So we'll go ahead and get started now. Thanks everyone for joining us tonight for this installment of the the AMSSM National Fellow Online Lecture Series. Before we get started with tonight's talk, I do want to highlight the next talk, which is going to be on November 24th at 1 Eastern time on sports psychology with Vicky Nelson as a speaker and Irv Asif will serve as the moderator for that talk. For tonight's talk, the pleasure of having Dr. Eric Wagner is one of my colleagues here at Emory. I'll talk about neurogenic thoracic outlet and brachial plexopathy or other plexus syndromes. Like I said, he's a colleague of mine here at Emory. He did his orthopedic surgery residency at Mayo and then followed that up with two fellowships, one in hand in microvascular surgery at Mayo and another in shoulder at Harvard, where there's also an international fellowship where he trained with world leaders in France as well. So he's been at Emory since 2018. He's extensively published with over 180 peer-reviewed journal articles, 280 national presentations, over 10 book chapters. So early on in his career, he's established himself as a national leader and then he's quickly establishing himself as a world expert in neurogenic thoracic outlet. And we share patients together at Emory for this condition. And I think he's just an excellent mind to pick on this topic and know he's going to give a great talk tonight. So I'll go ahead and I do want to cover the reasoning for this. So this, for the lecture series, this is to serve as an adjunct to each individual fellow's programs, educational programming, and it's not to take the place of anything. We want to provide the fellows with direct access to educational experience through both AMSSN members and invited guests, such as tonight in a variety of formats. And then overall, hopefully these will serve as an adjunct and help to prepare for CAQ exam preparation. So with that said, we've handled all of these things. If you do have a question during the talk, just go ahead and put it in the chat function. We'll let Dr. Wagner finish his talk. And then at the end of the talk, if you put your questions in Q&A, you can submit questions through chat or Q&A actually. And then we will also put the evaluation into the chat function if you'll follow that link to fill that out at the end of the lecture. So with that said, I'll let Dr. Wagner take it away. Fantastic. Thank you, Powers. Powers, you can see my screen, right? Yep. Perfect. So thank you very much. This is my honor to be able to give this talk. So where I'm going to talk about Neurogenic Thoracic Outlet and some other varicose plexus syndromes, the idea of kind of introducing you to some considerations about radiating shoulder pain, what to think about when you have patients like these, and some both established and novel ways to approach this. So my name is Eric Wagner. As Dr. Byers mentioned, I'm one of his partners at Emory. And although I do have disclosures, none are really relevant to this presentation. But I should disclose I am a product of my mentors, particularly in the shoulder world, both within the United States and abroad. And a lot of them have helped to serve how I approach and how I think about this relatively complex and kind of novel topic that we have. So I'm going to start out with a quick case study. You have this radiating shoulder pain, so either anterior or posterior, but in general, radiating shoulder pain. So like this 20-year-old female softball player presents with pain, paresthesias, and kind of pain that radiates around her anterior shoulder. It gets worse with row varieties activities. It's limiting her ability to play collegiate softball. She has pain with most motions, even at rest, and her shoulders are radioactive. So rating her shoulder from zero to 100, she rates as a 25%. Otherwise, she's healthy. As I mentioned, she's a collegiate softball player. So this radiating shoulder pain, we're going to go through some of the causes that can cause these athletes or even older patients to have this kind of radiating shoulder pain. What to think about. So naturally, we're going to go cover thoracic outlet syndrome, suprascapular neuropathy, some scapular problems, whether it's dyskinesia or weaning, quadrilateral space syndrome. And then obviously, whenever you're thinking about radiating shoulder pain, hand pain, elbow pain, you always have to think about cervical radiculopathy. So real quick, though, just to kind of give you some background about the shoulder and why I think it's the most fascinating joint in the body. Well, partly it's because it has so many planes of motion, and partly it has so many articulations that contribute to all these different planes of motion that are able to withstand such incredible forces. So if you look at the normal shoulder versus a shoulder that has a massive rotator cuff tear, you can see how much the scapular thoracic joint is moving, as well as the actual glenohumeral joint itself. And you can see in this patient that has a massive rotator cuff tear how it translates up, and you're really just dependent on only scapular thoracic motion. There's really no glenohumeral motion that's happening in this. And this is what comes to the idea of this shoulder joint. So the shoulder joint consists of not only the glenohumeral joint that we all focus on, we all talk about with regards to the rotator cuff and instability in the labrum, but also the scapular thoracic joint, as well as the AC and SC. But really, the scapular thoracic joint, as you can see, this dynamic floor of a normal shoulder, it contributes a huge amount to elevation, a huge amount to abduction, a huge amount to internal and external rotation. So when you're thinking about patients, when you're rehabbing patients, and when you're approaching pathology, it's not always glenohumeral pathology that you're dealing with. So on this topic, and kind of going into thinking about some of these syndromes that are associated with plexus and some of this radiating shoulder pain, I'm going to give you sort of a quick background on brachial plexus, on some of the syndromes that are associated with it, and then kind of go into both anterior and posterior radiating shoulder pain. So the plexus, as many of you know, it supplies the whole upper extremity. So from the shoulder all the way down to the fingertip, from C5 to T1, there's many different trunks and branches and cords. This is a case study of a patient