April 8, 2025 • 19 mins
Parsonage-Turner Syndrome can mimic several other shoulder conditions, leading to misdiagnosis and ineffective treatment if not properly identified and differentiated.
• PTS typically presents with sudden onset of severe shoulder pain lasting 2-3 weeks, often triggered by viruses or vaccinations
• Common symptoms include limited active and passive range of motion, weakness, atrophy (especially in deltoids), and sometimes altered sensation
• Rotator cuff tears differ by having better passive than active motion and usually having a clear mechanism of injury
• Cervical nerve root compression can be distinguished by performing Spurling's test and gentle cervical traction
• Adhesive capsulitis has a slower onset than PTS and typically doesn't cause the significant atrophy seen in PTS cases
• Diagnostic imaging should be used after thorough clinical examination to confirm suspected diagnosis
• EMG/nerve conduction studies are most helpful for confirming PTS after 3-4 weeks of symptoms
• Always check for skin changes like pustules or rashes that might indicate shingles, which can cause brachial neuritis
Join us for our upcoming live course on May 31st, 2025 where we'll cover more differential diagnoses like these. Visit the website link in the show notes for more information and to reserve your spot.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello everyone and welcome to episode 377 of the
OrthoEvalPal podcast.
I'm your host, paul Marquis.
Today we're going to be talkingabout Parsonage-Turner Syndrome
lookalikes.
We're going to be talking aboutwhat Parsonage-Turner Syndrome
is.
We'll talk about the mostcommon causes of PTS, we'll
discuss diagnoses that look andact like PTS, and we'll talk
(00:21):
about tips on how to tease thesediagnoses out, and so much more
.
But before we get started, Ijust want to make mention that
we have a couple sponsors thathelp us out with our show, and
first of all we have Rangemaster.
Rangemaster is known for theirshoulder rehab equipment.
They offer products fromshoulder wands to finger ladders
, overhead pulleys to shoulderrehab kits.
Rangemaster is your one-stopshop to help with the treatment
(00:44):
of frozen shoulders, post-oprotator cuff repairs, total
shoulder and reverse totalshoulder replacements and so
much more.
If you'd like to get a freesample of Rangemaster's Blue
Ranger pulley system, just emailjim at myrangemastercom and add
OrthoEvalPal in the subjectline.
And we also have MedCorpprofessionals.
Now, I know these folkspersonally from from Medcor.
(01:04):
They are great folks.
They're a locally owned andfamily operated medical supply
company.
They carry everything fromradial pressure wave units to
traction devices.
They have resistance bands tocompression garments.
Most impressively, though, istheir customer service.
It's second to none.
If you're looking for medicalproducts, like we do for our
clinic, or products for yourpatients, go to wwwmedcorprocom,
(01:28):
and if you use coupon codeOEP10, you can get $10 off a
Sondra cervical traction unit,and if you use code FIRSTTIME10,
you can get 10% off your firstorder at Medcor on their other
products.
So welcome back everyone.
Oh my, am I excited abouttoday's show.
I love doing stuff where we aretalking about differential
(01:52):
diagnoses and lookalikes andthings like that, because too
often we see patients who aremisdiagnosed and, as a result,
mistreated and not deliberatelybut they just get treatment for
a diagnosis that isn't correct.
So I'm really excited abouttoday's show.
When I first startedOrthoEvalPal, you know I had a
(02:14):
hard time figuring out what toname this venture slash business
of mine, so I thought I wouldtry to piece together something
that represented what I wastrying to achieve.
Hence ortho for orthopedics,eval, trying to help you fine
tune the evaluation process, andthen pal me, trying to help you
, my friends, to become moreconfident evaluating orthopedic
(02:37):
patients.
So you can have the fanciest ofexercise programs and treatment
techniques, but if youmisdiagnose the patient, then
you are now treating the wrongproblem, and I see this all the
time.
You know people tout on socialmedia that they've got the best
exercise for this particularproblem.
But how often have we seenpeople treat a rhomboid problem
(03:01):
directly with maybe soft tissuemodalities, maybe soft tissue
work, and it's a herniated discat C7.
And so until we manage that,we're going to continue to have
problems in that area.
