D-50 Clinical Case Slide - Shoulder III Thursday, June 1, 2017, 3: 15 PM - 5: 15 PM Room: 504
HISTORY: A 35-year-old right hand dominant male with a history of right rotator cuff injury years ago presented with right shoulder pain for 3 weeks. He plays recreational basketball regularly but did not recall a specific injury. He described intermittent numbness, burning, and aching of the right posterior shoulder and proximal arm. Denied weakness, neck pain, or changes in pain with arm movement.
PHYSICAL EXAMINATION: Examination revealed atrophy of the right infraspinatus when compared to the left. There was no tenderness to palpation along the scapula, periscapular muscles, clavicle, acromion, or rotator cuff insertion points of the proximal arm. Cervical and shoulder range of motion were full and non-painful. Empty can test elicited pain and slight weakness on the right compared to the left; resisted external rotation showed 4/5 strength on the right and 5/5 on the left; resisted internal rotation 5/5 bilaterally and without pain, and lift off limited on the right compared to the left. Spurling test negative. Remainder of bilateral upper limb strength was 5/5. Sensation intact throughout. Biceps, brachioradialis, and triceps reflexes symmetric. Radial pulses strong and symmetric.
1. Infraspinatus tear
2. Suprascapular nerve impingement.
3. Brachial neuritis
4. Cervical radiculopathy
5. Upper trunk brachial plexopathy
TEST AND RESULTS:
R upper extremity EMG:
Right infraspinatus with significant amount of abnormal spontaneous activity; normal motor unit action potential morphology and recruitment characteristics. All other muscles tested including the paraspinals were normal.
R shoulder ultrasound:
Hypoechoic 1.6 cm structure without internal color doppler flow adjacent to the supraspinatus muscle.
R shoulder MRI:
Large paralabral cyst measuring 11x31 mm transaxially, spanning the spinoglenoid notch cranially and caudally. Tearing of the posterior superior and posterior labrum. Edema within the infraspinatus muscle.
FINAL WORKING DIAGNOSIS:
Suprascapular nerve impingement due to paralabral cyst.
TREATMENT AND OUTCOMES:
1. Surgical referral
2. Underwent surgical decompression of the suprascapular nerve
3. Pending follow-up at this time
4. This case highlights the utility of EMG to diagnose an uncommon nerve entrapment in the setting of a common shoulder pathology