Various causes of shoulder pain have been described. This lady presented with nonspecific right(Rt) severe shoulder pain radiating to the hand she could not sleep for 1 year with weakness at thenar eminence. The patient had history of 2 shoulder arthroscopic procedures within1 month interval. Postoperative Rt shoulder MRI evaluation revealed supraspinatous partial thickness tear, subscapularis tendinopathy and superior labrum tear from anterior to posterior(SLAP). The patient was treated successfully with a Multimodal Intereventional Pain management techniques and after6 months she was able to successfully move her shoulder without pain and regain muscle power. Introduction: Shoulder pain is one of the most frequent musculoskeletal complaints, which increases with age(1). Surgery is more successful in patients under age 40 SLAP tears(2). Common shoulder problems in old age include rotator cuff injury, secondary impingement &SLAP .Less common causes include nerve injuries(1)& long thoracic nerve in addition to vascular problems(2).One mechanism involves forceful traction on biceps tendon when someone falls onto an outstretched arm(3).The neurovascular causes can be difficult to diagnose& require special diagnostic tests such as EMG, dynamic ultrasound (US) and MRI(4). Consensus is lacking on the ideal treatment. Multimodal techniques includes Interventional-based therapy that has shown significant results in treating many conditions, including osteoarthritis (OA). Aim: The objective is to describe a multimodal interventional pain management approach in the treatment of persistent shoulder pain after failed surgery. Methods: The procedure was performed at Safwet Al-Golf Hospital, Cairo, Egypt, for a 60 years old female diabetic patient with a long-term history of untreated shoulder pain. She underwent 2 shoulder arthroscopic procedures on August & November 2021 respectively, progressed postoperatively with standard rehabilitation to increase the range of movement (ROM), however there had been no improvement. On examination, the patient had Rt dermatomal C5,6, 7 hypothesia. Bed side US examination showed Rt subscapularis tendinopathy& impingement,Rt supraspinatous partial thickness tear(Fig.1,2) & impingement,Subacromion sub-deltoid bursitis(SASD), effusion at gelnohumeral joint. MRI Rt shoulder revealed, previous surgery in the form of acromioplasty, biceps tenotomy and interosseous repair, Acromio-clavicular (AC) Joint OA, partial thickness tear of supraspinatus tendon, subscapularis tendinopathy, SLAP injury & Degenerated Anterior Glenoid labrum. She was unable to initiate abduction & limited ROM at medial and lateral rotation with severe pain. The patient completed numerical rating scale (NRS), verbally reported at the beginning of each visit, indicating her level of pain on a scale of 0 to 10, 0 = no pain and 10 = worst pain. At the initial visit she reported 10 on NRS. The patient scheduled for interventional pain management procedure.

1. References:
1.Djade CD et al.,Eur J Pain.2020;24(1):39-50. 2. Nadeem IM et al., HSS J. 2020; 16(3):261-271.
3. George SZ et al.,Pain,2015;156(1), 148-56.4.Warrender WJ et al.,Am J Sports Med.2017; 45(7):1676-86.
5.Xiao M et al.,J Shoulder Elbow Surg.2021;30(11):2638-47.6.Liao W et al.,Med.2021;100(14): p e25431.
7.LawrenceTM et al.,J Shoulder Elbow Surg.2012;21(11):1464-9.8.Seenauth C et al., Altern Ther Health Med. 2018;
24(1):56-60. 9. Sampognaro G et al., Multimodal. [Updated 2022 Aug 21].
https://www.ncbi.nlm.nih.gov/books/NBK572072/ *Copyright © 2023 Dr. SN Fanous; MD, PHD, FIPP, DESA. Consultant of Anesthesia and pain management, drsherryfanous@yahoo.com
Abstract:
Various causes of shoulder pain have been described. This lady presented
with nonspecific right(Rt) severe shoulder pain radiating to the hand she could
not sleep for 1 year with weakness at thenar eminence. The patient had
history of 2 shoulder arthroscopic procedures within1 month interval. Post-
operative Rt shoulder MRI evaluation revealed supraspinatous partial
thickness tear, subscapularis tendinopathy and superior labrum tear from
anterior to posterior(SLAP). The patient was treated successfully with a
Multimodal Intereventional Pain management techniques and after6 months
she was able to successfully move her shoulder without pain and regain
muscle power.
Introduction:
Shoulder pain is one of the most frequent musculoskeletal complaints, which
increases with age(1). Surgery is more successful in patients under age 40
SLAP tears(2). Common shoulder problems in old age include rotator cuff
injury, secondary impingement &SLAP .Less common causes include nerve
injuries(1)& long thoracic nerve in addition to vascular problems(2).One
mechanism involves forceful traction on biceps tendon when someone falls
onto an outstretched arm(3).The neurovascular causes can be difficult to
diagnose& require special diagnostic tests such as EMG, dynamic ultrasound
(US) and MRI(4). Consensus is lacking on the ideal treatment. Multimodal
techniques includes Interventional-based therapy that has shown significant
results in treating many conditions, including osteoarthritis (OA).