So that's why I do theseepisodes, and I love doing the
ones like we're going to bedoing today, where we can talk
about a diagnosis and then talkabout all the other diagnoses
(03:23):
that can look like it.
But we'll help you tease thatout, we'll help you kind of sort
through that so you can, youknow, get a better handle on
what it is you are evaluating.
So, with that being said, let'sjust jump right into our show.
Today I recently had a patientwho had Parsonage-Turner
syndrome and I thought, you knowthis would be a great time,
because I spent a lot of timewith those patients just trying
(03:44):
to sort through is it ParsonageTurner?
Most of the time they come tous with shoulder pain, and I
have already done a full episodejust on Parsonage Turner
syndrome, which is episode 117,a long, long time ago.
But if you're interested inthat and looking at just the
specifics of PTS, go right tothat episode and I just talk
(04:05):
about that.
But today I want to talk aboutthe common lookalikes that can
kind of mimic this and this cango in any direction.
Okay, so if rotator cuff tearslook like Parsonage-Turner
syndrome, you can see a rotatorcuff tear and make sure you rule
out Parsonage-Turner syndrome.
Okay, so we've got four or fivediagnoses we're going to be
(04:25):
talking about today, the onesthat are most common.
There are many others that cancause shoulder pain and loss of
motion, but we're going toreally focus on three or four of
them here today.
So just a brief overview ofParsonage Turner Syndrome, which
can also be called brachialneuritis, which can also be
called brachial neuritis, youknow.
(04:47):
Usually the onset is very suddenand the pain is in the shoulder
and or arm.
Usually this pain isintractable.
It's very, very uncomfortableand really no matter what you
take, for medication doesn'tseem to help much.
This is neural discomfort.
It's usually really bad for twoto three weeks and then starts
to subside a little bit.
(05:08):
It's often associated with somealtered sensation in the upper
extremity, but often associatedwith, and more associated with
shoulder loss of function,weakness, atrophy around the
shoulder, especially thedeltoids.
It can affect the serratusaround the shoulder, especially
the deltoids.
It can affect the serratus.
It can affect the rotator cuffmusculature also and even get
(05:29):
down into a little further downinto the arm and affect the, you
know, the biceps and theforearm musculature too, but
most commonly the shouldermuscles.
Now, what are the most commontriggers for Parsonage-Turner?
Well, the top two would beviruses and vaccinations.
You can also have someautoimmune disorders that put
(05:52):
you at higher risk of developingParsonage-Turner syndrome.
Your range of motion is goingto be very limited, both
actively and passively, andgenerally because of the amount
of nerve pain and inflammationand irritation that they'll have
limited range of motion.
So right now, if you'rethinking in your head, well,
(06:13):
we've got shoulder pain, we'vegot altered sensation, we've got
loss of active and passiverange of motion, there should be
many diagnoses going throughyour head right now, thinking
well, it could be a frozenshoulder, it could be a rotator
cuff tear, it could be you knowsomething else.
So let's talk about some ofthose diagnoses that can look
like PTS.
We're going to start withrotator cuff tears.
(06:36):
A rotator cuff tear can be verypainful.
You can lose motion, butusually the differential here is
that you may have loss ofactive motion, but people with
rotator cuff tears generallyhave more passive range of
motion and so that will be alittle bit better than the
active range of motion.
(06:56):
The differential here is thatusually there's a mechanism of
injury a slip, a fall, maybe onan outstretched arm.
On a stepladder somebody fallsoff, grabs a gutter and are
suspended there with one arm.
Maybe they're pulling onsomething like cranking on a
lawnmower and they have thissudden pain in their shoulder.
There's some sort of mechanism.
(07:20):
Parsonage Turner syndromedoesn't usually come with trauma
to the shoulder or a directinjury to the shoulder.
As far as that goes, if youhave somebody who has a
degenerative rotator cuff tear,they may have had a slow onset,
unlike PTS, which is usually apretty sudden onset of
(07:40):
discomfort, of discomfort.
A lot of rotator cuff tears arenot all that tender around the
shoulder, whereas somebody whohas parsnips Turner will have a
lot of significant palpablediscomfort around the shoulder,
but not necessarily a veryspecific area.
It can sometimes be quite broador it can be tender in just one
spot, so that can vary also.
