Brief Near-Total Weakness of Shoulder

[facetguy]

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Since I feel as though I "know" you guys in here, I thought I'd ask about a case:

50 yo female, excellent physical condition, no significant medical hx except calcific tendinosis of the hip about 5 years ago which resolved with time and conservative care. Complains of marked weakness of the left shoulder (she's right hand dominant) which began 24 hrs earlier while she was helping to move a 42" TV still in the box (actually kind of nudged it she said, not full lift). No severe pain or weakness at that time, but got progressively worse over next several hours. Presents to me next day, unable to abduct or flex her left shoulder, arm held at side with elbow at 90. Recruiting traps/levator when attempts movement of shoulder. Very tender anteriorly.

Exam of cervical WNL (ROMs, no tenderness/spasm, distal myotomes 5/5). Denies UE paresthesia. Left shoulder very tender anterolaterally. Passive shoulder ROMS full, albeit with only moderate pain. External rotators (t. minor, infraspin) 5/5. Internal 5/5. Extension 5/5. Resisted abduction at 90 is 4/5 with pain. Resisted abduction at 10 degrees very weak. Supraspin in scaption very weak 2/5. Flexion is 3ish/5. Weakness is not due to pain inhibition. No defect in biceps. Speed's positive for pain and some weakness. Drop arm, empty can strongly positive.

So I'm thinking tear left supraspin, maybe biceps.

Order MRI. From radiologist: Teres minor, subscap, biceps intact. No labral tear. GH jt intact. Mild thickening, signal hyperintense along bursal surface of supra/infraspin with mild subacrom/delt bursa fluid. Tiny signal consistent w/ calcific tendinitis along anterior infraspin enthesis. Possible old Hill-Sachs (but no hx). No jt effusion.

So, no obvious tear.

It's now 1 week later. No treatment anywhere in interim week. Spoke to her by phone today (I know her personally). She feels almost completely normal! Virtually no pain, motion good.

WTF? Now, I haven't re-examined her again so I'm going by her word. But she says she feels almost completely normal.

No lower extremity symptoms were present last week, and she was fully alert, etc.

Any thoughts?

 

[clubdeac]

Ok never mind, I had an idea but it was wrong 😉

 

[specepic]

Mild stretch injury to plexus? More likely she was mad at her husband for making her help with TV.

 

[emd123]

I don't know what caused it, but you'll know what to do next time she comes in with the same thing. Nothing.

 

[SSdoc33]

RTC strain. not neurologic. weakness due to pain inhibition.

 

[melancholy]

Sounds mechanical, but could certainly go through a differential for neurological etiologies (albeit one week is a fairly quick resolution). Any interesting history of prior activities? (i.e. specific sports, occupational history, etc.) Was MRI with arthrography? (not sure you can totally rule out labral pathology, but a small point)

It seems like there was significant pain elicited with both active and passive manuevers. Are you fairly certainly that there's no element of pain-limited giveaway contributing to her weakness?

Can acute bursitis resolve fairly well in one week with conservative management and NSAIDS?

If she hasn't had any prior exercise regimen for cervical/UE/scapular stabilizers, it may be something to propose so it can be incorporated into her activity regimen for the future.

 

[facetguy]

Thanks for the replies. I don't think the weakness was pain inhibition in this case. I too had thought about the stretch injury to the plexus, but could that be the case if there was no initial 'stinger' type sensation? Not sure. And the rest of the motor testing was normal. There is no other significant history. The MRI was not an arthrogram.

If I didn't know this patient personally, I probably wouldn't believe her. But she had essentially zero ability to raise her arm actively last week (passively yes, actively no). Is it possible the calcified region of the tendon was causing some kind of mechanical dysfunction which somehow resolved so quickly?

I should also mention that she saw an ortho several days after she saw me. He offered to do a cortisone shot but she refused because pain wasn't that much of an issue.

I'll keep you posted if anything else interesting happens.

 

[SSdoc33]

Thanks for the replies. I don't think the weakness was pain inhibition in this case. I too had thought about the stretch injury to the plexus, but could that be the case if there was no initial 'stinger' type sensation? Not sure. And the rest of the motor testing was normal. There is no other significant history. The MRI was not an arthrogram.

If I didn't know this patient personally, I probably wouldn't believe her. But she had essentially zero ability to raise her arm actively last week (passively yes, actively no). Is it possible the calcified region of the tendon was causing some kind of mechanical dysfunction which somehow resolved so quickly?

