Upper Extremity Neuropathies in the Athlete...•Excise ganglion cyst; repair labrum. Axillary Nerve...
Transcript of Upper Extremity Neuropathies in the Athlete...•Excise ganglion cyst; repair labrum. Axillary Nerve...
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Upper Extremity Neuropathies
in the Athlete
David B. Gealt, DO
Assistant Professor RUSOM
Assistant Professor CMSRU
Assistant Director Sports Medicine
Director Sports Concussion Program
Cooper Bone and Joint Institute
AOASM
4/24/15
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Ultimate Question?
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Objectives
• Review Anatomy of Upper Extremity
• Identify Common Neuropathies seen in an
overhead athlete
• Review Diagnostic Evaluation and
necessary Testing
• Update on treatment and return to play for
Upper Extremity Neuropathies
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Introduction
• Throwing/Overhead Athlete subset of sports
medicine population
– Coordination of complex biomechanical,
kinematic, propioceptive events
– Huge stress placed on parts of body
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Kinetic Chain
• Energy from legs,
pelvis, trunk and
upper extremity
• Coordinated!
• From body to ball
• Result is ball flight
• Subtle changes in
velocity, direction,
rotation
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Phases of Throwing
• www.biomedsearch.com
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Phases of Throwing
• 1. Wind up
• 2. Early cocking
• 3. Late cocking
• 4. Acceleration
• 5. Deceleration
• 6. Follow-through
Cummins et al . Phys Rehabil Clin N. America vol 26.1
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Musculoskeletal System
• Bones of the
Shoulder
– Humerus
• Humeral head
• Greater tuberosity
• Lesser tuberosity
– Clavicle
– Scapula
• Glenoid
• Coracoid process
• Acromion
• Scapular body
– Supraspinatus fossa
– Infraspinatus fossa
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Musculoskeletal System
• Elbow Bones
– Humerus
• Trochlea
• Capitellum
– Ulna
• Oleceranon process
• Coronoid process
– Radial head
• Inherently stable
joint
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Musculoskeletal System• Muscles
– Deltoid
– Pectoralis
minor and
major
– Teres Major
– Latissimus Dorsi
– Etc.
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Musculoskeletal System
• Rotator Cuff
Muscles
– Supraspinatus
– Infraspinatus
– Teres Minor
– Subscapularis
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Muscles of the Elbow
• Brachialis and
Biceps
• Triceps
• FCU and FDS
important as
secondary
stabilizers during
throwing!
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Brachial Plexus
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Physiologic Pressure on a Nerve
• Likely due to ischemia:
– 20-30mmHg>>>>decreased epineural blood flow
– 30mmHg>>>>axonal transport disrupted
– 30-40mmHg>>>>paresthesias
– >60mmHg>>>>complete sensory/motor block
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Nerve Innervation ElbowI. Median Nerve (C6-T1; med/lateral cords)-
All ventral muscles of forearm except FCU
Wrist flexors/thenar eminence/volar 1st 3 digits and
lateral half of 4th
Cross elbow medially to antecubital fossa and pass
through 2 heads of pronator teres
Distally branches to Ant Interosseus Nerve.
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Median Nerve
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Median Neuropathy• Anterior Interosseus Syndrome
– Midshaft Fxr; well developed forearm
musculature
– Purely Motor: NO SENSORY LOSS!
– Late sign: OK sign (weakness of FPL/FDP)
– Weak pronation w/ arm
flexed
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Median Neuropathy
• Pronator Syndrome– Repetitive pronation/supination (racket sports)
– @ Ball release and follow through in throwers
– Pain on volar side of forearm
– N/T median n. distribution
– +/- weakness of thenar muscles (uncommon)
• Treatment: – Conservative w/ rehab
– NSAIDs
– Surgical exploration
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Radial Nerve Innervation
II. Radial Nerve (C5-C8/post cord)--EXTENSION
• Extension elbow/wrist/MTP and supination
• Sensory of dorsal forearm/hand,thumb
• Descends laterally and divides
1) superficial sensory branch
2) deep purely motor branch (Posterior Interosseus Nerve) as enters Arcade of Froshe (fibrous arch of supinator m.)