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Speaker 1 (08:38):
The next diagnosis I want to talk about would be a
cervical nerve root compression.
Now, a C5 nerve rootcompression can really look like
this, also because I havesomebody right now and if
anybody comes to my nextshoulder course, I'm going to
have side-by-side videos ofpeople with a c5 cervical nerve
root, somebody with a rotatorcuff tear, somebody with
(09:00):
parsnage turner syndrome, andyou almost can't tell the
difference and you can't.
You know.
You know when they'redemonstrating their range of
motion, you can't tell thedifference and you can't you
know when they're demonstratingtheir range of motion.
You can't tell the differencebetween any of them.
And so these are veryinteresting presentations.
We keep kind of exclusive forcourses and you know online
coaching and things like that,but a cervical nerve root
compression can cause you painin the shoulder.
(09:21):
You can get pain down the arm,which you can with parsnage
Turner Also.
You can get discomfort into thescapula, okay, and so we can
also have significant weaknessand altered sensation.
So this makes it reallydifficult to sort out.
Is this PTS or is this acervical nerve root compression?
How do we differentiate these?
(09:42):
Well, you can do some range ofmotion of the neck and, if you
take them into extension lateralflexion that is taking.
If you, if you do that kind oflike a Sperling's test to the
affected side, um, typically, ifyou have Parsonage Turner, you
(10:02):
are now going to put thebrachial plexus on slack, there
won't be as much tension, sothey could get a little bit of
relief, whereas if they had anerve root compression they will
have a re-exacerbation of theirpain, right, the next thing I
do is I'll give this patienttraction, so I'll lay them on a
table, put them flat on theirback and I will do some very
light traction of the neck.
(10:23):
Almost all nerve rootcompression patients will feel
better, unless they have amassive herniated disc.
There is just zero room in thatforamen and it is just packed
in there and they're going tocontinue to have pain.
But typically traction can makepeople worse and re-exacerbate
(10:44):
their symptoms if they haveParsonage-Turn, because what
you're doing now is you'reputting some neural tension on
that brachial plexus, all right,so anybody with brachial plexus
or PTS will generally have morediscomfort with traction of the
neck.
So again, if I tractionsomebody and they're saying, ah,
this pain is getting a lotworse, I've got to be very
(11:04):
suspicious that there is somesort of a peripheral nerve issue
that is causing this and notnecessarily a nerve root.
So deep tendon reflexes can bealtered with a nerve root
compression and not as likely,with a Parsonage-Turner syndrome
.
So those are different ways Iwould tease out or differentiate
(11:27):
between a cervical nerve rootcompression and PTS.
Now the next one adhesivecapsulitis.
This is really easy and to metreating adhesive capsulitis,
evaluating adhesive capsulitis,is probably the easiest shoulder
diagnosis to tease out.
These folks are going to havelimited active and passive range
(11:49):
of motion and you don'tgenerally gain much more passive
range of motion.
The onset is slow compared toPTS and this is not usually
affected by neurodynamic testingearly on.
And I say early on becauseoftentimes people will have
pretty decent motion, like theycan get to 90 to maybe 150
(12:11):
degrees fairly well with afrozen shoulder early on.
It will be painful but they maynot get a significant increase
in paresthesia throughout thearm.
The reason I mentioned early onis that when somebody has an
adhesive capsulitis for a longperiod of time let's say they've
had it for six months, ninemonths a year and they are just
not lifting that arm all the wayup overhead they lose that
(12:35):
neurodynamic ability, thatgliding of that brachial plexus
and all of the nerves in the armjust don't get that gliding and
sliding because they're notreaching overhead a lot.
That's why I do lots of mediannerve glides, ulnar nerve glides
, radial nerve glides with myfrozen shoulder patients.
Once things start to settledown and once we start to gain
(12:57):
motion, what you'll notice withthese folks is, as you start to
gain range of motion, they'regoing to say my arm is getting
more tingly, my fingers get moretingly and they put their arm
by their side and they feelbetter.
And that's just because theydon't have good neural mobility.
So that's why I say that and Iadd this to the picture.
But typically people withParsonage-Turner will just go
(13:19):
through the roof when you donerve gliding with them.
The other thing you should takeinto consideration are the
questions that you ask thepatient.
