Lateral Arm Numbness and Weakness: Consider Axillary Nerve Dysfunction

At the Centeno-Schultz Clinic we acknowledge that shoulder pain can compromise quality of life and athletic endeavors.

Our online book, Ortho 2.0 highlights a systemic evaluation of joint pain and dysfunction.  The approach is termed SANS.

The N is SANS denotes nerve dysfunction.

Axillary nerve dysfunction can be a cause of lateral arm numbness and shoulder weakness.

The Axillary nerve arises from the posterior cord of the brachial plexus, C5 and C6.

Course:  It crosses the antero-inferior aspect of the subscapularis muscle, passes behind the arm through the quadrilateral space, winding around the neck of the humerus ending in two major trunks:  anterior and posterior trunk.

Innervation:  Teres Minor and Deltoid

Sensory: Lateral deltoid also known as the regimental badge area.

Injury can occur at several sites along the nerve path:

Origin of the posterior cord

Anterior-inferior aspect of the subscapularis muscle

Quadrilateral Space:

The quadrilateral space is bounded superiorly by the teres minor muscle, inferiorly by the teres major muscle, medially by the long head of the triceps, and laterally by the humeral shaft.

Common presentation is dull intermittent ache or pain that is localized in the posterior and lateral shoulder.  Symptoms are exacerbated by active and resisted abduction and external rotation of the humerus.

Quadrilateral space syndrome is an affliction of middle-aged men and it presents classically in the throwing athlete and those with a history rotator cuff surgery.

Ultrasound examination is can be significant for atrophy of the teres minor muscle which is illustrated below.

 injury at several sitesgin from the posterior cordAnteroinferior aspect of the subscapularis muscle and shoulder capsuleQuadrilateral space

Suprascapular Nerve: A Key Player in Shoulder Function and Pain

At the Centeno-Schultz Clinic we understand shoulder pain.

Stem cell treatment is an alternative to traditional shoulder and rotator cuff surgery.

The suprascapular nerve is a key player in shoulder function and pain.

The suprascapular nerve is derived from upper trunk of brachial plexus typically C5 and C6.  It contains both motor and sensory components.  The sensory branches innervate the GH and AC joint whereas the motor branches innervates the supraspinatus and infraspinatus muscles

The suprascapular nerve runs lateral and beneath the trapezius and enters the supraspinous fossa through the suprascapular notch.  The suprascapular notch or referred to as the scapular notch is a notch in the superior border of the scapula through which the suprascapular nerve descends.  The supraspinous fossa is a concavity above the spine on the dorsal surface of the scapula that gives origin to the supraspinatus muscle.

MSK ultrasound is utilized to identify the nerve and any possible entrapment which can lead to pain and or weakness.

Sites of entrapment and clinical presentation will be discussed in future posts.

Ablation of the nerve utilizing radiofrequency has been described by Liliang as an effective treatment in the management of chronic shoulder pain.

Upshot:  the suprascapular nerve and its visualization is critical to the successful management of shoulder pain.

Thumb Arthritis Treated Successfully With Stem Cells

At the Centeno-Schultz Clinic we acknowledge the pain and restriction in range of motion associated with thumb arthritis.

Is there medical evidence that surgery for thumb arthritis is better than no surgery?  NO!

The latest large review of medical studies by Wajon contained little information that compared thumb surgery to non operative treatments.  Of note was the fact that participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects.  Adverse effects included  scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome.

Have stem cells been used successfully?  Yes!

Stem cell therapy is an alternative to traditional thumb surgery.

We just had a paper accepted for publication which examined the benefits of culture expanded Regenexx in the treatment of thumb arthritis.  This is a prospective, case series  with Six OA patients and four controls.  The mean reported pain relief was significantly higher +60%.

If you have thumb pain consider your options carefully.

Rotator Cuff Tears and Onset of Symptoms

At the Centeno-Schultz Clinic we acknowledge the pain, limitation and frustration associated with a rotator cuff tear.

A recent study from Norway examined the natural progression of rotator cuff tears in asymptomatic patients.

Was the progression of the rotator cuff tears correlated with the onset of symptoms?

Study:  50 patients with asymptomatic FT rotator cuff tears were followed using ultrasound and MRI imaging.

Changes of tear size, muscle atrophy, fatty degeneration, and condition of the long head of the biceps tendon were evaluated over 3 years.

