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Shoulder Pain in the Overhead Athlete: Thinking Outside the
(Glenohumeral) Box
AAPMR Annual Meeting| Boston, MA| October 4th , 2015
Jason L. Zaremski, M.D., CAQSMAssistant Professor, Department of Orthopaedics & RehabilitationDivisions of PM&R, Sports Medicine, & Research, University of Florida
Disclosures
None
Many Generators• Muscle• Tendon
– RC (tendonitis/-osis, partial tear, full thickness tear)• Joint
– Osteoarthritis– Labral– Instability (Subluxation, Dislocation)– Bursal Irritation/Inflammation
• Not coming from the Shoulder– Cervical Spine– Supratentorial– Neurological
• Suprascapular Nerve• Parsonage Turner
We Could spend all day…but• Adhesive Capsulitis• Parsonage Turner Syndrome/Brachial Neuritis• Ehlers Danlos-Syndrome• Long Thoracic Nerve Syndrome • Pancoast Turmor• Quadrilateral Space Syndrome• Suprascapular Neuropathy• Os Acromiale• CRPS• TOSSchulte KR, Warner JJ. Uncommon causes of shoulder pain in the athlete. Orthop Clin North Am. 1995 Jul;26(3):505-28.
Aval SM, Durand P Jr, Shankwiler JA. Neurovascular injuries to the athlete's shoulder: part II. J Am Acad Orthop Surg. 2007 May;15(5):281-9.Reeser JC. Diagnosis and management of vascular injuries in the shoulder girdle of the overhead athlete. Curr Sports Med Rep. 2007 Oct;6(5):322-7.
Let’s Focus on Just a few
• Parsonage-Turner/Brachial Neuritis– Iatrogenic Form
• Quadrilateral Space Syndrome• Thoracic Outlet Syndrome
Case #1
• 21 yo RHD male • Left Shoulder Pain & Weakness x 3 weeks• Denies prior neck or arm injuries. • Denies overhead sports activities such as
swimming or throwing. • He lifts weights and jogs on a treadmill. • His only reason for seeing a physician in the
last year has been for a check-up and a recent stomach bug after a cruise over winter vacation.
• Physical Examination = Weak with Empty Can Test and Abduction
• Xrays Negative• EMG/NCS = Isolated Unilateral
Suprascapular Nerve Positive Sharps and Fibrillations
Parsonage-Turner/Brachial Neuritis• Many Names (Neuralgic
Amyotrophy)• Cause: Unknown• Most Affected Peripheral
Nerves: Suprascapular & Axillary nerves with corresponding muscles
• 1.6-3 cases/100,000 (but underdiagnosed)
• Hereditary Form—very rare
(200 known cases)• Age of highest Incidence = 3rd
and 7th decades of life• Males > Females– 1.5:1 up to 11.5:1
Smith CC, Bevelaqua AC. Challenging pain syndromes: Parsonage-Turner syndrome. Phys Med Rehabil Clin N Am. 2014 May;25(2):265-77.Tjoumakaris FP , et al. Neuralgic amyotrophy (Parsonage-Turner syndrome). J Am Acad Orthop Surg. 2012 Jul;20(7):443-9
Etiology
Tjoumakaris FP , et al JAAOS 2012
Triggers• Not conclusively known• Viral infections (25% to 55%)• Immunizations (15%)• Perioperative and peripartum periods (>14%)• Following strenuous exercise (8%)– 2 cases in my clinic (both College Age Students)
Stutz CM: Neuralgic amyotrophy: Parsonage-Turner syndrome. J Hand Surg Am 2010;35(12):2104-2106.van Alfen N, van Engelen BG: The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain 2006; 129(pt 2):438-450.
Presentation-Pain• No constitutional symptoms • Lasts approximately 3-8 weeks• Sudden onset that may be exacerbated by
shoulder and elbow motion• As Pain subsides a flaccid paralysis may develop.
