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Approach to Posterior Shoulder and Upper Back Pain ...
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Good morning everyone, welcome to the approach to post your shoulder and upper back pain case based discussions. My name is Brian limb, I'm going to be your host and moderator today. I'm a clinical associate professor at the University of Washington, and also the associate program director of our sports medicine fellowship. So, I am joined today by a great panel of musculoskeletal physiatrist sports and spine physiatrist. I have Dr. Aaron Yang from Vanderbilt University here in Nashville, Tennessee. I'm actually here in Nashville, Tennessee with him just in a different conference room. I have Dr. Adele Miran from the University of Colorado. We got Dr. Adriel fry from evergreen sports and spine in Kirkland, Washington, and Dr. Nathan Olofson from Washington University in St. Louis, not to be mistaken for the University of Washington. The goal today is to discuss, hopefully six different cases, and the goal for the cases is really to highlight the approach to treating post your shoulder periscopular and upper back pain and personally I found these patients to be somewhat challenging when they come into the office. Oftentimes, they get a diagnosis from the PCP of having kind of a trapezius sprain or strain, or some sort of engagement. And there's certainly much more to that I mean there are a number of different ideologies which hopefully will highlight today through the course of discussing these six cases. All right, so let's get to the next slide here. So in this slide here. What I wanted to highlight is there isn't a defined area necessarily of where the poster shoulder or periscopic region is in terms of the borders but for me these are the borders, the superior border would basically be the upper trapezius here and probably the C7 spinous process medial border on it doesn't it is the thoracic spine lateral border would be the glenohumeral joint, and then the inferior border would be the inferior angle the scapula right here, and around the C7 vertebral body to highlight the anatomy a bit. Everyone knows that the trapezius muscles this large broad muscle extends from the circle spine down to kind of the, the mid back here, but if you peel that away underneath you're going to see some other areas of some importance, including the levator scapulae, which is shown here and then your rhomboid minor and rhomboid major that's attached to basically the scapula the meter board of the scapula. So then you have the scapula itself. You have a glenohumeral joint laterally here, and then what's not shown on this model is basically the rotator cuff muscles and tendons. So a lot of different structures that are in that region. So let's go ahead and start with the cases here. So, I've got a 21 year old male football player with a one week history of burning deep pain, just medial to the right scapula border after his arm was jerked across his body during a game kind of like this denies any fall onto the shoulder feels the pain is at the medial scapular border, but kind of deeper underneath the scapula itself. He dies any weakness, but feel something is torn in his muscles, and he also gets this sort of crunching sound like this creptus sound when he elevates and protracts his scapula past medical history, history of a stinger and a burn in the prior season, and no residual neurologic deficits. On exam, he's tended to palpation over the muscles just medial to the medial scapular border, but there's no tenderness over the thoracic spine, no pain with thoracic flexion and extension. No reproduction of pain with any sort of cervical motion at all, and no pain with shoulder joint range of motion both actively and passively. So I want to start with Dr. Frey here, Dr. Frey, having this case in front of you like, is there anything else you'd like to know in the history, physical exam and what do you think about your differential for this case. Yeah, so I think from a physical exam perspective, I would like to have a full shoulder evaluation just to make sure given some of the mechanism of injury during the game. I would also be interested in like looking at his scapula, probably have him at least in a gown so that I can evaluate any winging, look to see if there's any dyskinesis in terms of movement. And I would like to do a visual inspection to make sure I don't see any evidence of ecchymosis, given some of that acute onset symptoms as well. Some of the things that I might be thinking about would be something stemming from a tear in the area, given where he's tender, maybe an unusual rotator cuff issue or shoulder mechanism given what happened. Something maybe underneath his scapula, given some of that crepitus, such as a scapulothoracic bursa. I'd be less suspicious for neck or spine just given some of the mechanism and exam thus far. Got it, got it. So at this point in time, so let's just say that he's got maybe a little bit of pain with impingement maneuvers, but otherwise a good neurologic