who presents after a shoulder dislocation with an inability to move or shouldn't move the shoulder. And that's really what, besides a car crash, this is another very common situation where you have a patient who presents after dislocation, especially in older patients, and all of a sudden they can't move their shoulder. So this patient is under 40, naturally, and they dislocate their shoulder. You're going to work it up like you would with many of the football players and other athletes that you see. You're going to get an MRI. You're going to suspect a labral or a glenoid injury. But if they're over 40, you're really thinking more of like a rotator cuff injury or actually a nerve injury. And naturally, you start out with MRI, but these younger patients, especially those less than 40, you'd want to get an MRI arthrogram and then consider something like a Bancard or a Latter-J. But in these older patients, or maybe it's a younger patient that has a pretty severe football injury that's associated with dislocation, you're thinking about either a rotator cuff injury or, even more relevant to this discussion, a brachial plexus injury. So these brachial plexus injuries can be traumatic. So it can be these low-energy stingers that many of you have probably seen and evaluated. They can be high-energy, like car accidents or these shoulder dislocations I showed you earlier. Or in Atlanta, we're lucky enough to see a lot of iatrogenic or penetrating brachial plexus injuries. The plastic patterns are either a shoulder injury, so a shoulder or elbow weakness, as in the upper trunk, or hand weakness in a lower trunk injury. And the treatment, not really relevant to this discussion, but you'll work them up with EMGs, myelograms, MRIs, sero-examinations. There's various different treatments you can do for these, whether you're talking about nerve grafts or transfers, even tendon transfers. But why I bring up brachial plexus injuries and the whole idea of brachial plexus is when somebody shows up and they can't move their shoulder or they have significant weakness in the shoulder, you think about the brachial plexus, you think about brachial plexus injuries, naturally, if they're older, the massive rotator cuff tears are an important consideration. But this is also an important consideration. So Parsonage-Turner or brachial plexus neuritis, Parsonage-Turner is thought to be associated with an upper respiratory illness. So often, patients will have a viral URI, and then shortly after this viral URI, they'll have this sudden severe shoulder pain associated with gradual onset of muscle atrophy without any obvious injury, meaning that they all of a sudden can't move their shoulder. And now they're showing up and they didn't have an injury, they weren't in a football accident, they weren't in a car accident, yet they can't move their shoulder. Maybe it's their scapula, maybe it's their actual shoulder itself, but some aspect of the shoulder, usually their shoulder, it has some sort of dysfunction. Like I said, many patients have that history of viral URI, but not all patients. So sometimes you get lucky and on MRIs, you'll see this hyper intensity of the muscle, like in this Terry's minor. Now this could also be quadrilateral space syndrome, but nonetheless, this does help to confirm this diagnosis, because naturally this is diagnosis of exclusion. And ultimately, what's so hard about Parsonage-Turner is most patients recover, but it sometimes takes years, at least one year. 90% of patients by one year do fully recover. But in the meantime, patients actually are not going to be patient, they can't move their shoulder, they can't move their scapula, they can't move their arm, and they have marked dysfunction. Surgery is quite controversial, not something that I'm sort of going to go into in this, but really when you are treating these patients, it's really sort of maintaining what motion they have and trying to help their scapula, their rotator cuff, whatever it is that's paralyzed to really recover. All right, so now I'm going to get to the more the meat of the conversation, or meat of our talk. So we're going to talk about anterior and posterior radiating shoulder pain. Do you have a patient that shows up and has anterior radiating shoulder pain? There's multiple different things you can think about. Thoracic outlet syndrome without question is one thing that's previously thought to be relatively rare. I think we're realizing it's actually more common than you think. Pectoralis minor syndrome, which is basically like thoracic outlet syndrome or neurogenic thoracic outlet syndrome, but just really isolated to the pectoralis minor. And then naturally the AC joint can have radiating pain all over the place. Christian Gerber did a really nice study kind of showing the different manifestations of AC joint pathology. Bicep synoptic can make the patients feel like they're having pain kind of going up and down their arm. And then obviously any type of cervical or deep is an important concern. But we're going to talk about thoracic outlet syndrome or pectoralis minor syndrome. So for TOS or for thoracic outlet syndrome, vascular thoracic outlet syndrome is sort of one of the classic things that we used to think about, that we used to always talk about, and that we used to always sort of approach and treat. So vascular thoracic outlet is these vessels are emerging underneath the clavicle, between the clavicle and the first rib. They also have associations with the anterior middle scalene. Most of the time when you have vascular thoracic outlet, the symptoms are in the hand, not the shoulder. And patients have this renewed type of symptoms. So this quadrication in their hands. An angiogram or an MRI will show some narrowing of the actual vessels, especially if you do the provocative angiograms. And this test, the ADSEN test, has been thought to reduce the radial pulse when you extend the arm to the defective side, basically compressing the clavicle against the vessels and the first rib and inhaling deeply, trying to sort of compress those vessels and see if you feel reduced radial pulse. I'm going to talk about neurogenic thoracic outlet though, because really neurogenic thoracic outlet is the most common. Many studies have suggested 95 to 98% of patients who have thoracic outlet actually have neurogenic thoracic outlet. I think that number is probably even higher as we're learning more and more about this pathology. So you can