So somebody who has an adhesivecapsulitis more likely to be
diabetic, very likely to have athyroid problem and also very
likely to have some sort of ahereditary predisposition.
So if they have a familyhistory of it or maybe they're
(13:41):
of Northern European descent,they are more likely to have an
adhesive capsulitis, but not theatrophy to have an adhesive
capsulitis but not the atrophythat you will see with
Parsonage-Turner syndrome, andit can be pretty significant
atrophy.
I'm telling you, these folkswith Parsonage-Turner have a
significant amount of pain.
First two weeks to four weeksit's bad.
(14:03):
They can't sleep at night.
They can't move that arm.
They don't want to move thatarm.
They lose a significant amountof function.
The pain starts to settle downand then you start to see this
significant atrophy, usually ofthe deltoids.
That's what shows the most.
And then you can have someinstability of the shoulder,
like you'll see, like a, youknow, like a drop off sign or
(14:25):
that.
They'll tell you that thehumeral head feels like it's
falling out of the socket.
That's not uncommon, okay,because your deltoids are just
not functioning and so that willbe different than somebody with
an adhesive capsulitis who willhave a very stiff shoulder and
never have that feeling of theball falling out of the socket.
So at this stage of the game,how important is diagnostic
(14:48):
imaging?
Well, if you're really good atyour evaluation, you may not
need any imaging whatsoever,okay.
But if you're having a toughtime putting a finger on this
and and and you have some ideawhat their diagnosis is, then
you can drive them in thedirection of diagnostic imaging.
So let's just talk about, let'ssay, you suspect that they have
(15:10):
a Parsonage-Turner syndrome,then an EMG nerve conduction
velocity would probably be thefirst best step here.
If there was some sort of atrauma where they fell hard on
their back or something likethat, this test could be
appropriate after three to fourweeks.
But then you may be looking atsomething else like an x-ray or
(15:33):
MRI to make sure they don't havea fracture or something like
that could have contributed tothis.
But typically if you'resuspecting Parsonage-Turner and
they've got kind of the samepresentation that we talked
about earlier, then doingneurodiagnostic imaging would be
great.
Now if you suspect they have anadhesive capsulitis, I typically
(15:55):
don't have them x-rayed, unlessmaybe they are a little on the
older side, becauseosteoarthritis of the
glenohumeral joint can look justlike an adhesive capsulitis.
You can stretch an adhesivecapsulitis patient, you know,
very safely.
But if somebody has severearthritis, osteoarthritis and
(16:15):
this has happened to me where Istretched somebody who had
osteoarthritis I did not expectit in that patient.
But after two visits I saidthis is an unreasonable amount
of discomfort for such littlerange of motion with a
significant amount of clunkingin the shoulders.
So x-rays showed a significantamount of osteoarthritis ended
up having a total shoulderreplacement did very well after
(16:37):
that.
So keep that into consideration.
But there's no need for asignificant amount of imaging.
If you are suspicious that thepatient has an adhesive
capsulitis Now, if you aresuspicious that they have a
rotator cuff tear, well reallyyour MRI is going to be your
best bet, but do make sure thatyou clear all the neurological
stuff first before you run intothe MRI.
(17:00):
Now, the last one I want totalk about is a cervical nerve
root compression.
If I have somebody who has aloss of deep tendon reflexes,
loss of sensation along adermatome, I can reproduce their
symptoms with a Sperling's testand they have a positive
Bacardi sign and maybe Itraction their neck and they get
(17:20):
complete relief, but they'rejust not getting better.
I would definitely start withflexion and extension x-rays of
the cervical spine and then fromthere and that would be to see
if they have any instability andthen from there go into an MRI
and that can really help toidentify how much nerve
compression they have.
So it's, I just want to throwthis little tidbit or tip when
(17:45):
you take a look at these folks,do take a look at their skin
around the shoulder, you know.
See if there are any pustulesthere, any rashes.
We have seen people withshingles in the past and that
shingle it's in the family ofviruses will affect and cause a
brachial neuritis, and so youwant to take a look at that.
(18:06):
Sometimes getting on anantiviral early on can really
help calm this down.
A lot of people do well with asteroid also to kind of bat down
the inflammation around thenerves and give them a better
chance at recovering.
