The shoulder joint is the second largest and most mobile joint in the human body and can be easily understood if divided into three layers. view
Trauma is the term used to describe injury. Trauma is classified by its severity depending on the amount of force used to cause the injury. view
Shoulder Fractures or breaks in the shoulder can occur in the humeral bone, collar bone or the in shoulder blade. view
A shoulder dislocation is classified according to the direction of the dislocation (Anterior, posterior or multi-directional), the amount of force it took to dislocate the shoulder (Traumatic or Atraumatic), and whether it is accompanied by a fracture (fracture dislocation). view
Shoulder Arthritis is the loss of the cartilage cushion in the joint surfaces (blue section) that allows the smooth pain free gliding required during shoulder motion. view
Nerve compression syndromes are normally found in adults of all ages and it is rare to find nerve compression syndromes in patients younger than 20 years of age. view
Shoulder pain is the most common presenting shoulder complaint in an orthopedic practice. view
The shoulder is one of the most well perfused areas of the human body and because of this ample blood supply to the shoulder which carries circulating white blood cells, offers excellent protection against infection, consequently making a shoulder infection a rare occurrence. view
A Frozen shoulder also called adhesive capsulitis is a condition presenting with shoulder stiffness and severe shoulder pain when shoulder motion is initiated. view
Tumors are divided into benign and malignant types. view
A string-like structure consisting of multiple axons leaving the spinal cord. An axon is an extension of a nerve cell. Multiple nerve cells form the brain and spinal cord, sending signals to control all functions of the human body.
Main Functions of Nerves in Musculoskeletal System is to provide sensory feedback to the brain. This feedback is interpreted and determines which signals are sent through the nerve axons
Types of sensory functions:
Other functions include allowing muscles to perform motor functions. Also warning and preventing the body from being damaged by environmental factors via pain fibers. Pain fibers alert a person of environmental and internal pain, such as appendicitis or kidney stones
Brachial Plexus is a network formed from exiting neck nerves intermingling. It ends in specific nerves that control the entire upper limb; the shoulder, elbow, wrist and hand.
Five Major Nerves from the Brachial Plexus
Secondary Nerves from the Brachial Plexus
Symptoms of Nerve Pain
These symptoms are the hallmark of nerve pain, which continues with or without the use of our limbs. Rest pain, with symptoms of numbness, tingling or weakness, alerts an examiner that a nerve compression is most likely present.
If a muscle has a dense fascial cover, there is a change in pressure between the cover and the dense fascial edge. As a nerve glides repetitively between the fasical cover and fascial edge, the nerve can become compressed. This compression causes nerve swelling, which is called the edge effect.
Nerve compression syndromes are normally found in adults. It is rare to find nerve compression syndromes in patients younger than 20 years old.
Common Causes of Nerve Compression Syndromes
With aging, the water content of cells decrease. This leads to decreasing tissue flexibility as the collagen type of tissue changes to the less flexible type. The elastin part of muscle and ligaments decrease as well, further decreasing muscle flexibility. Nerve compression in the neck and shoulder typically presents with pain in the neck and shoulder.
Nerve pain has a constant presence occurring without the use of the limb but is often aggravated with use. Pain quality can vary from a dull ache to severe intolerable sharp stabbing pain. The temporal appearance is also variable and at times unpredictable, presenting without rhyme or reason. Examples of Nerve Compression Syndromes in Shoulder:
Suprascapular nerve compression typically occurs in two locations. When the suprascapular nerve exits the brachial plexus, it passes through the suprascapular notch. This space the suprascapular nerve travels through can become excessively tight, causing a dull constant ache in the shoulder. This ache is deep in quality and occurs at rest but is aggravated with use of the arm. The use of an EMG/NCS can be helpful in making the diagnosis, and diagnostic injections can be given in the office to confirm the diagnosis.
The suprascapular nerve can also be compressed in an area called the spinoglenoid notch from the presence of a ganglion cyst (fluid filled sack). A ganglion cyst most commonly arises from fluid leaking from the shoulder joint caused by a SLAP lesion. A SLAP lesion is a tear in the labrum which seals the glenoid rim. This type of compression results in the atrophy (withering away) of the muscle of the supraspinatus and infraspinatus. The compression of the spinoglenoid notch causes atrophy of the infraspinatus. The consequence of this compression is weakness of the rotator cuff muscles. These muscles raise the arm and allow the arm outside rotation.