either have compression within the interscaling triangle, it's a little bit less common, or more commonly below the pectoralis minor. So most of these patients will have anterior shoulder tightness. They'll feel like their shoulder is kind of, or their scapula is kind of protracted around. Many will have scapular dyskinesia. Many also will have radiating pain and parathesis. Now, not all of them have radiating pain and parathesis, but many of them do. Usually it's associated with repetitive overuse, particularly overhead athletes. The most common I've seen are softball players, volleyball players, basketball players, gymnasts. It's repetitive overuse of overloading or loading their front part of their chest. You know, weightlifters also have a big issue with this. And the examination, I'll go through this in a little bit more detail, but often the scapula won't move perfectly normally. They'll have tenderness either in their scalene or at the medial to the coracoid, right near the pectoralis minor insertion. And often they'll have a positive suprascapular stretch test. And I'll show you what that is in a second. So these are the different described examination maneuvers that have been classically described in the vascular surgery literature. So the adsense test, as I mentioned, for neurogenic thoracic outlet, you extend it to the affected side, you inhale deeply, and you see if you have pain radiating down the arm. The roost test is where you externally rotate and abduct. You pump the hand for three or four minutes, and then you see if the patient's had worsening symptoms or rapid fatigue. The right test is where you externally rotate and abduct the arm to 180 degrees. You inhale deeply and you see if you have radiating or worsening pain. But these all have high false positives. And if I can be frank, I actually don't really use them that much. I do look at them, but I don't consider them as the make or break in this diagnosis. This is an example of some of the examinations I like to use. So tenels in the interscaling triangle, tenels at the coracoid or just medial to coracoid. This is kind of the arm extension and stretch test for the pectomyosin minor and suprascapular nerve. This is the suprascapular nerve stretch test where you're kind of stretching the arm back. And then obviously looking at the scapula. And this is looking at the scapula, and you can see it's a little bit subtle, but she has this dyskinetic pattern where her scapula is not rotating properly, and it prevents her from lifting her arm up all the way. There's multiple other measurements that you can do. So the pectorals minor index is where you measure from the coracoid to the fourth rib, basically measuring the length of the pectorals minor. And then you divide it by the patient's height and you multiply it by 100. This is a way if you do it contralaterally, if you have sort of a 10 to 20% decrease, that's thought to be associated with the pectorals minor tightness or pectorals minor syndrome. You have scapular protraction height, the medial scapula angle, and the medial scapula height, all these different measurements that you can use to kind of help confirm that one side is different than the other, the scapula is not moving the same, and you have these sort of abnormalities within the scapula that you can sort of try to quantify. To diagnose it, really, you can look at a brachial plexus MRI, and we do get those. EMGs are important. And sometimes with POS, you actually see not necessarily the classic antebrachial cutaneous nerve that people describe, but actually more commonly, you'll see suprascapular neuropathy that presents in these patients. So the suprastenous and amphibious have some innervation problems. And then diagnostic injections are without question the mainstay to both diagnose and at least start treatment on this. So these diagnostic injections, you can see here, this is provided by my partner, Robbie Bowers. New York John P. and Kim Mounter also contribute. But as you can see how Rob was able to demonstrate the petrous minor with the vessels and the nerves surrounding the vessels underneath it. You can see as you move over to the coracoid, once again, you can see the vessels and the nerves kind of underneath it. And this video kind of really nicely shows the petrous minor going right over the top of the brachial plexus with these nerves and obviously the axillary artery just underneath it. So it kind of shows why it could get compressed and why this often can be an issue. This also is a nice dynamic video where you can kind of see it moving from adduction to abduction, how you can have compression of these nerves, particularly against the ribcage, particularly if that petrous minor is a little bit overactive. So how do I diagnose neurogenic thoracic outlet? Well, tennels or tennis palpation at the medial to the petrous minor, a positive stretch test, so bringing the arm behind and kind of stretching the petrous minor against the chest wall. Scapular dyskinesia or some sort of abnormalities within the scapula. A positive response to ultrasound guided injections within the petrous minor and or the suprascapular notch and a negative vascular angiography and an EMG workout that maybe will localize to the suprascapular nerve, but really won't show any signs of super cervical radiculopathy or anything else that shows of compressive neuropathy. When you refer patients to therapy, this unilateral corner stretch is one of my favorites. It really stretches out the petrous minor, stretches out that anterior chest. You also wanna do some scapular strengthening, postural correction. Remember when you do these things, deltoid and rotator cuff strengthening actually can make it worse. It actually contracts the anterior chest down potentially more, it won't necessarily help. This is really more of a scapular and kind of chest wall phenomenon. Really important to focus on the scapula, really important to retrain that scapular humeral rhythm. So coordinating the scapula and the humerus to basically work together and kind of move together without that kind of bumping disconnect pattern. And there's multiple different therapies that you can think about. So the scapular retraction, sleeper stretch, seated push-ups, butterfly seated. These are some of the ones I think are really helpful and really useful. There's many other ones that you can consider, but they're all about stretching and strengthening your scapula, your scapular