Presentation-Strength• Weakness typically develops within 2-4 weeks.• The muscles commonly affected include: – Infraspinatus – Supraspinatus – Serratus anterior – Biceps – Deltoid – Triceps
Dillin L, Hoaglund FT, Scheck M: Brachial neuritis. J Bone Joint Surg Am 1985;67(6):878-880.Tsairis P, Dyck PJ, Mulder DW: Natural history of brachial plexus neuropathy: Report on 99 patients. Arch Neurol 1972;27(2):109-117.Spillane J: Localised neuritis of the shoulder girdle: A report of 46 patients in the MEF. Lancet 1943;2:532-535.
Presentation-SensationDeltoid, lateral upper arm, and the radial aspect of forearm
Visual Presentation
• Trophic skin changes • Edema in the involved
extremity • Temperature dysregulation • Increased sweating • Changes in nail/hair
growth
PTS Diagnosis
• EMG/NCS• Radiographs – Shoulder to rule out Calcific Tendonitis or bony
lesion–CXR to rule out Pancoast Tumor
Imaging-MRI
Tjoumakaris FP , et al JAAOS 2012
Look for edema and show diffuse high-signal intensity.
EMG/NCS
• Acute denervation– Positive sharp waves and fibrillation – 3 to 4 weeks after the onset of symptoms – EMG performed 3 to 4 months after the onset of
initial symptoms may show chronic denervation and early reinnervation with polyphasic motor unit potentials.
Stutz. J Hand Surg Am 2010. Dillin L, et al. J Bone Joint Surg Am 1985.
Other Studies
• No specific Labs for PTS…only to rule out other– LFTs, ANA, CBC– CSF
Treatment• No specific treatment protocol currently exists• Early corticosteroid therapy may have a positive
influence on pain– PO v GH IA Injection plus Nerve block for Diagnostic
Purposes (ie Suprascapular Nerve)
• Acute pain combination long-acting NSAIDS + Opiate
van Alfen N, van Engelen BG, Hughes RA: Treatment for idiopathic and hereditary neuralgic amyotrophy (brachial neuritis). Cochrane Database Syst Rev 2009;3:CD006976.
PT and Education
• PT in the early phase• Educational strategies to help alleviate the
traction on the involved nerves – Increased mechanical sensitivity because of
inflammation.– Patients should use the affected limb as fully as
possible, but avoid strength training
Follow-up
• Monthly to assess progression in re-innervation. (Physical Exam)– 3-6 month EMG/NCS follow-up
• Denervation that persists for >1 year is unlikely to recover well– Any intervention to restore function should ideally be
undertaken at <1 year
Surgical Intervention
• By 6 to 9 months: If no evidence of regeneration or early recovery within a nerve distribution, then surgical referral.
Nath RK, Lyons AB, Bietz G: Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: Long-term results in 50 cases. BMC Musculoskelet Disord 2007;8:25.
Prognosis• Most patients recover within 2 years
– 2/3rd of patients show beginning recovery of motor function within 1 month of the onset of weakness.
• Chronic pain & persistent functional deficits in almost 1/3rd of affected patients after an average follow-up of >6 years.
• Upper trunk involvement = better prognosis • Duration of pain correlated with duration of muscle weakness.
van Alfen N, Brain 2006. Dillin L, et al. J Bone Joint Surg Am 1985.
Prolonged recurrent pain with no sign of motor recovery after 3 months is associated
with a poor prognosis.
Case #219 year old RHD competitive NCAA Swimmer present with right arm dullness and occasional cool sensation. Exacerbated with swimming and lifting weights; Better at rest and with arm below eye level. PMHx, PSHx, and Fam HX non-contributary. Examination is “normal.”
Quadrilateral Space Syndrome:Neurogenic and Vascular
• Compression of Axillary Nerve and/or Posterior Humeral Circumflex Artery
• Paresthesia and Digital Ischemia in overhead athletes due to repeated ER and Overhead activity (“L” position)
• Associated with PCHA Thrombosis and distal emboli
Brown SA et al. Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series. Mayo Clin Proc. 2015 Mar;90(3):382-94.