examination. There's no winging that you can observe, like no medial scapula winging or lateral scapula winging. I guess the question I'd have for you is, would you do any other diagnostic workup at this point? Yeah, I mean, I think an x-ray of the shoulder might be a reasonable thing to do in the office, just to take a look at things. If I had access to something like ultrasound, I might throw it on, just take a quick peek at his rotator cuff and maybe look at the area where he's most painful to see if I see anything concerning in the muscle. Yeah, so from an x-ray standpoint, are you thinking fracture or I'm just kind of getting a sense here from you? You know, not necessarily given the fact that he didn't fall on it. You know, I think that would be low on my differential, but given the acuity, I think it'd be worthwhile just taking a look at the shoulder joint. See if I see anything concerning from a high-riding humerus or just see if there's anything concerning from a dislocation. Like I said, given what has gone on and what he has described, I'm less suspicious for that, but it might be worthwhile taking a look. Anyone else have anything for a differential or thought process would be at the top? Yeah, I especially like that idea of the scapulothoracic bursitis, just given that kind of mechanical sense that the patient's feeling, that crunching sound. And, you know, I'd want to see if like when the shoulder moves, if I can kind of feel on the patient where that crepitus is actually located. Sure, sure. Sometimes it can be hard to diffuse at times. All right, so let's say you're in luck, okay? Let's say you're in luck, you're in a clinic where we just automatically get x-rays on everything that comes in if it's a shoulder region right here, right? So I'll put up some x-rays here for you and let me know what you think here. Yeah, just taking a look at these, they look pretty reassuring, very normal. I don't see anything concerning from an alignment perspective. Nothing obvious from arthritis, not that I would necessarily expect that given his age. The position of the humeral head is good. It's not high riding, which makes me feel reassured for a very significant rotator cuff issue. And so for those that are aware, you're just saying basically the rotator cuff holds that ball and socket in place. So if it's completely torn, that humerus can high ride basically, right? Yes. Looking at these x-rays, they look pretty normal. Playing here with a joint, normal space. I mean, he's a young guy, so you wouldn't expect to have any significant arthritis here. And then this axillary view, essentially looking, this is anterior and posterior, just making sure that there's no malalignment or dislocation, anterior shoulder dislocation here. All right, so you've got pretty normal x-rays. You're thinking maybe scapular thoracic bursitis or another issue with the periscapular muscles. What would you do from a treatment standpoint? You know, I think I likely would start him with some conservative treatment. His exam is pretty reassuring. I probably would have him start with some physical therapy first to see if we could improve his symptoms and have things improve. Okay. And from a therapy standpoint, I know we say physical therapy is physiatrist. We're really used to that. How would you direct the physical therapist? Let's say you're talking with a trainee and the trainee goes, well, you said physical therapy. What am I going to write in this referral? What would you have the therapist work on? Yeah, that's a great question. I think I would probably ask for maybe some hands-on modalities just from a pain control perspective, but really trying to focus on scapular mechanics, focus on scapular strengthening, position, posture, making sure there's not some other biomechanical thing that can be improved upon. Anything else, any other treatments that you guys would consider going for him? Not really. Okay. Great. So let's say he goes to physical therapy, right? And he's done six weeks of physical therapy and he's been diligently working on scapular strengthening, postural control, and he's not any better. So he comes back to you and says, hey, look, doc, I'm not any better. I still feel this pain right in that medial scapular border. I feel like something's torn, right? And I'm kind of losing faith in your abilities to help me. What's your next step? Is there anything that you would consider doing? Anyone. I mean, I think I would be open to getting some more advanced imaging with an MRI just to take a closer look. You know, I think the question might be, what might I take a look at with an MRI? That's a good question. I have. Yeah. Yeah. And so I think given his, where he feels his pain, I likely would put high on my list to get something like an MRI chest to look at those muscles. Other things that I would be thinking through and considering would be an MRI of the shoulder. Although I'm less suspicious for a shoulder issue given his exam and location. So that's lower on my list. You know, something of his spine, like the thoracic spine, I think also would be a lower