humeral rhythm and kind of this coordinated retraining of how these patients move their shoulders. I really like, TLSL patients don't actually really like that much, but I actually really like these figure of eight braces. So this is what we traditionally used to use for clavicle fractures, but you can get these figure of eight braces very cheaply off the internet or at most brace shops. And it kind of really helps to hold the scapula back, hold the patient's posture and really kind of improve their scapular humeral mechanics. One quick note. So scapular winging or scapular dyskinesia are not necessarily automatically neurogenic thoracic outlet syndrome. So I know I was talking about this idea of scapular winging a lot, but I want to sort of mention this, that as you can see in these two certain circumstances, so psoriasis anterior or long thoracic palsy, you can see in this young lady, her scapula is basically paralyzed. It's no longer able to be protracted against the chest wall and you can see kind of how it pops out and she was very, very limited in how much she can use it. The trapezius paralysis or spinal accessory paralysis, you can see he lost all of his external rotation of his scapula. So he's unable to lift his arm because he lost his external rotation. Instead, the scapula just rotates around the body and no longer does he have the scapular external rotation. So you think about this as lateral and medial, but it's really a loss of retraction against the body and a loss of lateral or a loss of external rotation of the trapezius. You can treat both these with a pectorals minor transfer, sorry, pectorals major transfer or the triple transfer. And just really quickly, I know this is a little bit outside the topic of this, but this is an example of scapular winging different from scapular dyskinesia. So this is a patient, 18 year old with scapular winging, shoulder pain for about a year and a half. She had a fall during cheerleading. She was significant pain, significant winging and had failed extensive shoulder scapular therapy. She was even being considered for a labor repair, but naturally this wasn't really her main cause and ultimately did not undergo that surgery. Her shoulder spectrum was 10% and she really, really was quite limited with this. And you'll see on this video how limited she was. So her trapezius and rhomboids were intact, but she really was not able to lift her arm because her scapula sort of lost that retraction against the chest wall. She had normal chondrology and she didn't have any signs of Ehlers-Danlos syndrome or any other hyperlaxity. But you can see here, she has this like scapula that's protruding out and is unable to be sort of stay against the chest wall because her serratus anterior is not working very well. You can see here, I'm testing the strength of her serratus anterior by having her push against it. And you can see on the other side, she's very strong, but on this side, she has basically no strength. And this is a really uncomfortable test for patients, but this is me holding the scapula reduced against the chest wall. You can see I can completely correct her ability to elevate her arm. Basically, I'm doing the function of the serratus anterior. You can see in these images, they're basically normal x-rays, normal images, although you could see why one of the surgeons thought she potentially had some posterior labral instability. Her brachial plexus MRI was basically normal, but her EMG did show some long thoracic rhythms. And so you have this patient who has a long thoracic denervation, no open injury, but likely a blunt or stretch trauma. So what do you do for this patient? Well, she had been referred to a sports psychologist. She'd been referred to a variety of other people as sort of a brother to the other surgeon to bounce around for a bit. Ultimately, we did decide to actually treat this with a, after an intraoperative EMG showed that there was no simulation. I'll just show this quick animation. So we did this sternal head of the pectoralis major transfer. So you take off the clavicular head, you then pass the sternal head of the pectoralis major back basically right next to the chest wall. And you can kind of imagine how it mimics the serratus anterior. And then you attach it in. So once again, you kind of see how the sternal head can mimic the serratus anterior. You attach it into this inferior angle of the scapula, reattach the clavicular head of the pectoralis major back to its insertion. You can kind of see the ultimate outcome. So you still have the clavicular head. So you still have that contour of the anterior chest wall, but the sternal head is now attached to the inferior angle of the scapula, as you can kind of see here. We wrote about this and looked up this study showing very good overall outcomes with this transfer. And you can see in this patient, so preoperatively versus preoperatively, we were able to use this transfer to basically correct her shoulder. Now you can see how her scapula moves. She's able to lift her arms completely overhead. And she really doesn't have any limitations. She was able to go back. She's now in college now. She's not actually competitively cheering, but she was able to go back to doing a variety of different activities without any real limitations. All right, so moving on to posterior radiating shoulder pain. So when you think about posterior radiating shoulder pain, there's a couple of things I want you to sort of have in your mind. Naturally, cervical radiculopathy. So if you have anything in your neck, it can cause anterior shoulder pain, it can cause posterior shoulder pain, cause pain going down to your elbow, down to your hand, but also consider the suprascapular nerve entrapment. You can also consider a little bit more rare, quadrilateral space syndrome, and then naturally problems with the scapula. So dyskinesia, winging, or even bursitis, capillaries and bursitis. And naturally, the AC joint really can be associated with a variety of different issues, including posterior radiating shoulder pain. So suprascapular neuropathy, and you probably have heard about this, but potentially maybe not as much as it maybe do, given how common, or relatively common, this actually is turning out to be. So suprascapular neuropathy, the suprascapular nerve goes through this really tight space, this really tight ligament, and it travels into the suprascapular, or the supraseus fossa, and then the infrasense fossa. So