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Radial Nerve Course
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Radial Neuropathy• Radial Tunnel
Syndrome
– Seen in dominant arm in racket sports
– No weakness
– May be confused w/ Lateral Epicondylitis
• Dull aching pain
• Pain w/ resisted supination/extension of middle finger
• Tender at muscle mass ~ 4 cm below elbow
• +Tinels
• Treatment
– Rest/Splinting
– NSAIDs
– Injections?
– Surgery last resort-decompression
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Radial Neuropathy• Posterior Interosseous
Syndrome (Motor)
– Dominant arm
– Compression injury
– Overuse or Fxr proximal radius
– Painless weakness of extensors (ck ECU)
– Radial deviation
– NO SENSORY LOSS!
– MRI changes
• Treatment
– Conservative
– Surgery if mass/fxr/dislocation
– Decompression
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Radial Nerve Injury
• Fracture of Humerus in throwing
– Middle distal 1/3 shaft
– Torsional force>tensile strength in bone
– Radial Nerve may be trapped in fragments
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Ulnar Nerve
• C8/T1 from medial cord
• Innervates elbow joint
• Intrinsic hand muscles
• FCU/FDP
• Sensory 4th/5th digits ulnar border
https://epsomtissuetech.wordpress.com
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Ulnar Nerve Compression Sites
msdlatinamerica.com
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Ulnar Neuropathy
• Cubital Tunnel- 2nd most common UE
compressive neuopathy
– Physiologic cause w/ flexion
– Overhead throwers/wgt lifting/racket
sports/musicians
– Often involve ligament injury/laxity*
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Symptoms and PE
Pain @ medial epicondyle w/ sensory
complaints of ulnar distribution into hand
Weakness thumb/finger abduction, pinch &
grip>>> dropping objects
Motor and Sensory Exam
Grip/pinch strength
Vibratory
2 Point Discrimination
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Physical Examination
• Tinel’s
• Elbow Flexion Test
• Elbow Scratch Collapse
Test
• Froment Sign
• Wartenburg Sign
• Claw hand
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Ulnar Neuropathy
• Cubital Tunnel– X-rays– MRI– EMG/NCV
• Treatment– Conservative
• Rest w/ night splinting• Education• NSAIDs• Rehab including ITP
– Surgery (may involve UCL)?• Throwers: anterior subcutaneous transposition or submuscular
transposition• RTP preoperative strength and mobility
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Cubital Tunnel Syndrome
• COMPRESSION
Pressures elevated in patients
undergoing UND and increased
in flexion (Iba et al JHS 2006)
Elbow flexion INCREASES
intraneural pressue @ cubital
tunnel
• TRACTION
• Unrestricted ROM produce
strains up to 29%
• Post UND strain dropped from
30.5% to 5.5% in patients (Ochi et
al JHS[EU] 2013)
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Lateral Antebrachial Cutaneous Nerve
Branch of Musculocutaneous nerve
Anterior Lateral Elbow Pain/paresthesias
in throwers
Bassett’s Lesion:
Pronation and Extension with ball
release
RICE, NSAIDS, INJECTIONS
May require surgical release @ biceps
aponeurosis if fail conservative care
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Suprascapular nerve
• Upper trunk C5-6 of Brachial Plexus
• Mixed motor/sensory
• Innervates subacromical bursae,AC & GH
joint, SS and IS muscle
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Suprascapular Nerve
• From brachial
plexus to shoulder
• Under superior
transverse scapular
ligament in
suprascapular notch
• Around spinoglenoid
notch to
infraspinatus
• e-algos.com
E-algos.com
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Suprascapular Neuropathy
• Dependent on site of injury involve SS/IS
– +/- posterior shoulder pain with weakness
• Trauma, Surgery,Ganglion Cyst, Overhead
activities with increase stress:
traction/compression
– Baseball 4% pitchers (cummins et al CJSM 2004)
– Volleyball players (Ferretti et al. ALSM ‘87)
Cummins et al . Phys Rehabil Clin N. America vol 26.1
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Suprascapular Neuropathy
• Dx: Clinical/ Imaging MRI/MR arthrogram
NCV/EMG
• Treatment:
–1st Conservative unless mass lesion
• Modify activity
• Rehab-flexibility/Postural ex/Improving IR
contractures/ Cuff strengthening
–Surgery