yield given I'm less suspicious for that, given what he's been describing and experiencing. Anyone else thinking about where they would image? I mean, I think we'd have to sort out how much we think is like intrinsic to the shoulder, like the glenohumeral joint versus the true pathology is like really medial, as Dr. Frey stated. Got it. I know there's some questions that come through the chat box or these suggestions, right? One was from an imaging standpoint. We talked to Kyle back about x-rays, but also looking at the scapula and scapular position on x-rays. I would agree with that to make sure there's no fracture. Didn't include that in here, but that's a good point here. So let's see here. And then someone asked about what about soft tissue MRI, right? So that's kind of what we're getting at here. So in terms of this case, these are cases that I've actually seen before. So kind of giving you a heads up on that. We ended up getting an MRI of the chest, especially where he was describing the pain, kind of that medial scapular border. Now I want to point out for those of you guys who are savvy looking at this, this has left. So this isn't actually his MRI. It's actually a similar case, but kind of get the point here. The arrow is essentially pointing at where he put the marker for where his pain was, like right in this region here. So I guess, Dr. Frey, what do you think about this MRI overall? This would be an axial MRI right here. And then this is a coronal here. Yeah, I would say it looks very reassuring and looking at his muscle bulk. I don't see anything concerning from a tear. I don't see any concerning atrophy, but I can see a little bit of maybe some of the glenohumeral cut through in those. Nothing is really standing out to me as being concerning, especially in the area where his marker is placed. Yeah, typically on these T2, like this is a T2 fat set. Essentially, I mean, you can see the muscles right here. This is going to be your trapezius. Deeper than that would be your rhomboids. This line right here is going to be your scapula right here and your subscap muscles right over in this region. What I want to point out is that, you know, you talked about MRI of the shoulder versus chest, right? If you get an MRI of the shoulder and those of you guys have ordered it, right, a lot of it's going to be right here. Your focus is going to be on the rotator cuff. But with the chest, you get really not great resolution of the shoulder itself because it's kind of a zoomed out view. So you're really looking at sort of the muscles in the back and of the chest here. Now, I don't know. I was going to open it up to you guys. Whenever I get MRIs, I'm always having to justify obviously with insurance companies why we're getting this. An MRI of the chest is one where, you know, if you're saying there's a muscle tear, I always get pushback because that isn't typically the indication that people are looking for. Is that something you guys have experienced? Yes. I have experienced pushback from that, sometimes having to do a peer-to-peer to explain my justification. Yeah. So this is essentially a normal imaging, right? So you've kind of ruled out a tear. The guy's kind of reassured. What's your treatment besides PT? Is there anything else that you would do for him at this point in time? No objections. Yeah. I think given what he had been describing from that crepitus, still experiencing some of that with the movement of his scapula, I would be inclined to potentially try a scapular thoracic burst injection just to see if that could be helpful. Yeah. I mean, I think that's one of them. I think someone said trigger point injections. I would consider trigger point injections too. Well, maybe this is kind of sort of mild fashional treatment here. The one thing that I was going to ask you guys too is like, you know, just thinking about this case here with your mind is what do you think about sort of like a dorsal scapular nerve entrapment or basically a pole? Is that something that you guys see a lot or even consider on your differential? Yeah. I personally haven't seen it much. I think it's fairly uncommon even though, you know, shoulder girdle nerve injuries in sports, especially football, are not rare. You know, I think it would be on the differential. I think there was a comment in the chat about his cervical spine. You know, if I wasn't seeing any signs really from the cervical spine on my assessment, then I agree with Dr. Frey that crepitus plus the location of the pain, especially if I think the crepitus is under the scapula, then I'd be moving considering towards that scapulothoracic burst injection. But certainly we'd want to make sure that the C-spine was not a contributing factor. Okay. So let's just say we did do a scapulothoracic burst injection. So just to give some background here, this is from the Journal of Ultrasound Medicine in 2019. This person's in this sort of chicken wing position, which helps to elevate the needle aspect of the scapula here. And you can do this in a few different ways. Like I personally do these under ultrasound