you can imagine the only other two places in the body, you have a ligament traveling, traveling under a tight ligament, is the carpal tunnel and the cubal tunnel. So we have entrapment, and very, very common entrapment in both of those. You can imagine you also have entrapment in this situation as well. So suprascapular nerve comes from C5 and C6. It innervates the suprasthenaeus and the infrasthenaeus muscles. And often these patients will have a deep, kind of medial shoulder pain. Sometimes they'll have a radiating posterior shoulder pain. Sometimes they'll have a weak suprasthenaeus and infrasthenaeus, but really it's more the deep, kind of radiating posterior shoulder pain. Because this nerve is both a motor and sensory nerve, and the sensory component of it travels through the bursa around the posterior aspect of the shoulder. To diagnosis, diagnostic ultrasound-guided injections are without question the mainstay of treatment for this. Robert Bowers and many of my colleagues are very, very good at this, very skilled at this, and they are able to visualize the nerve coming through the notch and then inject lidocaine plus steroids and potentially treat, but even more commonly, diagnosis. And just like you do with a guided injection into the carpal tunnel or cubital tunnel, you can really diagnose this pathology based off of these injections. When you think about suprascapular neuropathy, you want to think about the spinal glenoid notches that's often associated with a posterior labral injury. But even more commonly, the suprascapular notch or this entrapment at the suprascapular notch, I think is even more common than that spinal glenoid notch. So once again, you want to do a variety of different therapies and very similar to the pectoralis minor, scapular strengthening, stretching, postural correction, stabilizing your scapula, correcting your posture and your scapular humoral rhythm, and really focusing on your ability to sort of correct your mechanics of your shoulder. But this is particularly important for athletes and often we'll have athletes do whatever sporting event that they're doing in these figure eight braces to really kind of focus on correcting this and getting their mechanics and their motion back. And then these are, just like, as I mentioned earlier, some of my favorite ones, literally focusing on the scapula. There's many other ones as well. So suprascapular neuropathy can be treated arthroscopically as well. And actually, that's not the point of this test, but this does kind of show you that this ligament, it kind of gives you a visualization of why you'd have an issue with suprascapular neuropathy. So you can see the ligament, you can see us cutting the ligament with these arthroscopic scissors, and you can see this nerve coming in through the ligament. And you can kind of imagine why this nerve would be compressed in this really tight space underneath this ligament. So quadrilateral spasmodic syndrome. So this is another one that you want to consider when you have posterior radiating shoulder pain. It's a little bit less common than something like suprascapular neuropathy, but nonetheless, it's something to consider, particularly when to isolate to that posterior axillary fold. So really for athletes, it's those pitchers or the overhead athletes that get this. Often it's males and often it's weightlifters or relatively bulky patients. This is where the axillary nerve and the posterior hemocircumflex artery travel through the teres minor, teres major, and the triceps. And you can kind of see the anatomy here. So you have your teres minor, you have your teres major, and you have the axillary nerve traveling through this tight space here. And then the axillary nerve wraps around naturally and innervates the deltoid. So often patients who have pain in that posterior axillary fold, they'll have this posterior radiating shoulder pain around their shoulder. And it gets worse with abduction and resisted external rotation. So this shows an example of this posterior axillary pain. So right in that posterior axillary fold, patients will have pain there. They have pain with resisted abduction external rotation. So you're getting the teres minor to fire and they have pain when they're firing the teres minor because it's compressing that axillary nerve. And then naturally they have a right of weakness. Once again, that posterior axillary pain that the patients are having. So sometimes you'll get lucky when looking at this and sometimes you'll get an MRI and you'll actually be able to see this cyst that's sitting in the quadrilateral space. Now, not always. Not always are the patients MRI positive. And sometimes you'll get lucky with the EMG and show denervation at the axillary nerve. Once again, not always. When you treat this, you really want to focus on the rotator cuff. You want to focus on the scapula and really the ultrasound guided injections are the mainstay of both the treatment and the diagnosis. So you want injections. You want patients to get better with injections to confirm your diagnosis. But also often these injections will treat this pathology. It'll help with some of the inflammation that's around the serve. And surgery really is only an option once you've failed extensive amount of both physical therapy and injections. And it's not something that we like to jump to at all very quickly in this. So as we stated earlier, you really want to focus on the scapula and the scapular humoral rhythm. Now I'm going to show just a quick case study of this. So you have this patient that is a power lifter, worsening pain over 10 years. The pain is no prior injury, but the pain's located in the posterior axillary fold. It radiates around the shoulder posteriorly. He is a chronic methadone user and thus has been pushed around for the last couple of years. Basically told that he doesn't have anything wrong with him that's in his head, and he said he's a chronic pain user, et cetera, et cetera. His shoulder surjective is 5%. His VHS score is a nine to a 10 out of 10. He works in construction and he does like power lifting. You can see, and he gave me a position to show you this. So he has pain with a resisted abduction and external rotation. You can see it's quite painful, most motion in the shoulder. This guy was actually painful around his pec minor on the anterior part of his shoulder. As you can see when I tapped there and when I pushed. You can see how his shoulder is almost kind