Parsonage Turner Syndrome "Look-alikes"

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

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Chapters

• 0:00 Introduction to Parsonage-Turner Lookalikes
• 3:27 Understanding Parsonage-Turner Syndrome
• 6:33 Rotator Cuff Tears vs. PTS
• 8:38 Cervical Nerve Root Compression
• 11:30 Adhesive Capsulitis Differentiation
• 14:48 Diagnostic Imaging Considerations
• 18:18 Final Tips and Course Promotion

Transcript

Speaker 1: 0:00

Hello everyone and welcome to episode 377 of the OrthoEvalPal podcast. I'm your host, paul Marquis. Today we're going to be talking about Parsonage-Turner Syndrome lookalikes. We're going to be talking about what Parsonage-Turner Syndrome is. We'll talk about the most common causes of PTS, we'll discuss diagnoses that look and act like PTS, and we'll talk about tips on how to tease these diagnoses out, and so much more. But before we get started, I just want to make mention that we have a couple sponsors that help us out with our show, and first of all we have Rangemaster.

Speaker 1: 0:32

Rangemaster is known for their shoulder rehab equipment. They offer products from shoulder wands to finger ladders, overhead pulleys to shoulder rehab kits. Rangemaster is your one-stop shop to help with the treatment of frozen shoulders, post-op rotator cuff repairs, total shoulder and reverse total shoulder replacements and so much more. If you'd like to get a free sample of Rangemaster's Blue Ranger pulley system, just email jim at myrangemastercom and add OrthoEvalPal in the subject line. And we also have MedCorp professionals. Now, I know these folks personally from from Medcor. They are great folks. They're a locally owned and family operated medical supply company. They carry everything from radial pressure wave units to traction devices. They have resistance bands to compression garments. Most impressively, though, is their customer service. It's second to none. If you're looking for medical products, like we do for our clinic, or products for your patients, go to wwwmedcorprocom, and if you use coupon code OEP10, you can get $10 off a Sondra cervical traction unit, and if you use code FIRSTTIME10, you can get 10% off your first order at Medcor on their other products. So welcome back everyone.

Speaker 1: 1:46

Oh my, am I excited about today's show. I love doing stuff where we are talking about differential diagnoses and lookalikes and things like that, because too often we see patients who are misdiagnosed and, as a result, mistreated and not deliberately but they just get treatment for a diagnosis that isn't correct. So I'm really excited about today's show. When I first started OrthoEvalPal, you know I had a hard time figuring out what to name this venture slash business of mine, so I thought I would try to piece together something that represented what I was trying to achieve. Hence ortho for orthopedics, eval, trying to help you fine tune the evaluation process, and then pal me, trying to help you, my friends, to become more confident evaluating orthopedic patients. So you can have the fanciest of exercise programs and treatment techniques, but if you misdiagnose the patient, then you are now treating the wrong problem, and I see this all the time. You know people tout on social media that they've got the best exercise for this particular problem. But how often have we seen people treat a rhomboid problem directly with maybe soft tissue modalities, maybe soft tissue work, and it's a herniated disc at C7. And so until we manage that, we're going to continue to have problems in that area. So that's why I do these episodes, and I love doing the ones like we're going to be doing today, where we can talk about a diagnosis and then talk about all the other diagnoses that can look like it. But we'll help you tease that out, we'll help you kind of sort through that so you can, you know, get a better handle on what it is you are evaluating. So, with that being said, let's just jump right into our show.

Speaker 1: 3:37

Today I recently had a patient who had Parsonage-Turner syndrome and I thought, you know this would be a great time, because I spent a lot of time with those patients just trying to sort through is it Parsonage Turner? Most of the time they come to us with shoulder pain, and I have already done a full episode just on Parsonage Turner syndrome, which is episode 117, a long, long time ago. But if you're interested in that and looking at just the specifics of PTS, go right to that episode and I just talk about that. But today I want to talk about the common lookalikes that can kind of mimic this and this can go in any direction. Okay, so if rotator cuff tears look like Parsonage-Turner syndrome, you can see a rotator cuff tear and make sure you rule out Parsonage-Turner syndrome. Okay, so we've got four or five diagnoses we're going to be talking about today, the ones that are most common. There are many others that can cause shoulder pain and loss of motion, but we're going to really focus on three or four of them here today. So just a brief overview of Parsonage Turner Syndrome, which can also be called brachial neuritis, which can also be called brachial neuritis, you know.

Speaker 1: 4:47

Usually the onset is very sudden and the pain is in the shoulder and or arm. Usually this pain is intractable. It's very, very uncomfortable and really no matter what you take, for medication doesn't seem to help much. This is neural discomfort. It's usually really bad for two to three weeks and then starts to subside a little bit. It's often associated with some altered sensation in the upper extremity, but often associated with, and more associated with shoulder loss of function, weakness, atrophy around the shoulder, especially the deltoids. It can affect the serratus around the shoulder, especially the deltoids. It can affect the serratus. It can affect the rotator cuff musculature also and even get down into a little further down into the arm and affect the, you know, the biceps and the forearm musculature too, but most commonly the shoulder muscles.