guidance. And so you'd put an ultrasound here and you're essentially you're aiming the needle right underneath the scapula here to the bursa. Now there are a lot of different bursa around the shoulder, right? This is just showing you the scapulothoracic bursa would be located here. This is going to be the subscap bursa here. And then this is considered the trapeziothoracic bursa as well. I don't know. I mean, I don't know what you guys think, but this I have a lot of surgeons that send me patients for these scapulothoracic burst injections. And frankly, when I do these injections, even though they're under ultrasound guidance, I can only see the needle as far as it goes right at the scapula border because it shadows, right? I'll put a picture. This is actually the injection. Here's my needle coming in here, the scapula here, but underneath the scapula, because it's bone on ultrasound, it just shadows all the way through. So, I mean, frankly, I think I could be in some musculature that's underneath the scapula as well. But what do you guys think? I think it's hard to know what layer you're in when you're doing this. I personally do these under fluoroscopy. I find that it's hard for me to really see the needle the way I want to under ultrasound, especially like you stated, seeing the distal aspect of it. So I would set the patient up as you described and then really obtain essentially like a scapular wide view on fluoro, and then you kind of find that space between the scapula and the ribs and then walk your needle right in there. I usually aim towards the scapula and walk off rather than aiming towards the ribs. Anyone else do these differently or just don't even do them at all? Yeah, I do them under ultrasound. I think that's what I'm comfortable with. But after hearing Dr. Olofson talk about the fluoro guided approach, I think I might try it. Yeah, I might have to try that too as well. Great. Yeah. So just from a real case standpoint, he did this injection about two or three weeks later, he had complete resolution of his pain and he was happy. The question I always have though is, is it just the fact that you put steroid in an area and he's getting better? Right. So just regardless of what it is, is it just time? Because now it's like eight weeks, two months after the onset of symptoms. So is he just going to get better anyways? Right. And so, you know, I think that while we could offer injections and from a time core standpoint, they seem like they correlate with resolution of symptoms. We just got to be careful that it's not attributing that variable versus just time. Right. Great. Let's see here. Just monitoring the chat box here. Yeah, I mean, exactly. So it's Dr. Cianca. Thanks for mentioning you're injecting something you have not seen on imaging. You cannot see while you're injecting. So, yeah, I agree that it doesn't necessarily make a lot of sense, but it's, it's it's why we're having this discussion here. Great. So here's case two here. So I've got a 17 year old high school baseball pitcher with gradual onset of left scapula, left scapula and posterior shoulder pain. He feels weakness with throwing a ball, especially during cocking phase. So this abduction external rotation, no radiation of pain down his arm past medical history. None. He's got full cervical range of motion without pain. No muscular atrophy. He's got good strength with subscapular and supraspinous testing, but subtle weakness with resisted external rotation, non-tenor to palpation over the shoulder, bony promises, trapezius deltoid muscles right here. All right. So Dr. Miron, excuse me, Dr. Olson has want to pick on you. What are you thinking? Like anything else you'd want on your physical exam history? And what's at the top of your differential? Yeah. I'd like to know a little bit more about his, his shoulder exam. You know, I'd like to assess, you know, with some pocketed maneuvers, I'd like to assess, assess, assess his labrum. You know, I'd like to do like an O'Brien's test, maybe a labral shear test. And I'd really like to look at him posteriorly. I know it's mentioned that there's no muscular atrophy, but sometimes like, you know, infraspinatus atrophy or other things can be fairly subtle. I'd also like to see, you know, do some lower extremity testing to see if there's something that's clearly abnormal in his biomechanics that could be contributing to the shoulder problems. And she is a thrower. And then making sure that I'm not missing like the entirety of the neurologic exam that I'm missing, not missing some other masquerading thing where he's numb in some place or he's have some subtle weakness elsewhere, but. Yeah, no, I think that's a great point. Especially looking at the lower extremity power. I think that's something we neglect a lot in throwers and, and having to sort of talk to them about strengthening the hip abductors. So let's just say for argument's sake, he's got a little mildly positive impingement maneuvers, Hawkins and Nears, mildly positive O'Briens, but nothing that really stands out here. Anything that you're thinking on your top