Key Points

Eighteen of fifty tears developed symptoms over the three years.(36%)

Significantly larger increase in the rotator tear size (3X) in the newly symptomatic group when compared with the still-asymptomatic group.

The rate of progressing to advanced muscle atrophy was higher in the newly symptomatic group.

The rate of pathology of the long head of the biceps tendon was significantly higher in the newly symptomatic group.

Bottom Line

Over a three year period 36% of asymptomatic rotator cuff tears became symptomatic.  Increase in tear size and decrease of muscle quality were correlated to the development of symptoms.

If you have a rotator cuff tear be mindful and know the natural progression of tears.  Treat early on when symptoms occur.  Treatments at Centeno-Schultz Clinic include MSK US guided cSCP, PL and autologous bone marrow stem cells.

Lateral Elbow Pain: Posterior Interosseous Nerve Compression

At the Centeno-Schultz Clinic we acknowledge that lateral elbow pain can be debilitating and impact daily function.

Not all lateral elbow pain is lateral epicondylitis as illustrated by a recent patient seen in clinic.

Joey is a 17 y/o hocky player with 1 year history of lateral elbow pain which was constant, progressive in nature and aggravated with rotation of his palm upward (supination).  He has undergone PT, trial of NSAID’s, heat, ice and 2 steroid injections without relief.  High dose steroids have signficant side effect both on tissue and stem cell function.

Joey had compression of posterior interosseus nerve which was confirmed by MSK ultrasound.  Treatment options include US guided Regenexx PL/SCP injections and possible hydrodissection.   A patient’s testimonial illustrates the potential of treating nerve injuries with ulrasound guided platelet therapy.

The posterior interosseous nerve (PIN) is nerve in the forearm. 

Posterior Interosseous Nerve

It is the continuation of the deep branch of the radial nerve.  It passes thru supinator muscle in its course from anterior to the posterior surface of the forearm. The PIN may become entrapped at the tendinous border of the supinator known as Aracade of Froshse. Posterior interosseous neuropathy is purely a motor syndrome resulting in finger drop, and radial wrist deviation on extension.  

Other causes of PIN dysfunction include trauma, synovitis, tumors, and iatrogenic injuries.

Exam:

Pain with resisted supination of the forearm.

Pain with resisted extension of extension of middle finger.

Tenderness over lateral epicondyle and distally over the aracade of Froshe. 

Other causes of lateral elbow pain which warrant consideration include:

C7 radiculopathy

Lateral epicondylitis

Extensor tendon rupture

Intersection Syndrome: A cause of forearm pain

At the Centeno-Schultz Clinic we acknowledge that forearm pain can be disabling.

Intersection syndrome is a painful condition on the radial (thumb) side of the forearm when inflammation occurs at the intersection of the first and second extensor tendons. 

The first compartment is compromised of EPB (extensor pollicis brevis) and APL (abductor pollicis longus) whereas the second compartment includes ECRB and ECRL (extensor carpi radialis brevis and longus).

Presentation:  pain approximately 4 cm above the back of the wrist joint where the first and second compartment tendons cross.

 

Tendons are surrounded by a slippery sac called a tenosynovium which allows the tendons to glide.  Inflammation of the tenosynovium (tenosynovitis) impairs the tendons ability to glide and results in pain.

Etiology can be traumatic or due to repetitive wrist flexion and extension commonly seen in weightlifters ad rowers.

 Other causes of radial forearm pain include de Quervain tenosynovitis, thumb CMC arthritis, radial sensory nerve irritation and extensor pollicis longus (EPL) tendinitis.

In cases unresponsive to conservative therapy a guided injection under ultrasound is indicated.  At the Centeno-Schultz Clinic MSK US is utilized in joint, ligament and tendon injections.  Accuracy and visualization is critical for successful clinical results.  Below is an ultrasound image of the first and second compartment tendons crossing.  The white arrows identify the tendons of compartment 1 superficially crossing those of compartment 2.  This is the site of inflammation in intersection syndrome that results in radial side forearm pain.

Carpal Tunnel Syndrome: Overview

At the Centeno-Schultz Clinic we acknowledge that wrist pain can be painful and limiting.

Carpal Tunnel syndrome (CTS) is an entrapment of the median nerve in the carpal tunnel causing pain and numbness.  The carpal tunnel is an anatomical compartment located at the base of the palm.  Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch as illustrated below.

A successful case report utilizing  hydrodissection, a non surgical treatment has been discussed in a prior blog.

