Shoulder neuropathy

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Shoulder neuropathy can be defined as falling into three categories.

The first is a primary idiopathic neuropathy affecting the brachial plexus (Parsonage-Turner syndrome). The next is a neuropathy affecting the suprascapular nerve. The final is a neuropathy due to othger factors such as radiation.

Most cases of acute idiopathic brachial plexus neuritis occur between 20 and 60 years of age; however, cases have been reported in all age groups.

Symptoms with acute brachial plexus neuritis are severe, burning pain in the shoulder and upper arm with no apparent cause. On occasion, it may awaken the patient from sleep. In the majority of patients, the pain subsides over days to weeks, resulting in weakness of the upper arm. This profile of initial arm and shoulder pain followed by muscle weakness as the pain subsides is almost diagnostic of acute brachial plexus neuritis.

Physical examination shows weakness in the supraspinatus, infraspinatus, deltoid and/or the biceps muscles usually involving the upper plexus. The course of the neuritis is usually one of gradual improvement and recovery of muscle strength in three to four months. Some patients, however, experience residual muscle weakness. In general, a longer duration of pain will result in a longer delay in recovering strength.

Patients with cervical radiculopathy present with pain beginning in the neck area and radiating down the arm. The pain is associated with partial weakness in the muscles supplied by the involved nerve root and sensory loss in the associated dermatome.

Unlike acute brachial plexus neuritis, the pain, weakness and sensory loss associated with cervical radiculopathy tend to occur simultaneously. While acute brachial plexus neuritis involves multiple nerves of the brachial plexus, a radiculopathy by definition is restricted to one nerve root.

Magnetic resonance imaging (MRI) is the diagnostic procedure of choice for brachial plexopathy.

With a typical presentation and an examination suggesting nerve root involvement, the diagnosis of cervical radiculopathy may be confirmed by either cervical CT scan or MRI scan.

Electromyographic testing in patients with acute brachial plexus neuritis yields valuable information as well.

Treatment of patients with acute brachial plexus neuritis includes analgesics for several weeks and physical therapy to help maintain strength and mobility. The weakness in the shoulder muscles may require the use of a sling. Corticosteroids, although frequently used, are not of proven benefit.

Differentiation of acute brachial plexus neuritis from cervical radiculopathy may be difficult in some patients.

Findings on cervical MRI may be helpful if the study is normal or if there is evidence of appropriate nerve root compression, indicating cervical radiculopathy. Electromyography and nerve conduction studies are useful, especially when combined with a patient history and physical examination findings, but characteristic changes of a plexus abnormality may not be apparent for weeks following the onset of symptoms.

Suprascapular neuropathy is an underdiagnosed condition that results in impingement syndrome. The suprascapular nerve innervates the supraspinatus and the infraspinatus muscles. The neuropathy weakens these muscles unbalancing the rotator cuff force couple. This leads to cuff tendonopathy.

Athletes in overhead sports are especially prone to impingement from cuff imbalance.

The etiology of suprascapular neuropathy is unknown. The neuropathy can result from several factors.

The diagnosis is suspected in patients with impingement syndrome who have posterior cuff weakness that does not respond to rotator cuff rehabilitation coupled with rest. Shoulder MRI can be helpful if a ganglion cyst is present within the notch. The diagnosis is usually made with an electrodiagnostic exam.

Treatment is controversial. Patients who don't respond to conservative measures may opt for surgery.

Radiation therapy for lymphoma can also cause neuropathy. These can take the form of brachial plexopathy (arm/shoulder neuropathy).

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