12/9/2016

CHANG CJ

Disclosures

I have nothing to disclose UCSF 11 th Annual Primary Care Sports Medicine Conference: Upper Extremity

Stingers, Burners, and Cindy J. Chang, M.D. Winging: Associate Professor Primary Care Sports Injuries of the Upper Medicine Extremity

December 9, 2016

2

CHANG CJ CHANG CJ

Objectives Exam Room Tips • Stock gowns/sheets and paper shorts in the room • Review common upper extremity nerve injuries • Be able to get to both sides of the exam table seen in athletes • Have a step stool handy • Discuss return to play issues concerning specific upper extremity nerve issues

4 5

1 12/9/2016

CHANG CJ CHANG CJ

Case #1 Case #1

• 1994 AFC Championship Game • San Diego Charger upset the favored Pittsburgh Steelers 17-13 • Junior Seau recorded 16 tackles and a forced fumble despite: – Not being able to lift his arm above his shoulder – Playing with a bad left shoulder – Having a pinched nerve in his neck

6 7

CHANG CJ CHANG CJ

“Arm not fine? First Clear the Spine!” Taking a Really Good History

• Chief complaint -- eg, pain, numbness, weakness, location of symptoms? • Use a visual analogue scale -- patient's perceived level of pain • Anatomic pain drawings -- quick review of pain pattern.

8 10

2 12/9/2016

CHANG CJ CHANG CJ

Taking a Really Good History Taking a Really Good History • Onset, mechanism, what was done at that time? • Has the patient experienced previous episodes of similar symptoms or localized neck pain? When and • How do activities and head positions affect for how long? What helped? Other spine pain? symptoms? In what position does patient • Any symptoms suggestive of a cervical myelopathy, sleep? Ever wake up with pain? e.g., changes in gait, bowel or bladder dysfunction, or • Social history: sport/position, occupation, field sensory changes or weakness of the legs? of study, amount of computer use, ergonomic set-up, alcohol and tobacco use • What previous treatments (prescribed or self- selected) has the patient tried? – ice and/or heat – Medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]) – Physical therapy, traction, manipulation, acupuncture – Injections, surgical treatments

11 12

OLDCARTS MS OLDCARTS Mechanism of Injury

•Onset Symptoms •Location Onset •Duration Location •Character Duration •Aggravating/ Alleviating Character •Radiation Aggravating/ Alleviating •Timing/ Treatments Radiation •Severity Timing/ Treatments www.fammedref.org/mnemonic/pain- www.fammedref.org/mnemonic/pain- hx-old-carts-p hx-old-carts-p Severity

3 12/9/2016

CHANG CJ CHANG CJ

Typical Hx of Cervical Radiculopathy Typical Hx of Cervical Radiculopathy • Acute disc herniations and sudden narrowing of • Presents with neck and/or arm discomfort the neural foramen can occur in injuries of insidious onset involving cervical extension, lateral bending, or rotation and axial loading – range from a dull ache to a severe burning pain • Increased pain with these neck positions that • Initially, pain referred to cause foraminal narrowing medial border of – chief complaint may be shoulder pain • As radiculopathy progresses, pain radiates to upper or lower arm and into the hand – along sensory distribution of the involved nerve root

15 16

CHANG CJ CHANG CJ

Cervical Radiculopathy If you think it’s Cervical Radiculopathy…

• MRI most useful imaging choice • C-spine xrays including oblique views (“5 views”) may show degenerative changes – Order “7 views” if h/o trauma to neck

Eubanks JD, AFP 2010

18 19

4 12/9/2016

CHANG CJ CHANG CJ

If you think it’s Cervical Radiculopathy… Emphasize Posture

• Most patients <35 will do well with a trial of conservative management (time, meds, rehab/modalities). • Emphasize time. Emphasize activity. Emphasize posture. Emphasize restful sleep. Emphasize time.

The art of medicine consists of amusing the patient while nature

Eubanks JD, cures the disease.” AFP 2010 -Voltaire

20 21

CHANG CJ CHANG CJ

Case #1 Case #1 After making a tackle, the football player jogs off without assistance, but is carrying his left arm with his right. You question him on the sideline. Which of the following symptoms do NOT make you think this is a stinger? 47% A. He describes a burning type of pain 33% B. He describes weakness in only his wrist extensors 17% C. He feels numbness in both arms 3% D. He is having neck pain

22 23

5 12/9/2016

CHANG CJ CHANG CJ “““Burners/Stingers ””” “““Burners/Stingers ””” • Definition: – Nerve injuries resulting from trauma to neck or shoulder area – Cause a traction or compression along or cervical neck roots. • Diagnosis – Immediate onset of burning pain down the arm unilaterally – Can be associated with numbness or weakness Safran MR, • Lasts seconds to hours AJSM 2004

25 26

CHANG CJ CHANG CJ

“““Burners/Stingers ””” “““Burners/Stingers ”””

• Risk factors – Contact sports – Spinal stenosis • Symptoms – Usually last seconds to minutes – In 5-10%, can last hours to days or longer – Burn, electric shock, warmth, tingly – Numbness, weakness

27 28

6 12/9/2016

CHANG CJ CHANG CJ “““Burners/Stingers ””” Case #2 35 yo dragon boat racer walks into clinic to request a • Work-up if: prescription for physical therapy for her “ – Weakness lasts several days tendinitis”. You do a very quick exam and she is weak when testing all of her rotator cuff muscles. – Recurrent burners/stingers What should you do next? – Neck pain – Atypical symptoms, e.g. bilat UE A. Order an Xray 50% • Tests B. Check her sensation over her deltoid 39% – Radiographs to include flexion/extension views, region obliques C. Visually inspect her shoulder girdle – MRI C-Spine D. Write the prescription but limit to 3 6% 5% – EMG/NCS if > 3 weeks post injury and weakness wks with strict follow-up

29 31

CHANG CJ CHANG CJ

Scapular Winging The Role of the Scapula

• Scapula serves as the attachment site for 17 muscles • function to stabilize scapula to thorax, provide power to the , and synchronize glenohumeral motion.

