Pain Secondary to Other Neurologic Conditions

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It will be noted by the reader that the organization of this chapter by chief complaint requires some redundancy, as some underlying conditions may lead to several chief complaints. One such area is neurologic pathology of the shoulder. Some neurologic conditions present primarily as pain, although they may also present as weakness and paresthesias.28

In addition to nerve compression at the level of the cervical spine, athletes can present with neurologic pain that is from a more distal source. The initial differential diagnosis might include compression of the suprascapular nerve, burners or stingers, thoracic outlet syndrome, and brachial neuritis.

Compression of the Suprascapular Nerve

This condition more commonly presents as weakness and atrophy in the supraspinatus, infraspinatus, or both and is therefore covered more extensively in the section on weakness. However, when an athlete presents with posterior shoulder pain, especially in the presence of weakness of the spinatii, consideration of compression of this nerve should be considered.29-31 There are no provocative maneuvers that exacerbate the specific pain associated with compression of the suprascapular nerve, but, with a high index of suspicion, an injection of lidocaine into the area of the suprascapular notch may alleviate shoulder pain and be diagnostic. There are two common sites of compression for this nerve. The proximal site, at the suprascapular notch, both the nerve to the supraspinatus and infraspinatus can be compressed, leading to pain and weakness of both muscles. More distal compression can occur at the spinoglenoid notch, most commonly from a spinoglenoid notch cyst (usually associated with a posterosuperior labral tear), and can lead to isolated infraspinatus weakness.

Burners (Stingers)

Burners or stingers are common causes of pain and burning dysesthesias in the upper extremity. These injuries are most commonly the result of a violent stretch31 of the brachial plexus. These injuries are usually transient, lasting only a few seconds. As these often occur in game situations, especially in football, the athlete should be kept out of competition until symptoms resolve. The diagnosis of this condition is made almost on history alone, although a player might run off the field with a characteristic "dead arm" at his or her side. Symptoms should be unilateral, extremely painful with burning and paresthesias down the extremity, and transient. They may also be accompanied by weakness of the deltoid, biceps, spinatii, and brachioradialis. It is very important to distinguish a burner from cervical radicu-lopathy caused by compression of a nerve root. The former is usually self-limiting, while the latter is of more concern. Most patients with findings attributable to cervical radiculopathy, such as tenderness in the cervical spine, pain with motion, a positive Spurling's test, or pain with compression, should be considered for early workup with cervical spine radiographs, MRI, and electromyography.

Thoracic Outlet Syndrome

This condition should be suspected in a patient who complains of diffuse shoulder pain, especially accompanied by radiating paresthesias in the ulnar nerve distribution below the elbow. As paresthesias are more frequently the chief complaint with this condition, it is covered in detail in that section.

Brachial Neuritis

Occasionally, athletes will present with an acute onset of severe pain with no apparent traumatic history. This pain can be severe and will follow a variable distribution throughout the brachial plexus. In such a patient, a brachial neuritis can be the source. It has no known etiology and usually resolves over several weeks. In addition, it can often present with accompanying weakness, especially of the proximal musculature. This is generally a diagnosis of exclusion, and the examiner often makes this diagnosis only after obtaining imaging studies of the neck and elec-

Figure 16-20 Scapular winging.

tromyographic studies to rule out a specific source of compression.

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