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Q: Doc, doc there’s a patient with sudden onset shoulder pain which worsened precipitously over a couple of hours after recovering from the flu. What should we do?
A: Sounds like a typical history for Parsonage Turner Syndrome. You suspect this when there’s acute onset really severe shoulder pain after an infection, operation, pregnancy or vaccination.
A: It’s not that rare, some sources say that it actually affects 1/1000 people if you know what you are looking for.
A: Did you check for long thoracic nerve, suprascapular nerve, anterior interosseous nerve and radial nerve involvement? 70 percent of PTS patients have patchy involvement of the first 3 nerves and these are listed in order of the most commonly affected.
Q: What do you say. He’s got scapular winging, difficulty reaching overhead and externally rotating the shoulder, and a weak pinch grip on exam. Of course with the terrible pain he didn’t even want to move his arm so he hadn’t noticed.
Q: Goodness me, should we get an EMG?

A: Great question - PTS is a clinical diagnosis and history is what you need. You don’t need to EMG the infraspinatus or long thumb flexor or wrist extensors to show muscle weakness if these are present on exam.
A: You might want to distinguish between PTS and cervical radiculopathy - but EMG/NCS might not help you cuz the sensory responses might be normal in PTS and cervical roots can be affected in PTS - paraspinal muscles can show denervation.
Q: Well this guy is a recreational wrestler. He’s really upset, why him, he asks?
A: Two answers - immune system and the movements affecting the brachial plexus. Some believe that arm movements stretch the blood brain barrier at the plexus making it more susceptible to cell and antibody mediated immune responses.
Q: Do we treat it? It’s a monophasic illness right?

A: Yup it’s a monophasic autoimmune event usually with the nadir of weakness in week 4. Sorta like GBS if you think about it. If we treat we are hoping for a faster recovery. Pain relief can help patients tolerate PT.
Q: His pain started 2 weeks ago and it’s still a 7/10. Do we treat?
A: If in treatment window, that is within 1 month. Use pred 60mg daily x 1 week then a taper over the next week. Usually if pain responds to treatment it responds pretty quickly in a day. Response is about 30 percent.
Q: He says will he get it again? He never wants this pain again.

A: Well there’s a 25 percent chance of recurrence. If he’s got a familial form, that is, if there’s a family history of shoulder problems, then the recurrence rate is 75 percent. You can test for the SEPT9 gene.
A: Take note that the genetic form confers immune susceptibility to triggers - it’s not a neurodegenerative condition as you might expect genetic diseases to be - hence the treatment is exactly the same. That’s all folks, neuromuscular out. Insights welcomed from all.
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