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.

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.

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.

Steroids and Cell Death: Apoptosis

 

Apoptosis is the process of programmed cell death.  The process is controlled by a variety of factors both within and outside of  cells.  High dose steroids have been demonstrated to create cell death in muscles, bones, cartilage and ligaments.  High dose steroids are commonly used to treat a variety of painful conditions which include rotator cuff tears, lateral epicondylitis, patellar and Achilles tendonitis, pes anersine bursitis,  lumbar facet dysfunction and sciatica.

At the Centeno-Schultz Clinic we acknowledge the negative effect of  high dose steroids.  Our aim is to identify the source of a patient’s pain and provide a therapy which will attempt to repair the damaged tissue.  Our treatments are not aimed at advancing the degenerative process or triggering apoptosis.  Accordingly we use only very small doses of steroids when necesary and have a large number of regenerative therapies which promote healing: prolotherapy, platelet rich plasma (PRP), Regenexx SCP, Regenexx AD and Regenexx SD.

Shoulder Pain and Ultrasound Guided Injections

Platelet rich plasma, prolotherapy and autologous stem cells are non-surgical treatments for shoulder pain.  Clinical success is dependent upon selecting the appropriate treatment option and placing the solution into the targeted site.

Ultrasound has become the standard of care at the Centeno-Schultz Clinic.  Ultrasound does not involve exposure to x-rays and provides a rich image of the bone, muscles, tendons and ligaments. It also allows for a dynamic evaluation whereby the patient is able to go through the activities that cause them pain.  This is not the case with MRI’s given that they require a patient to remain completely still.  MRI’s provide a static image of the shoulder which may not be helpful in some cases of impingement.

This last weekend Ron Hanson M.D. was an instructor at a highly respected shoulder ultrasound course.

We are very pleased to have Ron’s gifted clinical and ultrasound skills here in Denver/Boulder area at the Centeno-Schultz Clinic.

Rotator Cuff Tears: Non-Surgical Treatment Options

The rotator cuff is compromised of 4 major muscles and tendons that act collectively to stabilize the shoulder joint.

The four muscles include the supraspinatus, infraspinatus, subscapularis and teres minor.  Tendons are the fibrous portion of the muscle that anchors the muscle to bone.  This fibrous anchor can be inflamed resulting in a tendinitis or can be  chronically degenerative resulting in tendinosis.  The one of  4 muscles can have a partial or full thickness tear.

At the Centeno-Schultz Clinic ultrasound is utilized to determine the source of pain.  The pain may arise from a tear in one or more of the four rotator cuff muscles or inflammation or degenerative changes in the fibrous tendon anchor. Other explanations exist which will be discussed in another blog.

Rotator cuff tears can be treated with Regenexx SD whereby a patient uses their own mesencymal stem cells.  Tendinosis  can be treated with Regenexx SCP.

The Regenexx family of procedures represent the highest quality stem cell therapy with the largest number of stem cell treatment options in one clinic and which are ICMS certified.

Another Success: Treatment of Supraspinatus Tear with Stem Cells

In a previous blog I discussed the clinical success of rotator cuff repair using expanded stem cell therapy.

Today we had the opportunity to review MRI images of an elderly patient who also underwent the Regenexx procedure 2 years ago for a supraspinatus tear.  AB  is an 80 y/o patient with neck, headache and shouder pain.  Her shoulder pain was severe and  she was unable to lift her shoulder.  She declined surgery and elected to proceed with mesenchymal stem cell therapy.  Her own stem cells were injected into the rotator cuff tear under x-ray guidance. 

To understand the differences in pre and post  MRI’s, some basic MRI concepts and anatomy is essential. 

The image above is the patient’s pre-injection coronal MRI.  The rotator cuff tendon is the area of interest.  The rotator cuff is compromised of 4 principle muscles.  Muscles have two parts:  the muscle belly and the attachment of the muscle to bone(tendon).  Tears in the rotator cuff commonly involve the tendon.

Above are AB’s pre and post MRI’s .  On the left the rotator cuff tendon(red arrows) are bright in color and mottled in appearance.  This means that it’s a full thickness tear with severe degeneration.  On the right is AB’s MRI 2 year post stem cell injection.  The rotator cuff tendon identified by the yellow arrows is better organized and darker in color consistent with significant healing.    This is consistent with her clinical improvement.  She reports 100% improvement in pain and  full range of motion.

Repair of Rotator Cuff Tear with Stem Cells

The rotator cuff is compromised of 4 principles muscles and their tendons:  supraspinatus, infraspinatus, subscapularis and teres minor.  Collectively they stabilize the joint and allow for movement .  Tendons at the end of the rotator cuff muscles can become torn resulting in pain and restriction in motion.  The majority of tears occur in the supraspinatus tendon. Typical presentation includes pain with impaired motion. Surgical treatment often involves arthorscopic repair, subacromial decompression or use of an anchor to secure the tendon to the bone.  Surgical complications included fatty atrophy, re-tears of the rotator cuff,  infection and failure.

 JG is a 32y/o patient at the Centeno-Schultz Clinic who suffered shoulder injury after a motor vehicle accident.   Despite surgery in the form of subacromial decompression  JG continued to have shoulder pain.  Repeat MRI demonstrated near complete rotator cuff tear involving the supraspinatus.  He declined surgery and opted to undergo the Regenexx procedure whereby he could use his own mesenchymal stem cells. 

2 years after stem cell therapy JG reports greater than 90 % reduction in pain and full range of motion. Post stem cell injection MRI is posted below.  The supraspinatus tendon is outlined with red circle.  On the left there is a significant tear whereas on the right the tear is significantly improved.  This corresponds with JG’s clinical improvement.  Other patients have also undergone successful stem cell therapy for rotator tendon tears.