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

11/30/2017 1

Broadening the Shoulder Differential Diagnosis

Anthony Luke MD, MPH, CAQ (Sport Med)

12/3/2017

Benioff Distinguished Professor in Sports Medicine Director, UCSF Human Performance Center University of California, San Francisco

Disclosure

• Founder, RunSafe™, RaceSafe™
• Founder, SportZPeak Inc.
• Sanofi, Investigator initiated grant

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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”

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Causes

• Acquired
• Surgery/scar tissue
• Mass/Cyst
• Infectious
• Viral
• Positional
• Subluxation
• Traction
• Compression

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

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Tendon vs Internal Derangement Pain

Tendon Pain

• May be present at the start of an

activity then “warm-up”

• Sore when the muscle is used
• Can be sore for > 24 hours or

longer

• May occur in “compensation”

Internal Derangement Pain

• Always present
• May be reproducible
• May have catching or giving way
• Worse or same with activity
• May have 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

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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

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Interscalene Region

• Interscalene groove, the

“envelope” provided by the scalene muscles and their investing fascia

• Interscalene groove lies

posterior to the clavicular head

• f 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

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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

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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

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Suprascapular Nerve Suprascapular Nerve Entrapment

• May be due to repetitive stress and stretching of suprascapular nerve during
• verhead 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.

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Quadrilateral Space Syndrome

• Teres major inferiorly, long head of triceps

medially, teres minor posteriorly, subscapularis anteriorly, and surgical neck

• f 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

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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

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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

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Scapular Dyskinesis

• Scapular dyskinesis is

common as a pattern of dysfunction, more than neurogenic winging

• Use impingement signs to rule

in shoulder problems

• Rotator cuff strength tests help

diagnose shoulder issues Treatment

• Strengthen
• Train functionally
• Biofeedback
• Tape

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

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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

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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
• ne hour. It gets bad enough she needs to stop her activities.
• She has neck pain but feels it’s unrelated.
• PMH – none

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Thoracic Outlet syndrome

• Repetitive upper extremity use
• shoulder, elbow, hand

‒ assembly line ‒ computer with mouse and phone

• Poor posture
• Reaching
• Stress
• Apical breathing

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• 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)

Thoracic Outlet syndrome

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.

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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.

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Diagnosis and Treatment

• Diagnosis often made clinically
• Duplex U/S or Helical CT may identify anatomy for potential surgery;

angiograms still done but invasive

• Electrophysiological nerve studies and Anterior Scalene Muscle blocks help

identify who requires surgery

• Treatment usually conservative
• Surgical decompression considered if anatomy can be corrected

Klassen Z et al. Clin Anat. 2014

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Vascular Problems

• Complaints of heaviness,

fatigue, paresthesias, and effort-related pain

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Arterial Compression

• Intermittent axillary artery

compression with the arm in abduction

• Resulting from hypertrophy of

the pectoralis minor and scalene muscles

• Arteriography with the arm in

120 degrees abduction

• Treated nonoperatively with

rehab

Ligh et al. Clin Orthop Relat Res, 2009

Case

• 32 year old Male baseball pitcher, works as a mechanic
• History of Labral repair when he was 20 years old. Returned to pitching
• Has had 1 week history of arm swelling
• No numbness, no pain
• Feels a bit stiff with range of motion

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Paget-Schroetter syndrome

• Effort-induced primary venous

thrombosis

• Compressing the thoracic outlet

veins and strenuous upper limb movement leads to vascular intimal damage

• Tx: Anticoagulants, thrombolytic

agents and thrombectomy

Cardiac Referred Pain

• Exercise, exertion, eating,

emotions, and exposure often precipitate angina.

• If nitroglycerin relieves the

attack, it is considered angina.

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Neurologic Investigations

• Diagnostic injection
• Lidocaine
• Steroid
• EMG /NCS
• Issues with accuracy
• Helpful if positive
• Can help with treatment and prognosis

Vascular Investigations

• Ultrasound
• Non invasive
• Operator dependent
• Angiography / MR angiography
• Needs Contrast dye
• Positioning very important

Thoracic outlet syndrome

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Take Home Messages

• Can you identify the pain generator
• Radicular dermatomal pain – Neuro
• Fatigue, swelling – Vascular
• Most things are treated conservatively

Surgical options

• If source can be identified

LUCKY 13th UCSF Primary Care Sports Medicine Conference San Francisco, Dec 6-8, 2018