Patients commonly experience numbness, tingling, or burning sensations in the thumb, index, long and radial half of the ring finger.

Common clinical examinations include Phalen’s maneuver and Tinel’s sign.

Most cases of CTS are of unknown causes.

Diagnosis is often made by EMG/NCS study whereby needles are placed into muscles and electrical activity is evaluated.  The needles and the procedure  can be painful.  At the Centeno-Schultz Clinic MSK ultrasound is a non painful alternative.  A median nerve greater than 10mm in area indicates carpal tunnel syndrome.  A transverse ultrasound image of the median nerve is illustrated below.

Tears in The Rotator Cuff: Articular and Bursal Sided Tears

Stem cell therapy is an alternative to shoulder rotator cuff surgery.

Shoulder surgery is associated with risks.  Extensive rehabilitation is often needed after a rotator cuff repair surgery due to the immobilization needed to help the sewn rotator cuff muscle or tendon to heal.  A recent study demonstrated that less mobilization and faster rehabilitation is better.

Woman have more problems with rotator surgery in part due to differences in stem cell numbers.  Regenexx C is an option that can increase the total number of stem cells at a site of injury.

The rotator cuff is compromised for 4 major muscles and tendons: the supraspinatus, infraspinatus, subscapularis and teres minor.

Most rotator cuff tears involve the supraspinatus tendon.  The anterior aspect of the distal supraspinatus is a common site of injury.  Accurate localization of the tendon tear is essential.  At the Centeno-Schultz Clinic MSK ultrasound and MRI are used to identify rotator cuff injuries.  Most tears are on either  the articular or bursal surface.  This is illustrated below in both longitudinal and  transverse views.

When in Doubt, Cut it Out

Patients are seeking alternatives to shoulder replacement surgery with increasing frequency.  Patients are concerned with complications, death and signficant downtime associated with shoulder replacements. 

The shoulder is a complex joint composed of tendons, ligaments, muscles and cartilage on the articulating surfaces.  Pain can arise from any or all of these structures.  At the Centeno-Schultz Clinic we are committed to identifying the principal source of pain in patients so a successful treatment regimen can be implemented.  Regrettably this is a universal practice.  DS is a case in point.

DS is an active 62 y/o rancher who sought a second opinion.  He had a 6 month history of left shoulder pain which was constant in duration, progressive in duration, principally located in the posterior shoulder without any radiations.  Aggravating factors including lifting whereas alleviating factors included rest and sleep.  DS had been evaluated by a surgeon and was identified as a suitable candidate for total shoulder replacement. DS had not undergone any conservative to date: no physical therapy, massage or myofasical deactivation.  X-ray was signficant for narrowing of the joint space.

DS and I were concerned that no conservative therapy had been undertaken.  Additionally the only study to date was an x-ray which examines bone and does not evaluate tendon, ligament or cartilage.  An MRI was ordered which was signficant for severe tendinosis of two of the rotator cuff tendons and arthritis of the shoulder joint.  DS declined the replacement and underwent two MSK US guided injections into the rotator cuff tendons and reports 65% improvement to date.  He is scheduled for additional treatment but remains active on his ranch without signficant limitations. 

Bottom Line:  Pain can arise from many different structures and can often times be treated successfully with non surgical regenerative treatments.

Treatment of Lateral Elbow Pain with PRP

Pain on the outside aspect of the elbow is referred to as lateral epicondylitis or tennis elbow.  It can be quite disabling affecting both the quality of life and range of motion.

Lateral epicondylitis is caused by irritation of the common extensor tendons as they insert onto the bony surface of the elbow.

PRP (platelet rich plasma) has become increasing popular as non surgical treatment in common orthopedic conditions.

Has it been used in the treatment of elbow pain?

Yes!

Peerbooms demonstrated PRP to be more effective than steroids in the treatment of lateral elbow pain.  100 patients were randomly assigned treatment with either PRP or steroids.  At one year 73% of patients treated with PRP reported significant improvement vs 49% in the steroid group.

Steroid use has been associated with significant side effects including ligament and cartilage compromise and cell death (apoptosis).

At the Centeno-Schultz Clinic advanced cell treatments including PRP are used in the treatment of lateral elbow pain and other common orthopedic conditions including meniscus tears, supraspinatus tears,  osteoarthritis of hip, knee and ankles.  MSK ultrasound and or x-ray is used in injections to ensure accurate placement of platelets.