I should also mention that she saw an ortho several days after she saw me. He offered to do a cortisone shot but she refused because pain wasn't that much of an issue.

I'll keep you posted if anything else interesting happens.

stretch injury to the plexus? what?

RTC strain. not neurologic. weakness due to pain inhibition.

 

[clubdeac]

I got it, hyperkalemic periodic paralysis. Often affects the shoulders

 

[melancholy]

Dunno about the calcific deposits suddenly becoming symptomatic, then asymptomatic within a week's time, however I could imagine that it could potentially cause some mechanical issues if conditions were right. Too bad you didn't have an ultrasound machine around to check it out, do some dynamic testing, etc.

 

[TX PAIN DOC]

Complains of marked weakness of the left shoulder (she's right hand dominant) which began 24 hrs earlier while she was helping to move a 42" TV still in the box (actually kind of nudged it she said, not full lift). No severe pain or weakness at that time, but got progressively worse over next several hours. Presents to me next day, unable to abduct or flex her left shoulder, arm held at side with elbow at 90. Recruiting traps/levator when attempts movement of shoulder. Very tender anteriorly.

Exam of cervical WNL (ROMs, no tenderness/spasm, distal myotomes 5/5). Denies UE paresthesia. Left shoulder very tender anterolaterally. Passive shoulder ROMS full, albeit with only moderate pain. External rotators (t. minor, infraspin) 5/5. Internal 5/5. Extension 5/5. Resisted abduction at 90 is 4/5 with pain. Resisted abduction at 10 degrees very weak. Supraspin in scaption very weak 2/5. Flexion is 3ish/5. Weakness is not due to pain inhibition. No defect in biceps. Speed's positive for pain and some weakness. Drop arm, empty can strongly positive.

Order MRI. From radiologist: Teres minor, subscap, biceps intact. No labral tear. GH jt intact. Mild thickening, signal hyperintense along bursal surface of supra/infraspin with mild subacrom/delt bursa fluid. Tiny signal consistent w/ calcific tendinitis along anterior infraspin enthesis. Possible old Hill-Sachs (but no hx). No jt effusion.

It's now 1 week later. No treatment anywhere in interim week. Spoke to her by phone today (I know her personally). She feels almost completely normal! Virtually no pain, motion good.

WTF? Now, I haven't re-examined her again so I'm going by her word. But she says she feels almost completely normal.

No lower extremity symptoms were present last week, and she was fully alert, etc.

Any thoughts?

Appears that the patient had an impingement syndrome due to her injury. Bursitis or tendinosis can cause symptoms that occur several hours after injury. Active movement is affected, passive movement is sometimes not affected. Pain is not always present and can be minor when present. Symptoms resolve once inflamation is decreased enough to reduce impingement. Performing an impingement test by injecting local +/- steroid, and patient regaining movement shortly after can help to confirm the diagnosis.

MR arthrogram is better to evaluate for subtle RTC injuries and labral tears.

 

[tchoupdoc]

I work in a university orthopedics practice. I had two similar cases in the last year, one after forcing open a stuck door, another atraumatic.

Both cases were large c5-6 disc compressing the cord. One of them had +hoffman's sign on the affected side. Absolutely no pain or numbness, just weakness. Both underwent urgent decompression. One is doing quite well, the other likely is not going to get any anterior deltoid function back.

 

[facetguy]

I work in a university orthopedics practice. I had two similar cases in the last year, one after forcing open a stuck door, another atraumatic.

Both cases were large c5-6 disc compressing the cord. One of them had +hoffman's sign on the affected side. Absolutely no pain or numbness, just weakness. Both underwent urgent decompression. One is doing quite well, the other likely is not going to get any anterior deltoid function back.

Perhaps if these patients had waited a week, everything would have resolved.😀 Just kidding.

In the case of my patient, there was no myotomal-based weakness.

 

[tchoupdoc]

Perhaps if these patients had waited a week, everything would have resolved.😀

True, but that would have been a much lamer story to tell in grand rounds 😀.

Seriously, I work with a sub-sub specialist in spine surgery. i've learned from him that critical cervical stenosis can do strange things like this. Might be worth imaging c-spine, not for surgery, but just to let her know if it's okay for her to continue with her mechanical bull riding.