Speaker 1: 5:39

Now, what are the most common triggers for Parsonage-Turner? Well, the top two would be viruses and vaccinations. You can also have some autoimmune disorders that put you at higher risk of developing Parsonage-Turner syndrome. Your range of motion is going to be very limited, both actively and passively, and generally because of the amount of nerve pain and inflammation and irritation that they'll have limited range of motion. So right now, if you're thinking in your head, well, we've got shoulder pain, we've got altered sensation, we've got loss of active and passive range of motion, there should be many diagnoses going through your head right now, thinking well, it could be a frozen shoulder, it could be a rotator cuff tear, it could be you know something else. So let's talk about some of those diagnoses that can look like PTS.

Speaker 1: 6:33

We're going to start with rotator cuff tears.

Speaker 1: 6:36

A rotator cuff tear can be very painful. You can lose motion, but usually the differential here is that you may have loss of active motion, but people with rotator cuff tears generally have more passive range of motion and so that will be a little bit better than the active range of motion. The differential here is that usually there's a mechanism of injury a slip, a fall, maybe on an outstretched arm. On a stepladder somebody falls off, grabs a gutter and are suspended there with one arm. Maybe they're pulling on something like cranking on a lawnmower and they have this sudden pain in their shoulder. There's some sort of mechanism.

Speaker 1: 7:20

Parsonage Turner syndrome doesn't usually come with trauma to the shoulder or a direct injury to the shoulder. As far as that goes, if you have somebody who has a degenerative rotator cuff tear, they may have had a slow onset, unlike PTS, which is usually a pretty sudden onset of discomfort, of discomfort. A lot of rotator cuff tears are not all that tender around the shoulder, whereas somebody who has parsnips Turner will have a lot of significant palpable discomfort around the shoulder, but not necessarily a very specific area. It can sometimes be quite broad or it can be tender in just one spot, so that can vary also.

Speaker 2: 8:03

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Speaker 1: 8:38

The next diagnosis I want to talk about would be a cervical nerve root compression. Now, a C5 nerve root compression can really look like this, also because I have somebody right now and if anybody comes to my next shoulder course, I'm going to have side-by-side videos of people with a c5 cervical nerve root, somebody with a rotator cuff tear, somebody with parsnage turner syndrome, and you almost can't tell the difference and you can't. You know. You know when they're demonstrating their range of motion, you can't tell the difference and you can't you know when they're demonstrating their range of motion. You can't tell the difference between any of them. And so these are very interesting presentations. We keep kind of exclusive for courses and you know online coaching and things like that, but a cervical nerve root compression can cause you pain in the shoulder. You can get pain down the arm, which you can with parsnage Turner Also. You can get discomfort into the scapula, okay, and so we can also have significant weakness and altered sensation. So this makes it really difficult to sort out. Is this PTS or is this a cervical nerve root compression? How do we differentiate these? Well, you can do some range of motion of the neck and, if you take them into extension lateral flexion that is taking. If you, if you do that kind of like a Sperling's test to the affected side, um, typically, if you have Parsonage Turner, you are now going to put the brachial plexus on slack, there won't be as much tension, so they could get a little bit of relief, whereas if they had a nerve root compression they will have a re-exacerbation of their pain, right, the next thing I do is I'll give this patient traction, so I'll lay them on a table, put them flat on their back and I will do some very light traction of the neck. Almost all nerve root compression patients will feel better, unless they have a massive herniated disc. There is just zero room in that foramen and it is just packed in there and they're going to continue to have pain. But typically traction can make people worse and re-exacerbate their symptoms if they have Parsonage-Turn, because what you're doing now is you're putting some neural tension on that brachial plexus, all right, so anybody with brachial plexus or PTS will generally have more discomfort with traction of the neck. So again, if I traction somebody and they're saying, ah, this pain is getting a lot worse, I've got to be very suspicious that there is some sort of a peripheral nerve issue that is causing this and not necessarily a nerve root. So deep tendon reflexes can be altered with a nerve root compression and not as likely, with a Parsonage-Turner syndrome. So those are different ways I would tease out or differentiate between a cervical nerve root compression and PTS.