So there you have it, folksparsonage turner lookalikes.
Diagnoses like these will bepart of our upcoming live course
(18:31):
on May 31st 2025.
So if you're listening to this,after this date we will be
having future courses, but forthis one coming up, it's coming
right around the corner.
If you are interested in thiscourse, let me know.
I'll save you a seat.
I believe I have four spotsleft as of today and I'll have
links in the show notes If youwant to get more course
(18:52):
information and go right to thewebsite.
I have a description oneverything in regards to this
course.
So, with that being said, folks, I hope you all have a great
day, be kind to each other andtake care.
Hello everyone and welcome to episode 377 of the
OrthoEvalPal podcast.
I'm your host, paul Marquis.
Today we're going to be talkingabout Parsonage-Turner Syndrome
lookalikes.
We're going to be talking aboutwhat Parsonage-Turner Syndrome
is.
We'll talk about the mostcommon causes of PTS, we'll
discuss diagnoses that look andact like PTS, and we'll talk
(00:21):
about tips on how to tease thesediagnoses out, and so much more
.
But before we get started, Ijust want to make mention that
we have a couple sponsors thathelp us out with our show, and
first of all we have Rangemaster.
Rangemaster is known for theirshoulder rehab equipment.
They offer products fromshoulder wands to finger ladders
, overhead pulleys to shoulderrehab kits.
Rangemaster is your one-stopshop to help with the treatment
(00:44):
of frozen shoulders, post-oprotator cuff repairs, total
shoulder and reverse totalshoulder replacements and so
much more.
If you'd like to get a freesample of Rangemaster's Blue
Ranger pulley system, just emailjim at myrangemastercom and add
OrthoEvalPal in the subjectline.
And we also have MedCorpprofessionals.
Now, I know these folkspersonally from from Medcor.
(01:04):
They are great folks.
They're a locally owned andfamily operated medical supply
company.
They carry everything fromradial pressure wave units to
traction devices.
They have resistance bands tocompression garments.
Most impressively, though, istheir customer service.
It's second to none.
If you're looking for medicalproducts, like we do for our
clinic, or products for yourpatients, go to wwwmedcorprocom,
(01:28):
and if you use coupon codeOEP10, you can get $10 off a
Sondra cervical traction unit,and if you use code FIRSTTIME10,
you can get 10% off your firstorder at Medcor on their other
products.
So welcome back everyone.
Oh my, am I excited abouttoday's show.
I love doing stuff where we aretalking about differential
(01:52):
diagnoses and lookalikes andthings like that, because too
often we see patients who aremisdiagnosed and, as a result,
mistreated and not deliberatelybut they just get treatment for
a diagnosis that isn't correct.
So I'm really excited abouttoday's show.
When I first startedOrthoEvalPal, you know I had a
(02:14):
hard time figuring out what toname this venture slash business
of mine, so I thought I wouldtry to piece together something
that represented what I wastrying to achieve.
Hence ortho for orthopedics,eval, trying to help you fine
tune the evaluation process, andthen pal me, trying to help you
, my friends, to become moreconfident evaluating orthopedic
(02:37):
patients.
So you can have the fanciest ofexercise programs and treatment
techniques, but if youmisdiagnose the patient, then
you are now treating the wrongproblem, and I see this all the
time.
You know people tout on socialmedia that they've got the best
exercise for this particularproblem.
But how often have we seenpeople treat a rhomboid problem
(03:01):
directly with maybe soft tissuemodalities, maybe soft tissue
work, and it's a herniated discat C7.
And so until we manage that,we're going to continue to have
problems in that area.
So that's why I do theseepisodes, and I love doing the
ones like we're going to bedoing today, where we can talk
about a diagnosis and then talkabout all the other diagnoses
(03:23):
that can look like it.
But we'll help you tease thatout, we'll help you kind of sort
through that so you can, youknow, get a better handle on
what it is you are evaluating.
So, with that being said, let'sjust jump right into our show.
Today I recently had a patientwho had Parsonage-Turner
syndrome and I thought, you knowthis would be a great time,
because I spent a lot of timewith those patients just trying
(03:44):
to sort through is it ParsonageTurner?
Most of the time they come tous with shoulder pain, and I
have already done a full episodejust on Parsonage Turner
syndrome, which is episode 117,a long, long time ago.
