1. Uncommon Causes of Shoulder Pain
NADHAPORN Saengpetch
Division of Sports Medicine
Department of Orthopaedics
Faculty of Medicine Ramathibodi Hospital
Mahidol University

2. Shoulder pain Related history Characteristic Location Onset
Provocative symptom(s)
Other possible correlated symptom(s)

3. Differential diagnosis
Lethalgy medical causes : MI, PE
Neurological : poliomyelitis, C-spine diseases (disc, root, cord)
Neuropathy : neuralgic amyotrophy, mononeuritis multiplex
Entrapment : brachial plexus, peripheral nerves
Thoracic outlet syndrome
Primary shoulder disorders*

4. Neuralgic amyotrophy

5. Neuralgic amyotrophy Brachial plexus neuropathy Brachial plexitis
Parsonage-Turner syndrome
(136 pts Lancet 1948;1:973-8)
Idiopathic brachial neuritis
Serum neuritis
Shoulder girdle syndrome ……
Neuralgic amyotrophy

6. Neuralgic amyotrophy Incidence 2-3 : 100,000
(McDonald BK Brain 2000;123:665-76)
(Beghi E Ann Neurol 1985;18:320-3)
The ever largest series 246 pts
(van Alfen N Brain 2006;129:438-50)
Male > female (2:1)
Etiology :
immune-mediated process
infection (25-55%)
strenuous exercise, vaccination,
post-surgical, hereditary
(Sathasivam S JBJS Br 2008;90:550-3)

7. Clinical features Pain is the first symptom (90%)
Acute severe burning shoulder pain, radiating to the arm ~ 39.7%
(van Alfen N Brain 2006;129:438-50)
Worsen by movement : most com fort in adduct shoulder and
flex elbow
Not aggravated by Valsalva maneuver and Spurling’s test
(DDx from C-radiculopathy)

8. Important feature Pain subsides and follows by muscle weakness**
Mimic rotator cuff/deltoid tendinopathy….that needs to be proved with imaging studies!

9. Clinical features
Weakness : develops within 2 wks, affects the upper brachial plexus 50% (isolation or several involvement)
(Hawkins RH JBJS Br 1987;69:195-8)
Inferior subluxation of the HH
Sensory involvement : hypoesthesia at deltoid, lateral arm and radial forearm
Autonomic dysfunction : trophic skin, increase sweating, etc.

10. electromyography Best done after 3 wks of the onset
Fibrillation potential
Abnormal distal conduction velocity
(Flaggman PD Arch Neurol 1980;37:160-4)
Demyelination in early stage
(O’Brien MD Lancet 1980;ii:975)
Axonal degeneration
Delayed distal latencies and decrease amplitude of CMAP
(Mullins GM Neurol Neurosurg 2007;109:661-6)

11. Other investigations CXR : useful to R/O Pancoast tumor
Blood tests : LFT, ESR, CRP, RF, ANA and anti-dsDNA
CSF study : mild pleocytosis, oligoclonal bands

12. Imaging studies
Coronal T1-weighted conventional spin echo (TR 700 ms, TE 20 ms)
Slide thickness 3 mm
MRN is superior to conventional MRI during the acute stage of diagnosis of NA
(Duman I Neurologist 2007;13:219-21)

13. MRI / MRN MRI Conventional post-Gd, Coronal view MRN Coronal short tau
inversion recovery view

14. treatment Steroid : methylprednisolone Narcotic : hydrocodone NSAIDs
Muscle relaxant : cyclobenzaprine
(Miller JD Am Fam Physician 2000;62: )
Physiotherapy & exercise

15. Prognosis Good prognosis with recovery onset 1-3 yrs.
(McCarthy EC CORR 1999;368:37-43)
75 % recover within 2 yrs
(Tsairis P Arch Neurol
1972;27:109-17)

16. Suprascapular nerve Entrapment (SSNE)
Usually been missed until atrophy or fatty infiltration are seen
Even miss by plain x-ray or CT scan
EMG is the gold standard to diagnose
Imaging hints : muscular edema, atrophy and fatty change
Labral/spinoglenoid notch cyst