Anatomy
Infraspinatus
Triceps
Teres Major
Deltoid Retracted
Artery & Nerve
Etiology
• Overhead Athletes with Abduction and ER– Baseball, Volleyball, Swimming, Yoga
• Laborers with overhead activities– Window Cleaners
Presentation
• Non-dermatomal Neurogenic Manifestations• Pain, Numbness, and weakness in Shoulder,
especially posterior– Radiation down arm possible
• Pain, Pallor, and Absent Pulses if Digital Ischemia present
Proposed Treatment Algorithm
Brown SA et al. Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series. Mayo Clin Proc. 2015 Mar;90(3):382-94.
DSA = Digital Subtraction AngiographySOL = Space Occupying LesionUEA = U.E. arterialEMG = poor sensitivity for nQSS but can rule out other pathology
Case #318 year old RHD female college student seen for
right arm “heaviness.” She was sedimentary until 4 months ago when she joined the rec
league crew team. Symptoms exacerbated with activity and improved at rest. Denies
temperature or neurogenic changes currently.
Thoracic Outlet Syndrome:Neurogenic and Vascular
• Compression of the brachial plexus and/or the subclavian vessels.
• nTOS = more common, pain, numbness, tingling, weakness, and vasomotor changes of the upper extremity.
• vTOS = uncommon and include thromboembolic phenomena and swelling.
Kuhn JE, Lebus V GF, Bible JE. Thoracic Outlet Syndrome. J Am Acad Orthop Surg. 2015 Apr;23(4):222-232
Anatomy • Interval from the supraclavicular fossa to the
axilla that passes between the clavicle and the first rib.
• It contains: – Subclavian artery – Subclavian vein – Brachial plexus.
Locations of Compression
Causes of TOS
Kuhn JE, Lebus V GF, Bible JE. Thoracic Outlet Syndrome. J Am Acad Orthop Surg. 2015 Apr;23(4):222-232
Clinical Presentation
• Highly Variable• nTOS presents as a constellation of UE
weakness, numbness, paresthesias, and pain in a non-radicular distribution. – i.e. Neck, trapezius, & chest pain, occipital
headache, and neurological symptoms into digits of the hand.
PE Maneuvers
Kuhn JE, Lebus V GF, Bible JE. Thoracic Outlet Syndrome. J Am Acad Orthop Surg. 2015 Apr;23(4):222-232
vTOS• vTOS significant swelling of the UE.• Deep pain in the UE, chest, and shoulder, – feeling of heaviness…worse after activity.
• May have cyanotic discoloration. • The SC vein is commonly compressed at the
costoclavicular junction where it passes anterior to the anterior scalene;
• A well-known subtype of vTOS is Paget-Schroetter syndrome, described as thrombosis of the subclavian vein caused by repetitive injury in relatively young and healthy persons.
Venous thoracic outlet syndrome. Hand Clin 2004;20(1):113–118.
1st Rib Resection
Diagnosis• Radiographs– C-Spine and CXR– No advanced imaging unless consideration of space
occupying lesion• Angiography with MR or CT• EMG/NCS– NCS velocity changes of MABC Nerve & Median Motor
N to APB– EMG fibrillations in T1 and C8 inconsistently
• Diagnostic Anesthetic Blockade– Anterior Scalene Block
Non-Surgical Treatment• Depends—nTOS v vTOS• nTOS: Physical Therapy (6 months)
– stretching, ROM, and tendon and nerve gliding techniques• U/S Guided Botox Injections• Patient education
– relaxation techniques, postural mechanics• Activity modification:
– Limiting repetitive, overhead stress• Nonsurgical management is reported to be less successful in
obese patients, in patients who are on workers’ compensation, and in patients with double-crush neurologic pathology involving the carpal or cubital tunnelsNovak et al. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am.
Torriani et al. Botulinum toxin injection in neurogenic thoracic outlet syndrome: Results and experience using a ultrasound-guided approach. Skeletal Radiol 2010.
Take Home Pearls
• 1. Thorough History and Physical Examination• 2. What exacerbates symptoms (via sports,
work, or other activity)• 3. Compare Sides
