Rotator Cuff or Parsonage-Turner Syndrome?
An Instructive Case
Written by: James Demetrious, DC, DABCO
Diplomate, American Board of Chiropractic Orthopedists
Chiropractors are Neuromusculoskeletal Specialists
Doctors of Chiropractic are important primary spinal care specialists who are uniquely qualified to assess, diagnose, order and interpret imaging and lab values, provide chiropractic care, and recommend ancillary medical care.
In practice, chiropractors are often faced with complex medical conditions that bridge disciplines and require careful consideration.
Complications Following Thyroid Surgery
A 17-year-old male patient underwent thyroidectomy. General anesthesia was utilized and the surgeon administered a regional cervical plexus block. The surgeon reported that the procedure went as well as could be expected.
In the recovery room, the patient reported new moderate right scapular, shoulder, and upper extremity pain. He noted weakness of shoulder abduction and external rotation.
Initial Medical Assessments
The attending surgeon opined that the patient had rotator cuff syndrome despite the patient’s young age, absence of prior complaints, and no physical activity that could explain that diagnosis. He recommended physical therapy.
Initial Chiropractic Assessment
In the recovery room, his chiropractor carefully assessed the patient. The patient had no comorbidities.
He was afebrile. The cranial nerve assessment was negative. The accessory nerves appeared unaffected with 5/5 trapezius strength. Sensitivity to pinprick was diminished on the right affecting the C3, C4, C5, C6 and C7 dermatomes. Bicep, tricep, and brachioradialis deep tendon reflexes were absent on the right. Motor evaluation of the upper extremities revealed 3–4/5 weakness affecting the right deltoid, biceps, and triceps. Hoffman and Tromner signs were not present. The remainder of his examination was negative.
The chiropractor offered the diagnosis of Parsonage-Turner Syndrome (PTS) due to the cervical plexus anesthetic block.
Misdiagnosis
Patients with PTS are often misdiagnosed with rotator cuff, glenohumeral adhesive capsulitis, and cervical radiculopathy. PTS should be considered in patients who exhibit acute shoulder/radicular symptomatology who have undergone vaccine and anesthetic block procedures. Additionally, patients who exhibit recalcitrant shoulder and reticular symptomatology should be re-evaluated.
Clues to the identification of PTS may include:
— acute and chronic neck and upper extremity pain that defies typical interventions;
— recalcitrant rotator cuff, frozen shoulder and radiculopathy diagnoses;
— unexplained polyneuropathy.
Confirmatory Evaluations
Imaging:
— MRI with contrast of the brachial plexus can evaluate signal intensities associated with acute plexitis.
— MRI without contrast of the shoulder can identify denervation atrophy.
Electrodiagnostic Assessment
—EMG can provide insight into PTS related denervation atrophy.
Why is the Correct Diagnosis Important?
PTS is frequently missed by healthcare providers. Patients are often misdiagnosed with rotator cuff, frozen shoulder and radiculopathy diagnoses that delays appropriate treatment. PTS is an upstream problem.
With plexitis, patients may suffer denervation with resultant atrophy of muscular end organs. This produces primary shoulder symptoms that are often misdiagnosed.
Early identification and Care of PTS
Early identification of PTS and medical administration of a prednisone dose pack can rapidly alleviate the associated plexitis and curtail the development of motor denervation and debilitating atrophy.
The inclusion of chiropractic care for patients with acute and chronic PTS may provide upstream alleviation of neurologic compromise.
Rehabilitation of musculoskeletal compromise is often necessary.
We offer extensive CE coursework related to this topic at PostGradDC.com:
— MRI Assessment of Peripheral Neuropathy
PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is an internationally distinguished board-certified chiropractic orthopedist, educator, author, and editor. Register for coursework at PostGradDC.com.