of your differential or differential in general? Yeah, I think the thing that I'm focusing in on here is that he has some subtle weakness with this external rotation. You know, I'd be waiting in my mind, like how much of this is pain limited versus how much of it is true weakness. You know, going down the path that it's true weakness, then I'm thinking about does he have, you know, a suprascapular nerve or an axillary nerve, such as like quadrilateral space impingement, quadrilateral space syndrome issue. You know, he could be- That's pretty rare though, right? It's fairly uncommon, yeah. He could be having some internal impingement of his rotator cuff with that late cocking phase that he gets into. It's just a biomechanical thing, and he's really, from a actual structural perspective, it's fine, but that weakness makes me worried about like, is it truly weak or is this a pain limited thing? You mentioned internal impingement. How's that really different from kind of typically what we see as general, like sort of, you know, regular impingement that we see of the rotator cuff? Yeah, so it's really like impingement of the kind of undersurface of your tendons on the humeral head and glenoid in that like max, that cocking phase of the throwing cycle. And so it's just like the, where the tendons are getting impinged is just a different location compared to your typical like impingement between the humeral head and the acromion. So at this point in time, based on what you have here, would you, do you need further diagnostic tests? Yeah, I think starting with an x-ray is a great place. I'd like, if I had ultrasound in clinic, I'd definitely want to look at his cuff and like his posterior labrum. Absolutely, if I had access to that, that's what I would do. Okay, so let's say this, yeah, I mean, you treat a lot of patients that come far away, right? Two hour drive, right? So let's say this is a college bound athlete. He's got really good scholarship potentials. I mean, yeah, you have x-ray in your clinics, you get x-rays, I'll show you some x-rays and you also have an ultrasound too. You can do both in the same thing because he's traveling from far away. So I'll show you these x-rays. What do you think of his shoulder? Really looks like a healthy shoulder. I mean, the humeral head is well seated. The AC joint looks fine. I don't see any obvious degenerative change. I also don't see any like calcifications. I don't see, that's not, I don't see any abnormalities with the glenoid on the axillary view. Yeah, they look pretty unremarkable. Yeah, you're looking for like, like bony Vanguard, correct? Yeah, I'm just looking for any sort of abnormalities. Maybe he could have like a deficient glenoid, you know, that's sometimes a scene, but really these x-rays look pretty unremarkable. Yeah, I'd agree. All right, so then I'm gonna put up some ultrasound images here. Yeah, no, just looking at these few views that we've got fairly unremarkable looking ultrasound, you know, I definitely wanna make sure that I'm looking at the posterior shoulder, you know, spinal glenoid notch, posterior labrum, which overall in these images don't look particularly revealing. Yeah, I would say I don't see very much here. This is the infraspinatus here, posterior labrum. Can't see the anterior labrum with this view here and then spinal glenoid notch. Infraspinatus for me looks good. Maybe there's a little anisotropy right here at that footprint here, but otherwise it looks pretty good here. So you've got the x-rays, you've got the sort of ultrasound. Let's say you did more of a comprehensive ultrasound, okay, we'll just argument here. What would you do from a treatment standpoint then based off of this, any of you guys? Yeah, I guess I can, I'll jump in first. You know, again, I would return to sort of like probably check his strength a couple of times. And if I'm like thinking that this is either pain limited or it's really not subtle, or sorry, if it's subtle or really not even real, then I might start with a course of PT but have close followup, you know, in a couple of weeks to make sure that I'm not missing something that's progressing versus if I'm convinced that, you know, this is really weak, then I might consider next steps. But let's say that I thought it wasn't really weak and then I would start him in PT and have him come back for a re-examination in a couple of weeks. Yeah, so you started in PT, like rotator cuff strengthening, lower extremity strengthening, right? Yeah, also like making sure that the posterior capsule isn't too tight. And then also, you know, eventually looking at a sport specific biomechanics. So I'd want to make sure that I'd be sending him to one of our good throwing thrower PTs so that they're not just, you know, we're not just doing van external rotation all day long and actually looking at the rest of it. Sure, that makes sense. Anyone else? Would you guys do anything else? No, I agree with Dr. Olson. I would start with some conservative treatment, but I agree with the close followup, especially if there was some concern for maybe a little