Aim:
The objective is to describe a multimodal interventional pain management
approach in the treatment of persistent shoulder pain after failed surgery.
Methods:
The procedure was performed at Safwet Al-Golf Hospital, Cairo, Egypt, for a
60 years old female diabetic patient with a long-term history of untreated
shoulder pain. She underwent 2 shoulder arthroscopic procedures on August
& November 2021 respectively, progressed postoperatively with standard
rehabilitation to increase the range of movement (ROM), however there had
been no improvement. On examination, the patient had Rt dermatomal C5,6,
7 hypothesia. Bed side US examination showed Rt subscapularis
tendinopathy& impingement,Rt supraspinatous partial thickness tear(Fig.1,2)
& impingement,Subacromion sub-deltoid bursitis(SASD), effusion at
gelnohumeral joint. MRI Rt shoulder revealed, previous surgery in the form of
acromioplasty, biceps tenotomy and interosseous repair, Acromio-clavicular
(AC) Joint OA, partial thickness tear of supraspinatus tendon, subscapularis
tendinopathy, SLAP injury & Degenerated Anterior Glenoid labrum. She was
unable to initiate abduction & limited ROM at medial and lateral rotation with
severe pain. The patient completed numerical rating scale (NRS), verbally
reported at the beginning of each visit, indicating her level of pain on a scale
of 0 to 10, 0 = no pain and 10 = worst pain. At the initial visit she reported 10
on NRS. The patient scheduled for interventional pain management
procedure.In the OR under strict sterile conditions, standard ASA monitor.
She was placed in Rt up position, and the skin overlying was prepared and
draped.A standard Radio-frequency (RF) lesion generator (Neurotherm) was
used for the whole procedure. After administration of local anesthesia, using
US guidance. a 22-gauge10 mm active tip RF needle 10 cm in length was
inserted, advanced toward the Rt cervical nerve roots 5,6,7 using the
interscalene approach(5) (Fig. 3,4). Proper localization of the nerves by
sensory & motor stimulation(50 Hz;1 ms pulsed width;up to 0.5 V) & (2 Hz; 1
ms pulsed width;up to 1 V) respectively. The patient reported paresthesia and
muscle contractions in the targeted dermatomes. 2 Pulsed Radio-Frequency
(PRF) cycles of 240 s each were performed. The RF current was at a width of
20 ms and at 42°C within. Then with US guidance the needle targeted the
Management of Persistent Pain after Shoulder Arthroscopy using
multiple Interventional modalities: Case Report - TH48
Fig. 1,2: Supraspinatous tendon showing partial thickness tear.
Fig. 3,4: Ultrasound image showing C5,6,7,8 nerve roots
circumflex (axillary)nerve at the neck of humerus, after sensory &
motor stimulation 8 minutes were delivered. Followed by identification
of suprascapular notch (6), targeting the suprascapular nerve to
deliver 480 sec of PRF. Simultaneously PRF was given intra-bursal at
the SASD (Fig.5). Then the Lipophilized growth factors extracted from
human platelet rich plasma (PRP) (ZIAREG-GF) was injected under
US guidance at Rt Supraspinatous Sheath (Fig. 6), Rt Subscapularis
& Glenohumeral Joint.
Fig.5: PRF needle intra-bursal at the SASD. Fig.6: The needle with
the Lipophilized growth factors to the Supraspinatous Sheath.
The patients was observed for 2 hours after the procedure, to ensure
no significant complications then discharged.
Results :
Follow up weekly for 1 month. After which the patient reported an
average of 60% pain reduction. After 4 months, she was gaining
gradually the ROM and strength, however there was fatigue on mild
effort. A swimming program was developed to improve her muscular
endurance without creating a load over the shoulder joint. After 12
sessions over 1 month, there was a great improvement in shoulder
fatigue due to the large role of the lower trapezius muscle in
maintaining proper scapulohumeral rhythm (7). Reassessment 6
months later, showed the patient’s pain score was 0 on NRS and she
had gained the shoulder’s full ROM and strength.
Conclusions:
The findings suggest that prolotherapy may be an effective treatment
for chronic shoulder pain & an alternative to surgery (8).Another
aspect of this case is that she was treated successfully with non-
operative Interventional pain management techniques. Although there
are no published data regarding the success rates of multimodal
interventional pain techniques (9). It is reported that PRF of
interscalene (5) & suprascapular nerve (6) can be successful in the
treatment of post-operative shoulder pain. Thus, these techniques
should be considered as a first-line treatment in the management
persistent post-operative shoulder pain.
COI Disclosure: No Conflict of Interest.
Sherry N. Fanous*, Safwet El Golf Hospital, Cairo, Egypt
Keywords: Ultrasound – Shoulder –Radiofrequency – Interventional Pain Management