But if you're interested inthat and looking at just the
specifics of PTS, go right tothat episode and I just talk
(04:05):
about that.
But today I want to talk aboutthe common lookalikes that can
kind of mimic this and this cango in any direction.
Okay, so if rotator cuff tearslook like Parsonage-Turner
syndrome, you can see a rotatorcuff tear and make sure you rule
out Parsonage-Turner syndrome.
Okay, so we've got four or fivediagnoses we're going to be
(04:25):
talking about today, the onesthat are most common.
There are many others that cancause shoulder pain and loss of
motion, but we're going toreally focus on three or four of
them here today.
So just a brief overview ofParsonage Turner Syndrome, which
can also be called brachialneuritis, which can also be
called brachial neuritis, youknow.
(04:47):
Usually the onset is very suddenand the pain is in the shoulder
and or arm.
Usually this pain isintractable.
It's very, very uncomfortableand really no matter what you
take, for medication doesn'tseem to help much.
This is neural discomfort.
It's usually really bad for twoto three weeks and then starts
to subside a little bit.
(05:08):
It's often associated with somealtered sensation in the upper
extremity, but often associatedwith, and more associated with
shoulder loss of function,weakness, atrophy around the
shoulder, especially thedeltoids.
It can affect the serratusaround the shoulder, especially
the deltoids.
It can affect the serratus.
It can affect the rotator cuffmusculature also and even get
(05:29):
down into a little further downinto the arm and affect the, you
know, the biceps and theforearm musculature too, but
most commonly the shouldermuscles.
Now, what are the most commontriggers for Parsonage-Turner?
Well, the top two would beviruses and vaccinations.
You can also have someautoimmune disorders that put
(05:52):
you at higher risk of developingParsonage-Turner syndrome.
Your range of motion is goingto be very limited, both
actively and passively, andgenerally because of the amount
of nerve pain and inflammationand irritation that they'll have
limited range of motion.
So right now, if you'rethinking in your head, well,
(06:13):
we've got shoulder pain, we'vegot altered sensation, we've got
loss of active and passiverange of motion, there should be
many diagnoses going throughyour head right now, thinking
well, it could be a frozenshoulder, it could be a rotator
cuff tear, it could be you knowsomething else.
So let's talk about some ofthose diagnoses that can look
like PTS.
We're going to start withrotator cuff tears.
(06:36):
A rotator cuff tear can be verypainful.
You can lose motion, butusually the differential here is
that you may have loss ofactive motion, but people with
rotator cuff tears generallyhave more passive range of
motion and so that will be alittle bit better than the
active range of motion.
(06:56):
The differential here is thatusually there's a mechanism of
injury a slip, a fall, maybe onan outstretched arm.
On a stepladder somebody fallsoff, grabs a gutter and are
suspended there with one arm.
Maybe they're pulling onsomething like cranking on a
lawnmower and they have thissudden pain in their shoulder.
There's some sort of mechanism.
(07:20):
Parsonage Turner syndromedoesn't usually come with trauma
to the shoulder or a directinjury to the shoulder.
As far as that goes, if youhave somebody who has a
degenerative rotator cuff tear,they may have had a slow onset,
unlike PTS, which is usually apretty sudden onset of
(07:40):
discomfort, of discomfort.
A lot of rotator cuff tears arenot all that tender around the
shoulder, whereas somebody whohas parsnips Turner will have a
lot of significant palpablediscomfort around the shoulder,
but not necessarily a veryspecific area.
It can sometimes be quite broador it can be tender in just one
spot, so that can vary also.
Speaker 2 (08:03):
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Speaker 1 (08:38):
The next diagnosis I want to talk about would be a
cervical nerve root compression.
Now, a C5 nerve rootcompression can really look like
this, also because I havesomebody right now and if
anybody comes to my nextshoulder course, I'm going to
have side-by-side videos ofpeople with a c5 cervical nerve
root, somebody with a rotatorcuff tear, somebody with
(09:00):
parsnage turner syndrome, andyou almost can't tell the
difference and you can't.
You know.
You know when they'redemonstrating their range of
motion, you can't tell thedifference and you can't you
know when they're demonstratingtheir range of motion.
