Case: 23-year old with Parsonage-Turner syndrome

Subjective Exam:
Your patient is a 23 year old, left hand dominant, male presenting to outpatient PT with complaints of right scapular pain that began approximately 1 year ago of insidious onset. He was diagnosed with Parsonage-Turner Syndrome by a neurologist after seeking treatment for his symptoms. Thus far, he has consulted with his primary care physician, a cardiologist, a neurologist and a physical therapist.  He denies any trauma, but does mention having a history of heavy power-lifting.  He states the pain in his right scapular region began as a pinching/burning sensation that was accompanied by a unilateral headache in the sub-occipital region lasting less than 1 hour. The onset of his symptoms typically occurred after prolonged sitting at his desk while studying. His headache only occurred during the first 2-3 days of his initial onset of symptoms.

He reports previous PT was helpful with pain through treatment that included massage, stretching, strengthening, and a TENS unit. He also describes sitting in positions with his back supported reduces his pain.  He mentions coughing, sneezing, and burping as factors that increase his symptoms. He recently started a "lifestyle" change and has since lost 20-30 pounds after becoming less active and gaining 60 lbs. He denies any changes in bladder, speech, vision, hearing, and or dizziness.

EMG results revealed chronic right suprascapular and dorsal scapular neuropathies, no other significant findings noted

Chen, S., et al. (2016). "Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations." Muscle Nerve 54(3): 371-377.

Pain chart

Observation

Height: 5'8'' Weight: 240 lbs  BMI: 36.5
Observation, Static standing posture:
- right scapula approximately 4 inches from mid-line and left scapula approximately 2 inches from mid-line
- prominent medial and inferior borders of right scapula noted upon inspection
- dowager's hump noted in upper thoracic region
- muscle atrophy noted in right posterior shoulder girdle and periscapular muscles
- normal tone, no fasciculations noted

Self Assessment?

1. Based on the history and observation, is there anything else you would like to know?
2. Do you have enough information to make a preliminary physical therapy diagnosis?
3. How does his diagnosis of Parsonage-Turner Syndrome influence his symptoms?
4. What would you include in you objective exam that may provide more insight to this case?

Objective Exam

The range of motion in his involved extremity when assessing shoulder elevation was reduced in flexion, abduction. He had approximately 150 degrees in each direction before having complaints of posterior shoulder girdle pain. He demonstrated superior border dysfunction and ipsilateral cervical lateral flexion when attempting to exceed his available range. Assessment of his thoracic extension and seated trunk rotation based on the expected available range of motion was 25% to the right (reproduction of posterior shoulder girdle pain) and 50% to the left, in addition to 50% of trunk extension. He demonstrated a reduction in chest expansion with a reproduction of his posterior shoulder girdle symptoms.

Case summary

In this case, the patient was deemed appropriate for outpatient physical therapy services. Differential diagnosis for his shoulder pain consisted of referred pain from the liver and gall bladder, cervical spine, C5-C6 more specifically, costovertebral or costotransverse joint pain and rotator cuff pathology. His symptoms of headache that were present during the acute phase of his injury were thought to be of little significance to this case as symptom onset was approximately 1 year ago. 

The patient did not have risk factors or symptoms that would increase the likelihood of his pain being visceral in origin. This includes a history of liver disease, over the age of 40, a diet low in fiber, high in cholesterol or high in fats, yellow eye coloration, complaints of nausea/vomiting, or episodes of sudden intense pain not alleviated with position change. His medical diagnosis of Parsonage Turner Syndrome was not consistent with current clinical presentation of anterior chest and posterior shoulder girdle pain detailed as burning and pinching in nature. The EMG findings of neuropathy of the suprascapular nerve and dorsal scapular nerves are significant when assessing the patient's strength and movement patterns related to shoulder elevation, but are an unlikely culprit of this patient's chief complaint. However, the suprascapular nerve, a mixed nerve, has sensory distribution to the lateral aspect of the arm and functions primarily in its motor innervation of the supraspinatus and infraspinatus muscles.

Upon further investigation, his burning sensation was diffuse throughout the posterior shoulder girdle and anterior chest. These symptoms were described as beginning posterior over the scapula with a gradual progression to the anterior aspect of his thorax. His feeling of localized pinching was reproduced with deep inhalation/exhalation, ipsilateral trunk rotation and palpation proximal to the region of the costo-transverse and costo-vertebral joints. 

After a bio-mechanical exam of the upper quadrant was performed, the patient was treated for costo-vertebral and costo-transverse joint pain and muscle imbalances related to shoulder elevation.