33 34

7 12/9/2016

CHANG CJ CHANG CJ

Scapular Motion Scapular Stabilizer • Elevation and upward rotation : • Scapular protraction (anterior and lateral motion): serratus anterior, pectoralis major and minor muscle • Scapular retraction (medial motion) : rhomboid major and minor muscles

35 36

CHANG CJ CHANG CJ

Scapular Winging Scapular Winging

• (LTN) is branch of • Observe active forward brachial plexus C5, 6, 7 flexion and abduction from behind patient • Seen in pectoral region on surface of serratus • Watch for scapular winging anterior, just behind on descent mid-axillary line • Dysfunction also common with rotator cuff tears and instability • Wall push up – for more pronounced winging seen with Long thoracic Nerve injury – serratus anterior palsy

37 38

8 12/9/2016

CHANG CJ CHANG CJ

Scapular Winging - LTN Scapular Winging – LTN - Treatment • Nonoperative • Mechanisms of injury to long thoracic nerve – observation, bracing, and strengthening – iatrogenic from anesthesia • observation minimum 6 months for nerve to recover • 10% had prior surgery • Operative – repetitive stretch injury (most common) – pectoralis transfer; decompression, neurolysis, and • increased risk with head tilted away during tetanic electrical stimulation overhead arm activity • failure of spontaneous resolution after 1-2 years – compression injury • direct compression of nerve at any site – scapula fracture Nawa S, Nath RK et al, J Brach Plex BMC Periph Nerve Inj Musculoskeletal 2015 Disorders 2007

39 40

CHANG CJ CHANG CJ Case #3 Case #3 She plays outside hitter on a volleyball team which increased practices to 5x/wk a month ago preparing 22 yo RHD woman presents with increasing right for nationals. You suspect what pathology? shoulder pain despite doing rehab exercises diligently every day. This is what you see on A. Suprascapular nerve entrapment at the observation: resulting in atrophy of the supraspinatus

B. Suprascapular nerve entrapment at the 35% spinoglenoid notch resulting in atrophy of the 31% infraspinatus and teres minor 26% C. Suprascapular nerve entrapment at the suprascapular notch resulting in atrophy of the supraspinatus and infraspinatus 8% D. Suprascapular nerve entrapment at the spinoglenoid notch resulting in atrophy of the infraspinatus

41 42

9 12/9/2016

CHANG CJ CHANG CJ

Suprascapular Neuropathy Suprascapular Neuropathy

• If atrophy of both • Atrophy of both infraspinatus and – Surgical supraspinatus decompression – Compressed at – Release of transverse suprascapular scapular ligament at notch suprascapular notch • Only atrophy of • Atrophy of infraspinatus infraspinatus – Compressed at – Decompress ganglion, paralabral spinoglenoid cyst at spinoglenoid notch notch – Traction injury – Release spinoglenoid ligament

44 45

CHANG CJ CHANG CJ

Suprascapular Neuropathy Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity • Non-operative Treatment – Activity modification, formal • Return to Play shoulder rehab program – Pain resolved – Rehab performed for a minimum of 6 months – Full pain-free neck and upper extremity ROM – EMG/NCS – Normal strength • Operative • preferably compared with – Structural lesion seen on preseason baseline MRI (cyst, labral tear) – Normal reflexes – Nerve decompression if ’ failure of extended – Negative Spurling s test nonoperative management Huang P et al, – Negative imaging studies Safran MR, Sports Health AJSM 2004 (~ 1 year) 2015

46 47

10 12/9/2016

CHANG CJ CHANG CJ

Burners/Stingers, Winging and other Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity Nerve Injuries of the Upper Extremity • Absolute contraindication to RTP • Return to Play – no – Symptomatic disc herniation universally accepted • Relative contraindication to RTP criteria ° – Prolonged symptomatic burner/stinger lasting >24 – Can the athlete protect – ≥ 3 stingers; must have full return of ROM, normal themself from further strength, and no baseline discomfort injury? • No contraindication to RTP – Can the athlete – Degenerative disc disease; only occasional neck successfully play their stiffness and pain and no changes in baseline neurological status sport?

– < 3 episodes of a stinger lasting <24 ° with full ROM Creighton DW – Long term and short term Cantu RC et al, and no neurological deficit et al, CJSM risks vs. benefits? CSMR 2013 2010

48 49

CHANG CJ CHANG CJ “You don't stop exercising because you Burners/Stingers, Winging and other grow old. Nerve Injuries of the Upper Extremity You grow old because you stop exercising.” - Anonymo us • Prevention – Proper technique – Neck and shoulder girdle strengthening – Balance (core) training – Additional protective padding

50 52

11