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Shoulder Pain - Proper Diagnostic Testing in Shoulder Pain Cases


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Shoulder pain syndrome is an especially frequent challenge accountable for numerous medical professional visits annually. Coming on the heels of back pain, it is the 2nd most typical musculoskeletal complaint. Severe shoulder pain can have debilitating effects on one’s daily life. Your shoulder contains a wealth of nerve endings. Typically soreness or damage in one part of the body can be sensed in a different spot. This can called referred shoulder pain.

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Shoulder Pain - Proper Diagnostic Testing in Shoulder Pain Cases

  1. 1. How does EMG/NCV fit in aTertiary Care Shoulder Practice?Vivek Agrawal, MDThe Shoulder CenterCarmel, Indiana
  2. 2. The Shoulder• Present cases tohelp highlight theimportance ofdetailed shouldergirdle/cervicalEMG/NCV for ourshoulder patients.
  3. 3. Case #1• 84 y/o retired business ownerreferred with persistentshoulder pain/ debility.• RIGHT TSA 10/2006• RIGHT TSA revision and RCR2007• RIGHT shoulder arthroscopydebridement and RCR 2007• Peripheral Neuropathy• TIAs
  4. 4. Case #1• Right shoulder:Neurovascular Exam: Anterior Interosseousintact, Posterior Interosseous Nerve Intact,Radial Nerve Intact, Ulnar Nerve intact, MedianNerve Intact, Radial pulse present, Ulnar pulsepresent.Inspection: infraspinatous atrophy ;PREVIOUSDELTOPECTORAL INCISIONS.Sensation to Light Touch Normal.Active ROM: Active FF/ER/IR (90)=30/20/10.Active External Rotation Severely Limited.Active Internal Rotation Dorsum of hand tobuttock.Passive ROM: PassiveFF/ER/IR(90)=60/50/20.Strength testing: Deltoid: +3/5.Infraspinatus: +4/5.Subscapularis (Belly Press): Positive.Palpation: RENT Test Positive for FullThickness Tear.• Cervical Spine C3-4Spondylolisthesis GRADE I; C4-5C5-6 C6-7 Advanced DJDMultilevel Arthrosis• EMG/NCV• Supraspinatus: 2.3ms latency and0.5mV amplitude• Infraspinatus: 2.7ms and 0.2mVand Temporal Dispersion• Normal Axillary Nerve• No evidence of Radiculopathy,Plexopathy.
  5. 5. Case #1• Based on Severe SuprascapularNerve Pathology but Intact Deltoidperformed:• Right Reverse Total Shoulder withRemoval of Failed TSA inSeptember 2008• Examination April 2010:• Excellent Pain Relief and OverheadFunctionRight shoulder:Inspection: all surgical woundshealed.Active ROM: Active AB=155.Strength testing: Deltoid: -5/5.Infraspinatus: -5/5.Subscapularis (Belly Press):+3/5.
  6. 6. Case #2• 57y/o with persistent pain/debilityfollowing hemiarthroplasty performedDec. 2007 complicated byintraoperative spiral fracture• Left shoulder:Neurovascular Exam: Anterior Interosseousintact, Posterior Interosseous Nerve Intact, RadialNerve Intact, Ulnar Nerve intact, Median NerveIntact, Radial pulse present, Ulnar pulse present.Inspection: infraspinatous atrophy// left deltoidatrophy present// all surgical wounds healed// noscapular winging.Sensation to Light Touch Diminished.Active ROM: Active FF/ER/IR (90)=70/10/25.Active External Rotation Hand behind head withelbow held forward.Active Internal Rotation Dorsum of hand to L3.Passive ROM: Passive FF/ER/IR(90)=,ACTIVE=PASSIVE.Strength testing: Deltoid: +3/5.Supraspinatus: +3/5.Infraspinatus: +4/5.Subscapularis (Belly Press): -5/5 (Break Away).
  7. 7. Case #2• EMG/NCV-• Posterior Deltoid 1+ fibrillationpotentials, 1+ positive sharpwaves, increased polyphasicmotor units with prolonged axillarylatency 6.6-7.8ms with amplitudes5.8-7.7mV. Demyelinative AxillaryNeuropathy without ConductionBlock• SSN-prolonged latency to SSN7.0ms with low amplitudes 1.1-2.6mV and temporal dispersion• Cervical Radiculitis/Radiculopathyat C6 and/or C7
  8. 8. Case #2• Referred for primaryevaluation and treatmentof radiculopathy• Had C6 and C7 selectiveblocks and goodneurogenic symptomcontrol with multimodalregimen• Left shoulder arthroscopic globalcapsulotomy and extensive debridement,acromioplasty, distal clavicle resection,suprascapular nerve decompression(bony suprascapular notch) and axillarynerve decompression
  9. 9. Patient #2• Visit 15 months postop:• Excellent Pain Reliefand below shoulderlevel function withROM:FF/ER/IR(90)=125/70/70.
  10. 10. Case #3• 25 year old male presents with c/o pain Hx ofgarage door falling and crushing cervical vertebraeapprox 1 yr ago had A&P cervical fusion , Location:anterior and posterior radiates down arm to elbow ,numbness and tingling, c/o weakness and atrophy. ,Nature: dull in cervical area, sharp in shoulder ,,reports popping with some movements that ispainful., Aggravated by: reaching overhead for shortperiods of time, reaching across chest, twisting,driving, lifting over # 5• Right Shoulder Exam: Dynamic Scapular Winging• Strength testing: Deltoid:, +5/5.Supraspinatus: +4/5 improved to -5 withscapula stabilized.Infraspinatus: +5/5.Teres Minor (Hornblowers): Intact.Subscapularis (Belly Press): +5/5.Subscapularis (Lift Off): +5/5.Palpation: ACJ non-tender SLAP testpositive RENT Test is negative.Tests: POSITIVE OBRIEN positiveYergasons.Stability tests: post. apprehension positive.
  11. 11. Case #3• EMG/NCV:• SSN: Normal latency with severely lowamplitudes to both Supra and Infra withsignificant conduction block• Chronic C6 and C7 radiculopathy• Normal Axillary Nerve Function• Normal Long Thoracic and Dorsal Scapularand Thoracodorsal Nerve Studies• Referred for Diagnostic SSN block whichdid not provide much relief (? Severeconduction block)• Mechanical Symptoms severe enough atshoulder that wanted to proceed withArthroscopic Management.• RIGHT shoulder arthroscopic capsularshift with extensive labrum repair, type IISLAP lesion repair, and suprascapularnerve decompression
  12. 12. Suprascapular Nerve
  13. 13. Suprascapular Nerve
  14. 14. Neuralgic AmyotrophyNeuritis (Mono or Multifocal)• Significant number ofthese patients haveconcurrent shoulderpathology/pain• Frozen Shoulder– Axillary and SSN• Rotator Cuff Tear• Unstable Shoulder
  15. 15. EMG/NCV• Important to includedetailed objectivecriteria for SSN andAxillary Nerve• Large differential forparascapular andshoulder pain withsignificant NeurogenicContribution.
  16. 16. Click Link Below to VisitThe Shoulder CenterThank You!