of rotated around or his scalp is rotated around and kind of protracted. You can imagine how the pectoralis minor kind of being tight would cause this. And you can see how he's relatively limited in what he can do based off his pain. He has tendons palpation not only at the pectoralis minor, but he also has tendons palpation at his posterior axillary fold. And he has pain, as you saw earlier, with resisted abduction and external rotation when he's in 90 degrees of abduction. In general, his imaging was relatively normal. His plane radiographs showed no real abnormalities. There wasn't much labeled faulty, maybe a small, subtle slap tear. But this is the gentleman who had this cyst that you can see that was sitting in his posterior in his quadrilateral space. And just because you see a cyst in the quadrilateral space does not necessarily mean that's the diagnosis. But it is important to combine that with an injection, with an EMG, and see if there actually is denervation, and see if there actually is response to the injections. So this guy got very good relief from the quadrilateral space injection. So if I say, if you get greater than 50% relief from that injection, I can say that a positive response. He got very good relief from the pectoralis minor injection. So he got 85% relief from that injection, but nothing from the suprascapular nerve. And then before getting to me, he had multiple subacromal injections and clonohemo injections that did not give him relief. So what do you do in this methadone, chronic methadone user, who has what appears to be some pathology associated with the pectoralis minor and his quadrilateral space? Do you continue with non-operative management? He's already seen multiple psychologists, including being seen in the pain clinic, or do we release? And we ended up not just releasing the quadrilateral space, but actually also his pectoralis minor. And not necessarily going into surgical technique of this, but this kind of shows, not all of these patients are crazy. Now, we definitely have plenty of these patients who are, you know, there is a significant psychological component to this, but sometimes they actually have these real pathologies that really can do, and you can see at two weeks, he was already weaning off methadone. I don't have the eight week video, but at eight weeks, you know, he was basically back to almost normal. And this is after 10 years of dealing with this. So some of these patients do have real pathology and they do have something that can be treated. So sort of before I go into this final thoughts, I hope you're getting a sense that we're kind of talking about a variety of different pathologies, ranging all kind of around the brachial plexus or branches off the brachial plexus, associated with scapodiskinesia, thoracic outlet. They're kind of all tied together in a lot of respects. And that's what we're kind of learning as a field is how these all can be kind of tied together and how they're actually not as uncommon as we think, and how that many of these can be treated both without surgery and with surgery. So once again, when you're thinking about these patients with radiating shoulder pain, whether it's radiating anterior shoulder pain or radiating posterior shoulder pain, obviously you want to think about their neck. Obviously you want to make sure they don't have some sort of cervical problem, cervical tracheopathy. Particularly in these young athletes though, you want to think about, is this a neurogenic thoracic outlet? Is this a compression of the nerves as they travel underneath the pectoralis minor? Is this a suprascapular neuropathy? Is this something of this tight ligament, that tight space where that nerve is traveling under just like the carpal tunnel and cubital tunnel? When these are compressive neuropathies that we don't talk about all the time. Is there something else like the quadrilateral space or partial insurer that's contributing to this patient's pathologies? So here's an example. I talked about this at the beginning. So a 20 year old female that has pain, paresthesias and weakness. She gets worse with over activities. She has pain that radiates down her arm. So this has been going on for a little over a year. Her shoulder subjective value is 25%. She has tried extensive, both injections and physical therapy, including I want to say somewhere between three and six months of therapy with a therapist that I personally work with on a regular basis. She is a collegiate softball player, but has been really limited and had to sit out her sophomore season. And once again, you've seen this, or I showed this video earlier, but she has a positive TNLs at her pec minor, but not at her scaling. She has a positive stretch test, as you can kind of see here. She did have a positive suprascapular not stretch test as well. She did not have any signs of neurogenic, I mean, of vascular thoracic out syndrome, but she did have some signs of neurogenic thoracic out syndrome and some scapular dyskinesia, or just some irregularity or asymmetry when you look at both scapulas and how they kind of moved. Imaging was basically normal. She was referred to me by one of my sports colleagues who had diagnosed her with a slap tear. I was actually considering the slap repair, but didn't really feel like her symptoms matched the slap pathology. On EMG, she did have some signs of supraspinatus and infraspinatus denervation. Now they still work, but they were being slightly denervated. So she did have some signs of suprascapular neuropathy. Her CT angiogram and her TS protocol was basically negative. Her brachial plexus MRI was negative and her C-spine was negative for a pretty extensive workout. Now, so we do this extensive workout for her, but then we also do an ultrasound guided injection to a supraspinatus and into her pectoralis minor. So Dr. Byers did both of these, gave a very good relief with the supraspinatus and with the lidocaine only injection into the pectoralis minor, she got 75% pain and functional relief. And I called her that night, I call most of these patients the night of, asked them to do a variety of different activities to ask them to see if they actually get relief from these injections. And she did. So what do you do for this patient? Well, there's a variety of different options and there's a variety of different considerations in what her actual diagnosis is. But I'm just gonna show you this quick surgical video. I realize that this is