17. Location of ssne Superior transverse Scapular ligament
Inferior transverse
Scapular ligament
(Spinoglenoid lig.)*
(Westerheide KJ Orthop Clin North Am 2003;34:522)

18. Suprascapular nerve entrapment (SSNE)
Suprascapular notch –SSN (SST+IST)
traction /compression
tethering effect of the ligament
Spinoglenoid notch –SGN (IST alone)
traction (overhead athlete)
a ganglion cyst*

19. Muscular edema is the
most sensitive for SSNE
compares with EMG
(Ludig T Eur Radiol 2001;11:2161-9)

20. Symptomatic ganglion cyst
Non operative
avoid repetitive overhead
PT scapular stabilizers and cuff
Operative
image guided aspiration (?recur)
open decompression
arthroscopic decompression
or combine procedures

21. (Paitt BE J Shoulder Elbow Surg 2008:11(6);600-4)

22. (Am J Sports Med 1996:26(6);759-63)

23. (Arthroscopy 2006:7;721-7)

24. Amber-color, gelatinous material Postero-superior capsulotomy
Repair of type II
SLAP lesion
(Abboud JA CORR 2006)
(Iannotti JP Arthroscopy 1996)
(Lichtenberg S Knee Surg Sports Traumatol Arthrosc 2004)

25. (Arch Orthop Trauma Surg 2006:126;621-3)

26. 42 pts with S-P cyst and labral tear
Capsulolabral tear forces joint fluid into the tissue => one-way valve cyst
Labral repair alone leads to cyst resolution and pain relief
Average cyst diameter 2.4 cm
No attempt to evacuate the cyst
Improved Rowe score and MRI

27. Pre operative
Post operative
Persist TMi atrophy
( Schroder CP JBJS Am 2008;90:523-30)

28. Working room under
the SST
Portal localization
(J Shoulder Elbow Surg 2008;17:616-23)

29. Arthroscopic
decompression
2 notches at the
same time
(fresh cadavers)

32. Satisfied decompression
Complete decompression 18/20 of suprascapular notch
20/20 of spinoglenoid notch

33. Quadrilateral space syndrome
(QSS)

34. Facts First reported in 1955 and1983
(Cahill BR J Hand Surg Am 1983;8:65-9)
Fibrous band compress the axillary nerve and posterior circumflex humeral artery
Vague posterior shoulder pain, paresthesia and weakness of TMi & posterior deltoid
0.8% incidental finding from MRI
(Cothran RL Jr Am J Roentgenol 2005;184:989-92)

35. The fibrous sling arises from the LHT is a normal finding
(McClelland D J shoulder Elbow Surg 2008;17:162-4)

36. Provocation tests Shoulder abduction to 90º
fully internal rotation…then
external rotation*
Subsequent pain and paresthesia over the shoulder blade
(McClelland D J Shoulder Elbow Surg 2008;17:162-4)

37. Investigations for QSS
MRI provide additional detail to electrophysiologic studies
acute T2 fast spin echo FS,
increase SI = neurogenic edema
chronic T2 spin echo, diffusely increase SI = outline muscle bulk
(Breddella MA Skeletal Radiol 1999;28:567-72)

38. Doubt MRI
(Sofka CM Skeletal Radiol 2004;33:514-8)
2,563 shoulder MRI with 3% isolated TMi denervation (some with EMG)
Other causes of TMi atrophy
surgical intervention posterior portal malposition, instability sx, capsular thermoplication
translation/dislocation traction, capsulolabral damage
nerve irritation RC, LHT

39. MRA / CT Angiography

40. 5 years later
(Sanders TG Arthroscopy 1999:6;632-7)

41. 5 years later

42. Other Anatomic causes Glenoid labral cysts A ganglion
Muscle (SSC) hypertrophy
A spike of bone after a scapular fracture

43. (Amin MF Skeletal Radiol 2006;35:956-8)

44. The healed bone impinged on the space

45. (McClelland D Am J Sports Med 2008;36(8):1615-7)

46. Surgical decompression
(McAdams TR Am J Sports Med 2008;36(3):528-32)
3-D CT angiogram