Right Shoulder Pain

Abstract

HISTORY: A 48 year-old right-handed AAF with no significant PMH presented with right shoulder weakness and pain for 2 weeks. There was no inciting event or recent changes in activity. Her symptoms began 2 weeks after a viral URI. She works as a network manager and started developing acute pain for a few days, which was followed with stiffness, weakness and numbness on the lateral side of her arm. The pain then become constant and the numbness and tingling were intermittent and radiating into her hand. Her symptoms had been worsening over the prior week specifically with overhead activity. She had been using NSAID’s, ice/heat and massage with no relief PHYSICAL EXAMINATION: Winging of the right scapula was noticed as well as tenderness over the deltoid. Passive ROM was normal with decreased active ROM; forward flexion and abduction 0-120 degrees, abduction external rotation 0-60 degrees. Supraspinatus, infraspinatus and triceps strength 3/5 with normal deltoid and trapezius strength. Hawkin’s, Neer’s, Empty can, and Impingement tests are all positive. Obrien’s, Yergason’s and Crossover tests negative. DIFFERENTIAL DIAGNOSIS: Parsonage-Turner syndrome, Cervical disk disease, Shoulder impingement syndrome, Neoplastic brachial plexopathy, Supraspinatus tendinopathy TESTS AND RESULTS: Xray were obtained; no fracture, arthritis or soft tissue abnormalities were seen. Patient was sent for cervical and plexus MRI as well as EMG and nerve conduction studies. MRI results were without infiltrating process or extrinsic compression on the brachial plexus. Cervical spine MRI revealed a small right central disc extrusion without impingement. Nerve conduction studies demonstrated significant differences between the right and left Median and Ulnar nerves. The right Median and Ulnar nerves F-wave latency showed no response compared to 20.3 msc on the left side, which is consistent with a proximal injury as at the level of the plexus. FINAL WORKING DIAGNOSIS: Parsonage-Turner syndrome OUTCOME: Patient was given Toradol and Depomedrol IM as well as Medrol dose pack and Amitriptyline. She was also referred to PT. RETURN TO ACTIVITY AND FOLLOW UP: 7 weeks after the initiation of the treatment patient reported almost complete resolution of her symptoms. She was instructed to follow up as needed if not complete resolution within 8 weeks.