Quadrangular space syndrome (QSS) is a rare condition often presenting with shoulder pain brought on by repetitive overhead activities. Other rarer causes include benign cysts or arterial aneurysms. QSS, like suprascapular nerve compression, is an axillary nerve compression arising from the brachial plexus. This axillary nerve is accompanied by the posterior humeral circumflex artery (PHCA) at the shoulder level. This neurovascular bundle can become compressed as it passes through the quadrangular space. A nerve conduction study can be of assistance but often times can be negative. A MR angiogram focusing on the area is helpful and treatment is symptomatic initially.
Parsonage Turner Syndrome, or brachial neuritis, is a rare syndrome of unknown cause; it is linked to a viral origin affecting the brachial plexus. The diagnosis is one of exclusion, requiring the ruling out of other causes.
Patients with this condition present with an insidious onset of intense shoulder pain progressing over a 2-3 day period and slowly dissipating after 2 weeks. This is followed by weakness in the shoulder and upper limb muscles, in some instances progressing to atrophy and paralysis. The majority of patients have complete resolution of their symptoms over time but it can take up to 2 years.
Treatment is symptomatic, focusing on maintaining limb mobility and electrical stimulation to maintain joint flexibility and muscle mass.
Thoracic Outlet Syndrome (TOS) also known as Thoracic Outlet Compression (TOC), is a nerve compression syndrome of the thoracic outlet. The thoracic outlet is where the brachial plexus exits the neck area to travel down the arm as individual nerves.
Common TOS/TOC Patient Histories
Types of Thoracic Outlet Compression
Vascular (2% of total cases)
1. Subclavian Artery Compression
2. Internal Jugular Vein Compression
Nerve Types (98% of total cases)
3. Neurogenic Thoracic Outlet Compression
4. Disputed Neurogenic Thoracic Outlet Compression
A diagnostic injection can be given in the office with lidocaine at the inter-scalene level to confirm the diagnosis. If more than 50% of the pain is alleviated with the injection, and the rest of the clinical picture is present, without another diagnosis to explain the symptoms after a thorough workup, then a presumptive diagnosis of disputed neurogenic thoracic outlet compression is made.
Complex Regional Pain Syndrome (CRPS)
CRPS was previously known as Reflex Sympathetic Dystrophy. Causes of CRPS can occur as a consequence of minor and often insignificant trauma or a major violent trauma.
Types of Complex Regional Pain Syndrome:
Type I CRPS
Type II CRPS
Type III CRPS
It is very important to distinguish the different types of CRPS. For example, Type II CRPS has a higher response rate and if a nerve compression syndrome is identified as the cause, surgical decompression will resolve the symptoms.
Type I CRPS is a nonsurgical condition. However, there is the exception that an implantable nerve stimulator can be used to control pain when other conservative options are exhausted.
Symptoms in CRPS result from nerve dysfunction affecting the musculoskeletal system and blood vessels feeding the affected area.
Common CRPS Symptoms
The history and physical exam is the most important, along with a geographic palpation. Recommended Tests:
All nerve compression syndromes are first treated by differentiating the severity of the compression. Mild to moderate nerve compression syndromes can be treated with non-operative measures under the following circumstances:
If those conditions are met, a conservative trial is the way to go.
Stellate ganglion blocks given by the pain specialist with the concomitant use of a continuous nerve catheter will help initially in allowing the patient to participate in therapy and also to confirm the diagnosis. Several courses of stellate ganglion blocks are required however, for progress to be achieved. Nerve suppression pain medications such as Neurontin, Lyrica and Elavil may be used.
In severe compression cases it is unlikely non-operative measures will achieve a positive result.
The surgical treatment of nerve compression about the shoulder goal is to release the offending structures making the space where the nerve is traveling through too tight.
CRPS is treated through a joint effort involving the physician, therapist and a pain consultant. Therapy has the best track record and is the foundation of treatment. Patient education is critical in obtaining treatment success.