Speaker 1: 11:30

Now the next one adhesive capsulitis. This is really easy and to me treating adhesive capsulitis, evaluating adhesive capsulitis, is probably the easiest shoulder diagnosis to tease out. These folks are going to have limited active and passive range of motion and you don't generally gain much more passive range of motion. The onset is slow compared to PTS and this is not usually affected by neurodynamic testing early on. And I say early on because oftentimes people will have pretty decent motion, like they can get to 90 to maybe 150 degrees fairly well with a frozen shoulder early on. It will be painful but they may not get a significant increase in paresthesia throughout the arm. The reason I mentioned early on is that when somebody has an adhesive capsulitis for a long period of time let's say they've had it for six months, nine months a year and they are just not lifting that arm all the way up overhead they lose that neurodynamic ability, that gliding of that brachial plexus and all of the nerves in the arm just don't get that gliding and sliding because they're not reaching overhead a lot. That's why I do lots of median nerve glides, ulnar nerve glides, radial nerve glides with my frozen shoulder patients. Once things start to settle down and once we start to gain motion, what you'll notice with these folks is, as you start to gain range of motion, they're going to say my arm is getting more tingly, my fingers get more tingly and they put their arm by their side and they feel better. And that's just because they don't have good neural mobility. So that's why I say that and I add this to the picture. But typically people with Parsonage-Turner will just go through the roof when you do nerve gliding with them.

Speaker 1: 13:22

The other thing you should take into consideration are the questions that you ask the patient. So somebody who has an adhesive capsulitis more likely to be diabetic, very likely to have a thyroid problem and also very likely to have some sort of a hereditary predisposition. So if they have a family history of it or maybe they're of Northern European descent, they are more likely to have an adhesive capsulitis, but not the atrophy to have an adhesive capsulitis but not the atrophy that you will see with Parsonage-Turner syndrome, and it can be pretty significant atrophy. I'm telling you, these folks with Parsonage-Turner have a significant amount of pain. First two weeks to four weeks it's bad. They can't sleep at night. They can't move that arm. They don't want to move that arm. They lose a significant amount of function. The pain starts to settle down and then you start to see this significant atrophy, usually of the deltoids. That's what shows the most. And then you can have some instability of the shoulder, like you'll see, like a, you know, like a drop off sign or that. They'll tell you that the humeral 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 will be different than somebody with an adhesive capsulitis who will have a very stiff shoulder and never have that feeling of the ball falling out of the socket.

Speaker 1: 14:44

So at this stage of the game, how important is diagnostic imaging? Well, if you're really good at your evaluation, you may not need any imaging whatsoever, okay. But if you're having a tough time putting a finger on this and and and you have some idea what their diagnosis is, then you can drive them in the direction of diagnostic imaging. So let's just talk about, let's say, you suspect that they have a Parsonage-Turner syndrome, then an EMG nerve conduction velocity would probably be the first best step here. If there was some sort of a trauma where they fell hard on their back or something like that, this test could be appropriate after three to four weeks. But then you may be looking at something else like an x-ray or MRI to make sure they don't have a fracture or something like that could have contributed to this. But typically if you're suspecting Parsonage-Turner and they've got kind of the same presentation that we talked about earlier, then doing neurodiagnostic imaging would be great.

Speaker 1: 15:50

Now if you suspect they have an adhesive capsulitis, I typically don't have them x-rayed, unless maybe they are a little on the older side, because osteoarthritis of the glenohumeral joint can look just like an adhesive capsulitis. You can stretch an adhesive capsulitis patient, you know, very safely. But if somebody has severe arthritis, osteoarthritis and this has happened to me where I stretched somebody who had osteoarthritis I did not expect it in that patient. But after two visits I said this is an unreasonable amount of discomfort for such little range of motion with a significant amount of clunking in the shoulders. So x-rays showed a significant amount of osteoarthritis ended up having a total shoulder replacement did very well after that. So keep that into consideration. But there's no need for a significant amount of imaging.

Speaker 1: 16:43

If you are suspicious that the patient has an adhesive capsulitis Now, if you are suspicious that they have a rotator cuff tear, well really your MRI is going to be your best bet, but do make sure that you clear all the neurological stuff first before you run into the MRI. Now, the last one I want to talk about is a cervical nerve root compression. If I have somebody who has a loss of deep tendon reflexes, loss of sensation along a dermatome, I can reproduce their symptoms with a Sperling's test and they have a positive Bacardi sign and maybe I traction their neck and they get complete relief, but they're just not getting better. I would definitely start with flexion and extension x-rays of the cervical spine and then from there and that would be to see if they have any instability and then from there go into an MRI and that can really help to identify how much nerve compression they have. So it's, I just want to throw this little tidbit or tip when you take a look at these folks, do take a look at their skin around the shoulder, you know. See if there are any pustules there, any rashes. We have seen people with shingles in the past and that shingle it's in the family of viruses will affect and cause a brachial neuritis, and so you want to take a look at that. Sometimes getting on an antiviral early on can really help calm this down. A lot of people do well with a steroid also to kind of bat down the inflammation around the nerves and give them a better chance at recovering. So there you have it, folks parsonage turner lookalikes.

Speaker 1: 18:25

Diagnoses like these will be part of our upcoming live course on May 31st 2025. So if you're listening to this, after this date we will be having future courses, but for this one coming up, it's coming right around the corner. If you are interested in this course, let me know. I'll save you a seat. I believe I have four spots left as of today and I'll have links in the show notes If you want to get more course information and go right to the website. I have a description on everything in regards to this course. So, with that being said, folks, I hope you all have a great day, be kind to each other and take care.