out of your realm of what you're concerned about, but I do want you to see this because it helps you to see not only the supraspinatal relief. So this is the suprascapular notch. And this is, look how much inflammation is around that ligament. So there's the ligament kind of coming across here. And this is all the inflammation around there. And you can see we're using these tiny little fancy arthroscopic scissors to clean off and eventually cut that ligament. But once again, see all this information around her actual nerve. And this is a 20 year old collegiate softball player. You can see that we were able to release the nerve and you can see how open her nerve is and how much inflation you can imagine how much, why she'd have compression of that nerve in that area. And then once again, you can see her nerve being nice and released. So now this is at the supraspinatal notch. Now, just as you do with an older son, you go from the back of the coracoid, which is at the supraspinatal notch, where you visualize when you're doing that injection. And you're moving all the way to the front part of the shoulder. So basically from the kind of the back part of the shoulder to the front part of the shoulder. And now you see, we kind of turn the camera and looking back down into the shoulder. So this is looking at the front and down back into the shoulder. This is your CA ligament. This is your coracoid. This is your conjoint tendon. So now I'm exposing the, from the conjoint tendon, the pectoralis minor. So the pectoralis minor is over here on this side, kind of deep inserting onto the conjoint area. Deep inside here, you can see the pectoralis minor inserting onto this coracoid. So here arthroscopically, we're releasing the pectoralis minor off of its coracoid. You can see you do this kind of carefully because naturally there's some very important vessels and very important nerves right underneath it. But you have this really nice visualization doing it arthroscopically. And I would submit to you, it's much safer to do it arthroscopically than open, much lower risk of complications. You have much better visualization. You can see this is, the pumping is the axillary artery, the nerves, the brachial plexus all around there. You can see the pectoralis minor and how far it's actually retracted back from the coracoid. So you can kind of see here, you know, you had the coracoid over here and the pectoralis minor has not only been released, but retracted all the way back. So it kind of shot like a slingshot all the way back. And I can't even bring it back into the coracoid. So you can see this patient did quite well. Two weeks afterwards, her pain was basically gone. We just let her start moving. Eight weeks afterwards, pain was gone. Her shoulder trabectomy was 85% back from, if you remember, I believe it was like 10% preoperatively. And then by 16 weeks, she was already back playing softball. And you can see it's around Christmas time, but she was already back playing softball. She had sent me multiple videos and multiple pictures of her playing third base and was able to get back. And now she currently is playing, well, up until coronavirus was playing softball. So I'm going to kind of leave you with a couple of things. One, if you're approached with a patient that has a paralyzed shoulder, meaning that they can't move their shoulder, whether a young patient, an older patient, somewhere in between, you think about brachial plexus injuries, especially that upper trunk, C5, C6, C7, brachial plexus injury. If they don't have a history of an injury, think about Parsonage-Turner syndrome. As this is and does happen, now, it doesn't always last a year, and often it'll resolve relatively quickly, but sometimes it does last up to a year. And it is important to consideration when you're thinking about a patient, particularly with a history of severe shoulder pain without a specific injury. And naturally, you want to think about a massive rotator cuff tear, particularly those that are irreparable, can really mimic these brachial plexus injuries. If you have anterior radiating shoulder pain, you can think about thoracic outlet syndrome. And that's really, if I see a patient with anterior radiating shoulder pain, and it's not biceps, meaning it's not in their biceps, it's actually like more chest or anterior part of their shoulder kind of radiating down their arms, you think about thoracic outlet syndrome. You can naturally always think about cervical radicular update, because all of these can be mimicked by cervical radicular update. But nonetheless, thoracic outlet syndrome is important, and I think much more common than we realize consideration, particularly in these athletes, particularly in overhead athletes. And then finally, posterior radiating shoulder pain. So a patient has pain that's either medial in their shoulder, or medial in their shoulder that kind of radiates posteriorly. Think about the suprascapular nerve, as I showed you on those surgical videos and some of those diagrams. I mean, it's a tight, tight canal that it travels through in the suprascapular notch. You can think about quadrilateral space syndrome. Now that's much less common, but the axillary nerve as it travels between the teres minor and teres major, you can imagine it can rest back there. And then you think about scapular dyskinesia or scapular winging. Naturally, scapular problems can drive or can be symptoms of many of these other problems. They're important to consider. When you're examining a patient, I employ all the residents and all the fellows that work with me. Make the patient, whether it's a female, make them take off their shirt and put in a gown, or it's a male, make them take off their shirt and please look at their scapula. So many patients get misdiagnosed because nobody ever took the time to look at their scapula and to see if their scapula was actually contributing to some of these pathologies. So if I can teach you anything or encourage anybody who's listening to this, anything from this talk, it's pay not only attention to the rotator cuff that we talk about all the time or the labrum that we talk about all the time and that are very important and relevant, but think about some of these other pathologies and particularly look and think about the scapula as a contribution to a lot of the different, especially kind of unique or chronic pathologies that people have not been diagnosed on before. So I'd like to thank you for