• Resection Superior Transverse Scap Ligament
• @ spinoglenoid ligament-decompression
• Excise ganglion cyst; repair labrum
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Axillary Nerve• Posterior cord C5-6 nerve root
• Motor function Deltoid and Teres Minor
• Sensory lateral shoulder/joint capsule
• Exits posterior with PHCA through
quadrangular space
– Teres Minor
– Long head triceps
– Teres Major
– Humeral shaft
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Axillary Neuropathy
• <1% of all nerve injuries
• Trauma
• Quadrangular Space Syndrome
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Axillary Neuropathy
• Extensive DDx Bryan el al AJSM
• Dull ache/burning/fatigue with throwing
– Atrophy Deltoid
• X-rays/MRI/ EMG/NCV
• Treatment
– Conservative
– Sx: Iatrogenic, trauma,lesion, no nerve recovery
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Thoracic Outlet Syndrome:
Types
• Compression of
neurovascular bundle
at the thoracic outlet:
– Brachial plexus
(nTOS)
• 95%: most difficult to
diagnose and treat
– Subclavian artery
(aTOS)
• <1%
– Subclavian vein
(vTOS)
• 2-3%
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Anatomy of Thoracic Outlet
• Bony Boundaries
• Scalene triangle
• Costoclavicular space
• Pectoralis minor space
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Thoracic Outlet Syndrome
• Compression results
from combination of
anatomic variants,
physical activities and
other events.
• Scalene muscles: wide
vs narrow triangle,
congenital bands
• Cervical ribs
• Anomalous first ribs
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Characteristics
• Age: 20-50
– <5% teenagers
– 10% over 50
– >65 rarely
• Sex: female 70%
– Cervical ribs more
common in female
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TOS Symptoms
nTOS
• Pain, parasthesias, numbness,
weakness
• Throughout affected hand/arm
• Not necessarily localized to
peripheral nerve distribution
• Extension to shoulder, neck,
upper back not infrequently
vTOS aTOS
• Symptoms
• Pain
• Tightness
• Discomfort during exercise
• Edema
• Cyanosis
• Increased venous pattern
• Tenderness over axillary vein
•Symptoms
•Finger or hand ischemia
•Cutaneous ulcerations
•Forearm pain with use
•Pulsatile supraclavicular
mass/bruit
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nTOS Symptoms
“Upper plexus” disorders –
radial and musculocutaneous
nerve distributions
“Lower plexus” disorders –
median and ulnar nerve
distributions
–Occipital headaches
–Perceived muscle weakness
• Actual weakness and atrophy
are rare
–Vasomotor symptoms
• Vasospasm, edema,
hypersensitivity (CRPS)
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Physical Exam: TOS• Check pulses
• Listen for bruits
• Note
edema/cyanosis/collateral
veins
• Tenderness over scalene
or pec minor
• Decreased sensation to
light touch
• Provacative maneuvers
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Physical Exam: TOS
• Adson Test
• Healthy volunteers have
up to 50% positive test
• Unreliable for diagnosis
of TOS!!
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Physical Exam TOS: EAST
• Elevated arm stress
test
• Most accurate clinical
test (per Roos)
• “surrender” position
for 3 minutes while
opening/closing hands
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Physical Exam TOS: EAST
• nTOS: heaviness,
progressive weakness,
numbness, tingling in
fingers, progressing up
arm
• vTOS: cyanotic arm
with distended
forearm veins
• aTOS: ischemic,
cramping pain
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nThoracic Outlet Syndrome:
Treatment
• PHYSICAL
THERAPY
• Posture correction
• OMM
• If no improvement,
surgical
decompression versus
living with symptoms.
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Thoracic Outlet Decompression
• Transaxillary versus
Supraclavicular approach
• Resection of anomalous 1st
ribs or cervical ribs
• Resection of anterior and
middle scalene
• Possible pec minor tenotomy
or brachial plexus neurolysis
• Possible vascular
reconstruction
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Conclusion
• A thorough and complete history is key
• Understanding the anatomy will help with
the diagnosis
• Review Imaging and EMG/NCV
• Review the treatments with each athlete
• Know the Anatomy!!
• EAT A CHEESESTEAK
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