shoulder pain - proper diagnostic testing in shoulder pain cases

How does EMG/NCV fit in a Tertiary Care Shoulder Practice?

Vivek Agrawal, MDThe Shoulder Center

Carmel, Indiana

The Shoulder

• Present cases to help highlight the importance of detailed shoulder girdle/cervical EMG/NCV for our shoulder patients.

Case #1

• 84 y/o retired business owner referred with persistent shoulder pain/ debility.

• RIGHT TSA 10/2006 • RIGHT TSA revision and RCR

2007 • RIGHT shoulder arthroscopy

debridement and RCR 2007• Peripheral Neuropathy• TIAs

Case #1• Right shoulder:    

       Neurovascular Exam:  Anterior Interosseous intact, Posterior Interosseous Nerve Intact, Radial Nerve Intact, Ulnar Nerve intact, Median Nerve Intact, Radial pulse present, Ulnar pulse present.        Inspection:  infraspinatous atrophy ;PREVIOUS DELTOPECTORAL 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 to buttock.        Passive ROM:  Passive FF/ER/IR(90)=60/50/20.        Strength testing:  Deltoid: +3/5.        Infraspinatus:  +4/5.        Subscapularis (Belly Press):  Positive.        Palpation:  RENT Test Positive for Full Thickness Tear. 

• Cervical Spine  C3-4 Spondylolisthesis GRADE I; C4-5 C5-6 C6-7 Advanced DJD Multilevel Arthrosis 

• EMG/NCV

• Supraspinatus: 2.3ms latency and 0.5mV amplitude

• Infraspinatus: 2.7ms and 0.2mV and Temporal Dispersion

• Normal Axillary Nerve

• No evidence of Radiculopathy, Plexopathy.

Case #1• Based on Severe Suprascapular

Nerve Pathology but Intact Deltoid performed:

• Right Reverse Total Shoulder with Removal of Failed TSA in September 2008

• Examination April 2010:

• Excellent Pain Relief and Overhead Function    Right shoulder:            Inspection:  all surgical wounds healed.        Active ROM:  Active AB=155.        Strength testing:  Deltoid: -5/5.        Infraspinatus:  -5/5.        Subscapularis (Belly Press):  +3/5. 

Case #2• 57y/o with persistent pain/debility

following hemiarthroplasty performed Dec. 2007 complicated by intraoperative spiral fracture

• Left shoulder:            Neurovascular Exam:  Anterior Interosseous intact, Posterior Interosseous Nerve Intact, Radial Nerve Intact, Ulnar Nerve intact, Median Nerve Intact, Radial pulse present, Ulnar pulse present.        Inspection:  infraspinatous atrophy// left deltoid atrophy present// all surgical wounds healed// no scapular winging.        Sensation to Light Touch  Diminished.        Active ROM:  Active FF/ER/IR (90)=70/10/25.        Active External Rotation  Hand behind head with elbow 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). 

Case #2

• EMG/NCV-

• Posterior Deltoid 1+ fibrillation potentials, 1+ positive sharp waves, increased polyphasic motor units with prolonged axillary latency 6.6-7.8ms with amplitudes 5.8-7.7mV. Demyelinative Axillary Neuropathy without Conduction Block

• SSN-prolonged latency to SSN 7.0ms with low amplitudes 1.1-2.6mV and temporal dispersion

• Cervical Radiculitis/Radiculopathy at C6 and/or C7

Case #2

• Referred for primary evaluation and treatment of radiculopathy

• Had C6 and C7 selective blocks and good neurogenic symptom control with multimodal regimen

• Left shoulder arthroscopic global capsulotomy and extensive debridement, acromioplasty, distal clavicle resection, suprascapular nerve decompression (bony suprascapular notch) and axillary nerve decompression

Patient #2

• Visit 15 months postop:• Excellent Pain Relief

and below shoulder level function with ROM: FF/ER/IR(90)=125/70/70. 

Case #3• 25 year old male presents with c/o pain  Hx of

garage door falling and crushing cervical vertebrae approx 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 is painful., Aggravated by: reaching overhead for short periods 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 with scapula stabilized.        Infraspinatus:  +5/5.        Teres Minor (Hornblower's):  Intact.        Subscapularis (Belly Press):  +5/5.        Subscapularis (Lift Off):  +5/5.        Palpation:  ACJ non-tender SLAP test positive RENT Test is negative.        Tests:  POSITIVE O'BRIEN positive Yergason's.        Stability tests:  post. apprehension positive. 

Case #3• EMG/NCV:

• SSN: Normal latency with severely low amplitudes to both Supra and Infra with significant conduction block

• Chronic C6 and C7 radiculopathy

• Normal Axillary Nerve Function

• Normal Long Thoracic and Dorsal Scapular and Thoracodorsal Nerve Studies

• Referred for Diagnostic SSN block which did not provide much relief (? Severe conduction block)

• Mechanical Symptoms severe enough at shoulder that wanted to proceed with Arthroscopic Management.

• RIGHT shoulder arthroscopic capsular shift with extensive labrum repair, type II SLAP lesion repair, and suprascapular nerve decompression

Suprascapular Nerve

Suprascapular Nerve

Neuralgic AmyotrophyNeuritis (Mono or Multifocal)

• Significant number of these patients have concurrent shoulder pathology/pain

• Frozen Shoulder– Axillary and SSN

• Rotator Cuff Tear• Unstable Shoulder

EMG/NCV

• Important to include detailed objective criteria for SSN and Axillary Nerve

• Large differential for parascapular and shoulder pain with significant Neurogenic Contribution.

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