: Diminution or elimination of the pulse and reproduction of the paresthesias  Studies show poor to good specificity and good sensitivity. 16

11/30/2017 Wright’s Hyperabduction Test  With patient seated, the clinician hyperabducts and externally rotates the patient’s arm while assessing the ipsilateral radial pulse  Positive findings: Diminution or elimination of the radial pulse and reproduction of the paresthesias  No studies have examined validity Roos Stress Test  Patient holds shoulders in abduction and external rotation at 90 degrees with elbows flexed at 90 degrees and repeatedly open and close their hands for three minutes.  Positive findings: Reproduction of their symptoms or a sensation of heaviness and fatigue.  No studies have examined validity of the Roos stress test as it pertains to thoracic outlet syndrome. 17