Shoulder Pain: It Really Gets On My Nerves

HISTORY: An active 69-year-old female with history of breast cancer s/p chemo/radiation presented to clinic for evaluation of one month of left shoulder pain. She noted acute onset pain in the left scapular region that peaked within 48 hours of onset. She described it as aching and radiating down her upper arm. She had 4 ED visits with the month due to the pain severity. Pain was worse at night and associated with decreased strength in her left arm. Denied any problems with balance, coordination, bowels, or bladder. She had several imaging studies that revealed on mild subacromial bursitis and cervical spondylosis. Gabapentin, cyclobenzaprine, lorazepam, steroid injection, and prednisone burst were all tried without any lasting relief of symptoms. Physical Exam: No obvious deformity of either arm was noted. Only mild tenderness to palpation over the left subscapularis muscle. Full active and passive range of motion were noted. LUE strength exam notable for weakness of wrist extension, thumb abduction, and second and fifth digit abduction. Sensation was intact to light touch in both upper extremities. Reflexes were 2+ bilaterally, and special testing of the shoulder was negative including Hawkins, Neer's, Speeds, Yergason's, and O'Brien's. Differential1. Parsonage Turner Syndrome2. Cervical Radiculopathy3. Radiation Plexopathy Tests and ResultsDVU of LUE: No evidence of DVT within the imaged veinsMRI C Spine: Multilevel degenerative changes of the cervical spine. Mild to moderate narrowing at C5/6 not significantly changed from MRI two years prior. XR L Shoulder: No acute fracture or dislocation. Mild/Moderate AC and GH Joint arthritis. MRI L Shoulder: Mild bursal surface stranding and intrasubstance clefting and tendinosis of the supraspinatus and infraspinatus. EMG: Electrodiagnositic evidene of C7 and C8 radiculopathy with small amount of axon loss that could represent neuralgic amyotrophy in the appropriate clinical setting. Final Diagnosis: Neuralgic Amyotrophy/Parsonage Turner Syndrome Treatment and Outcomes1. Gabapentin titrated up to 600 mg TID from 100 mg TID with noted improvement in pain2. Patient started PT for preservation of strength and ROM3. Has been able to resume some activity while still participating in PT.