You can't tell the differencebetween any of them.
And so these are veryinteresting presentations.
We keep kind of exclusive forcourses and you know online
coaching and things like that,but a cervical nerve root
compression can cause you painin the shoulder.
(09:21):
You can get pain down the arm,which you can with parsnage
Turner Also.
You can get discomfort into thescapula, okay, and so we can
also have significant weaknessand altered sensation.
So this makes it reallydifficult to sort out.
Is this PTS or is this acervical nerve root compression?
How do we differentiate these?
(09:42):
Well, you can do some range ofmotion of the neck and, if you
take them into extension lateralflexion that is taking.
If you, if you do that kind oflike a Sperling's test to the
affected side, um, typically, ifyou have Parsonage Turner, you
(10:02):
are now going to put thebrachial plexus on slack, there
won't be as much tension, sothey could get a little bit of
relief, whereas if they had anerve root compression they will
have a re-exacerbation of theirpain, right, the next thing I
do is I'll give this patienttraction, so I'll lay them on a
table, put them flat on theirback and I will do some very
light traction of the neck.
(10:23):
Almost all nerve rootcompression patients will feel
better, unless they have amassive herniated disc.
There is just zero room in thatforamen and it is just packed
in there and they're going tocontinue to have pain.
But typically traction can makepeople worse and re-exacerbate
(10:44):
their symptoms if they haveParsonage-Turn, because what
you're doing now is you'reputting some neural tension on
that brachial plexus, all right,so anybody with brachial plexus
or PTS will generally have morediscomfort with traction of the
neck.
So again, if I tractionsomebody and they're saying, ah,
this pain is getting a lotworse, I've got to be very
(11:04):
suspicious that there is somesort of a peripheral nerve issue
that is causing this and notnecessarily a nerve root.
So deep tendon reflexes can bealtered with a nerve root
compression and not as likely,with a Parsonage-Turner syndrome
.
So those are different ways Iwould tease out or differentiate
(11:27):
between a cervical nerve rootcompression and PTS.
Now the next one adhesivecapsulitis.
This is really easy and to metreating adhesive capsulitis,
evaluating adhesive capsulitis,is probably the easiest shoulder
diagnosis to tease out.
These folks are going to havelimited active and passive range
(11:49):
of motion and you don'tgenerally gain much more passive
range of motion.
The onset is slow compared toPTS and this is not usually
affected by neurodynamic testingearly on.
And I say early on becauseoftentimes people will have
pretty decent motion, like theycan get to 90 to maybe 150
(12:11):
degrees fairly well with afrozen shoulder early on.
It will be painful but they maynot get a significant increase
in paresthesia throughout thearm.
The reason I mentioned early onis that when somebody has an
adhesive capsulitis for a longperiod of time let's say they've
had it for six months, ninemonths a year and they are just
not lifting that arm all the wayup overhead they lose that
(12:35):
neurodynamic ability, thatgliding of that brachial plexus
and all of the nerves in the armjust don't get that gliding and
sliding because they're notreaching overhead a lot.
That's why I do lots of mediannerve glides, ulnar nerve glides
, radial nerve glides with myfrozen shoulder patients.
Once things start to settledown and once we start to gain
(12:57):
motion, what you'll notice withthese folks is, as you start to
gain range of motion, they'regoing to say my arm is getting
more tingly, my fingers get moretingly and they put their arm
by their side and they feelbetter.
And that's just because theydon't have good neural mobility.
So that's why I say that and Iadd this to the picture.
But typically people withParsonage-Turner will just go
(13:19):
through the roof when you donerve gliding with them.
The other thing you should takeinto consideration are the
questions that you ask thepatient.
So somebody who has an adhesivecapsulitis more likely to be
diabetic, very likely to have athyroid problem and also very
likely to have some sort of ahereditary predisposition.
So if they have a familyhistory of it or maybe they're
(13:41):
of Northern European descent,they are more likely to have an
adhesive capsulitis, but not theatrophy to have an adhesive
capsulitis but not the atrophythat you will see with
Parsonage-Turner syndrome, andit can be pretty significant
atrophy.
I'm telling you, these folkswith Parsonage-Turner have a
significant amount of pain.
First two weeks to four weeksit's bad.