your time. This is my cell phone. Please feel free to text me or email me with any questions. This is also my email address. Please feel free to reach out to me if you have any questions or any comments. I'd love to talk to you more. I can send you articles. I can send you our therapy protocols. I can send you Dr. Bowers and my protocol for how to work up and diagnose thoracic outlet syndrome and variety of these other policies, as well as happy to weigh in my opinion on anything. So please feel free to reach out to me and don't hesitate. So thank you very much for your time. And I guess I'll turn this back over to Robert Bowers or Dr. Bowers. Thanks, Eric. That was great. You know, since I started working with Dr. Wagner, I've learned so much about thoracic outlet syndrome and some of these different conditions and how much more common they are than what we previously believed. And because of working with him, a suprascapular notch injection is now in my toolbox of something that I use very, very frequently for shoulder pain and shoulder patients. So I've just learned a ton since working with him. Now, with that said, we've got a couple of questions in the chat and Dr. Wagner, they are directed for you. You can take this first one. Yeah. And let me go back to the chat. Where'd it go? Hold on a second. I lost my... Chat function there. Well, this is, give me one second. Okay. So the first question here is, so when you do, and it's about the injection protocol that we use, when you do a pec minor and a suprascapular notch injection, do you do them sequentially or at the same time? And then following that up, if you do them sequentially, how far apart do you space them? And do we use steroid or other drugs or do we use steroid or just anesthetic? Yeah, no, wonderful, wonderful question. Absolutely wonderful question. And if you look in the literature, there's lots of variability on this. So we have a standardized protocol. Happy to send out to anybody that's interested and I'm sure Dr. Bowers would also. So what we do is, depending on their pain, depending on their presentation, let's say you come in, you think they have thoracic outlet, they have pain, they have tenderness around the coracoid, maybe they have a kind of medial or posterior radiant shoulder pain, maybe they don't. We start out with a suprascapular notch injection with lidocaine and with corticosteroids. An idea with that is, do patients get immediate relief or do they get some sort of sustained relief? Just like you would with a carpal tunnel or a cubital tunnel injection. Then a couple of weeks later, so somewhere between two and four weeks later, depending on Dr. Bowers' schedule, depending on the patient's schedule, they will have a lidocaine only injection into the pectoralis minor. And the idea is a lidocaine only injection. We're not necessarily trying to treat the pectoralis minor issue with that because naturally the whole brachial plexus is underneath it. You could argue maybe we could throw in some steroids, but I just don't believe that steroids really would do that much to it. It's a contracted muscle, it's a tight muscle, it's not really inflammation like the suprascapular notch. And so we do lidocaine only and then Dr. Bowers texts me and tells me a patient that he did this injection. And usually that evening, potentially even the next morning, I will reach out to the patient, ask them to do a variety of different maneuvers, whatever it was that was replicating their pain and ask them if they got pain relief from it. And like I said, 50, 60% or greater pain relief being able to do these different maneuvers in my mind is a positive response. We are currently exploring the role of like Botox and if you Botox pectoralis minor, does that help to diagnose it? I can't imagine it really helps to treat it. Lots of studies have shown that doesn't really work so well in treating this, but there's not been as much in the diagnostic algorithm. And we're in the process of refining this diagnostic algorithm as there's not a lot of really good science behind this. If you notice, I didn't quote a lot of studies partly because there's not just like really good science behind this. Traditionally, this is a vascular surgeons sort of approach and the vascular surgeons would take out the first rib, they do this big scalenectomy, they do this kind of transacular where they go up through the armpit. And you can imagine all the sort of complications, 25, 30% complication rates with these surgeries. So this is something that like, if I can be frank, has not been really scientifically investigated thoroughly at this point. And I hope over the next five, 10 years, you're gonna learn a lot more. I showed you some of what we know, but hopefully we're gonna know a lot more in the next decade or so. Great. Anything else to add to that, Bauer? Yeah, the only thing that I would add is that I've played around with the different volumes to use for the PEC minor injection. And then also have not just lidocaine, I've put some ropivacaine in it too, just to get a prolonged response, just to kind of let it, since Dr. Wagner will contact them later that night. And so, but from a volume standpoint, played around with something between 10 and 15 CCs. If you look in the literature, I mean, there are some that know a much larger volume than that, but usually we'll do around 10 and 15 CCs. And then from a suprascapular notch standpoint, I've thought of using more volume, but generally use around five CCs. They're just a mixture of local anesthetic and not a lot of corticosteroid, just use the half CC of dexamethasone typically. So that's really the only thing I'll have to add. And that was the main question that we had. I don't see any others in the chat function. So we'll let everyone go and enjoy the rest of their evening. So thanks again to everybody for attending this installment of the Fellows Online Lecture Series. If you are able to, please go to the chat function and click on the survey monkey and fill out the feedback form. That would be outstanding. Otherwise, just remember the next installment is November 24th on sports psychology, and we will see you then. Thanks so much, everyone. Thank you guys. Have a wonderful night.

3rd Edition, CASE 38

3rd Edition

Neurology

neurogenic thoracic outlet syndrome

brachial plexopathy

radiating shoulder pain

diagnosis techniques

scapular dyskinesia

injection protocols

non-surgical treatments

orthopedic surgery