SHOULDER WEAKNESS - GERIATRIC GOLFER

Abstract

247 HISTORY - An active 73 year old male recreational golfer presented with a chief complaint of right sided neck pain and shoulder weakness of one week duration. The pain started insidiously, was exacerbated by neck movement, and was maximally relieved by rest. He denied antecedent trauma or previous shoulder injury though related a prior history of left cervical radiculopathy twenty years ago. The right shoulder weakness significantly affected his back-swing and was most obvious when he attempted any overhead motions. Furthermore, he reported a vague numbness in the right hand and on rare occasion experienced pain radiating to the right elbow. Additional past medical history included chronic obstructive pulmonary disease, hypothyroidism, hypertension, and an elevated prostate specific antigen(PSA). PHYSICAL EXAMINATION - Neck range of motion (ROM) was full in all planes but precipitated right posterior neck and trapezius muscle pain. On palpation there was minimal cervical paraspinal and shoulder girdle muscle tenderness. Passive right shoulder ROM was normal however, active ROM was limited to 80 degrees of forward flexion and abduction. Shoulder impingement tests were mildly to moderately provocative. Reflexes were normal except for an equivocally reduced right biceps reflex. Manual muscle testing revealed moderate weakness in the right deltoid, biceps and supraspinatus. Sensory examination was normal. Foraminal compression maneuvers were negative. DIFFERENTIAL DIAGNOSIS: Cervical radiculopathy Rotator cuff tendonitis or tear Brachial plexopathy (traumatic, neoplastic, idiopathic) TESTS AND RESULTS: Serology - CBC and sTSH were normal, PSA was highly elevated at 50.9 X-rays cervical spine (with flexion/extension) - Mild degenerative changes with no evidence of instability. MRI cervical spine - No disk herniations or neuroforaminal stenosis. EMG - Consistent with right upper trunk brachial plexopathy. MRI brachial plexus - No evidence of mass lesion or traumatic plexopathy. FINAL/WORKING DIAGNOSIS: Neuralgic Amyotrophy (Idiopathic Brachial Plexopathy) Probable prostate cancer. TREATMENT: Modalities (heat and ice) for pain control as needed. Non-steroidal anti-inflammatory drugs or acetaminophen as needed. Shoulder ROM exercises. Review proper shoulder biomechanics to normalize glenohumeral and scapulothoracic rhythm. Sub-maximal rotator cuff strengthening. Sub-maximal biceps and deltoid strengthening. Recommend Urologic Consultation for prostate evaluation.