(14:03):
They can't sleep at night.
They can't move that arm.
They don't want to move thatarm.
They lose a significant amountof function.
The pain starts to settle downand then you start to see this
significant atrophy, usually ofthe deltoids.
That's what shows the most.
And then you can have someinstability of the shoulder,
like you'll see, like a, youknow, like a drop off sign or
(14:25):
that.
They'll tell you that thehumeral head feels like it's
falling out of the socket.
That's not uncommon, okay,because your deltoids are just
not functioning and so that willbe different than somebody with
an adhesive capsulitis who willhave a very stiff shoulder and
never have that feeling of theball falling out of the socket.
So at this stage of the game,how important is diagnostic
(14:48):
imaging?
Well, if you're really good atyour evaluation, you may not
need any imaging whatsoever,okay.
But if you're having a toughtime putting a finger on this
and and and you have some ideawhat their diagnosis is, then
you can drive them in thedirection of diagnostic imaging.
So let's just talk about, let'ssay, you suspect that they have
(15:10):
a Parsonage-Turner syndrome,then an EMG nerve conduction
velocity would probably be thefirst best step here.
If there was some sort of atrauma where they fell hard on
their back or something likethat, this test could be
appropriate after three to fourweeks.
But then you may be looking atsomething else like an x-ray or
(15:33):
MRI to make sure they don't havea fracture or something like
that could have contributed tothis.
But typically if you'resuspecting Parsonage-Turner and
they've got kind of the samepresentation that we talked
about earlier, then doingneurodiagnostic imaging would be
great.
Now if you suspect they have anadhesive capsulitis, I typically
(15:55):
don't have them x-rayed, unlessmaybe they are a little on the
older side, becauseosteoarthritis of the
glenohumeral joint can look justlike an adhesive capsulitis.
You can stretch an adhesivecapsulitis patient, you know,
very safely.
But if somebody has severearthritis, osteoarthritis and
(16:15):
this has happened to me where Istretched somebody who had
osteoarthritis I did not expectit in that patient.
But after two visits I saidthis is an unreasonable amount
of discomfort for such littlerange of motion with a
significant amount of clunkingin the shoulders.
So x-rays showed a significantamount of osteoarthritis ended
up having a total shoulderreplacement did very well after
(16:37):
that.
So keep that into consideration.
But there's no need for asignificant amount of imaging.
If you are suspicious that thepatient has an adhesive
capsulitis Now, if you aresuspicious that they have a
rotator cuff tear, well reallyyour MRI is going to be your
best bet, but do make sure thatyou clear all the neurological
stuff first before you run intothe MRI.
(17:00):
Now, the last one I want totalk about is a cervical nerve
root compression.
If I have somebody who has aloss of deep tendon reflexes,
loss of sensation along adermatome, I can reproduce their
symptoms with a Sperling's testand they have a positive
Bacardi sign and maybe Itraction their neck and they get
(17:20):
complete relief, but they'rejust not getting better.
I would definitely start withflexion and extension x-rays of
the cervical spine and then fromthere and that would be to see
if they have any instability andthen from there go into an MRI
and that can really help toidentify how much nerve
compression they have.
So it's, I just want to throwthis little tidbit or tip when
(17:45):
you take a look at these folks,do take a look at their skin
around the shoulder, you know.
See if there are any pustulesthere, any rashes.
We have seen people withshingles in the past and that
shingle it's in the family ofviruses will affect and cause a
brachial neuritis, and so youwant to take a look at that.
(18:06):
Sometimes getting on anantiviral early on can really
help calm this down.
A lot of people do well with asteroid also to kind of bat down
the inflammation around thenerves and give them a better
chance at recovering.
So there you have it, folksparsonage turner lookalikes.
Diagnoses like these will bepart of our upcoming live course
(18:31):
on May 31st 2025.
So if you're listening to this,after this date we will be
having future courses, but forthis one coming up, it's coming
right around the corner.
If you are interested in thiscourse, let me know.
I'll save you a seat.
I believe I have four spotsleft as of today and I'll have
links in the show notes If youwant to get more course
(18:52):
information and go right to thewebsite.
I have a description oneverything in regards to this
course.
So, with that being said, folks, I hope you all have a great
day, be kind to each other andtake care.
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