subtle weakness, I'd like to keep a close eye on him. Yeah, so let's just say for argument's sake, he did four weeks of physical therapy, right? And he's not any better. His dad is in the office with me now in followup four weeks and he's mad as hell because he can't pitch and essentially he's missed out on a lot of scouting opportunities since they're not able to showcase, so he's losing out potentially on scholarships, right? What would be your next step right here? Yeah, well, I mean, in this age group, and we already know what his rotator cuff looks like, I'd be starting to think a lot about the labrum and I'd wanna make sure that I'd assess for that. I'd re-examine for strength to see if there's any change to that external rotation that we were commenting on previously. And given that he has this kind of posterior shoulder and periscopular pain, common things being common, I'd wanna take a look at his labrum. All right, so let's say he's a little weaker in external rotation than compared to your first exam, right? Okay. Any role for advanced imaging at this point? Yeah, I think we're at the stage where getting an MR and probably doing an arthrogram would be of value. So with the things on the differential, we'd be able to image many of them. So let's say a labral tear, let's say that there's actually some denervation, like having a rare nerve injury or something like that, we should be able to see denervation on our fluid-sensitive sequences. Just because it's fairly early, we wouldn't think there's a lot of atrophy at this point in time. Got it. And any reason why you get, let's say like an MR arthrogram versus a regular MRI, any difference? Yeah. Say that again, I get kind of cut out. Yeah, so any reason for getting MR arthrogram versus just a regular MRI if you're looking at the labrum? Yeah, unless there's like a really high Tesla, like a 3T MRI to really differentiate the labrum. I just think that the resolution of the labrum is better with an arthrogram. The MSK radiologists and my surgical colleagues here certainly prefer that arthrogram when we're trying to answer a question about a labrum. Yeah, I mean, here at the University of Washington, I think a lot of folks would prefer an MR arthrogram, but there's some argument, if you have access to a 3T MRI, you can be able to take a look at labral pathology pretty well here. We have access to that as well. So I think a lot of it for me is also thinking about if someone needs surgery potentially, that sort of a surgical choice. All right, so I'll just jump to here. We ended up getting an MR arthrogram in the shoulder here. What do you think here, Dr. Olson? I'll just put the arrow here. Yeah, I mean, there seems to be a large, fairly uncomplicated looking, but like a fluid-filled mass in that spinal glenide notch. I suspect it's probably a parallel cyst filling up that spinal glenide notch. Yeah, I would agree there. Comment for me, this muscle right here, what do you think about this? I mean, you see this cyst here. And it certainly is contacting the muscle. It doesn't look like the muscle is overtly bright or atrophic. So even though the patient is having some weakness, it doesn't appear that there's clear, obvious, obvious signs of denervation, at least on the MRI. But that would be a concern, given the location of the cyst for the suprascapular nerve. Why do you think we didn't see, at least I'll go back to the ultrasound here, I don't clearly see like a cystic structure here. Why might not you have seen a cyst? It could be dynamic. It could be relative to activity. It could be relative to arm position. There's a number of factors where it could just sort of come and go, or maybe we, you know, we're all imperfect. Maybe we didn't image it well enough. Maybe we missed it and it was there. Got it, from an ultrasound standpoint, so user-dependent. Yeah, I mean, also, I mean, thinking about maybe it was a small cyst to begin with, you just can't appreciate it. And then now it's grown over time. Those are thoughts that I have here. Anyone else? Totally. Yeah, I think your point of it, like could be evolving over time is a really apt one. Okay, treatment-wise, based on this? Yeah, at this stage, I mean, we have a clear mass lesion here. You know, I'm not really concerned that it's anything but a cyst, but like this cyst is reflecting what's going on with the labrum, likely. You know, it looks like there's signal here, probably a tear in the posterior labrum, that, you know, the cyst is not going to get better, likely, unless that's addressed. So I would have him see one of my surgical colleagues for a consultation. I've had, you know, a number of patients like this. Every once in a while, the surgeon will send it back to say like, hey, can you aspirate this just because we can't get them in in a reasonable time? But I would want them to be connected with the shoulder surgeon early, that we know what's going on. Anyone else would aspirate this? I've never aspirated a cyst in the back part of the shoulder. Yeah, I agree with Dr. Olovson. My instinct would have been to have him see a surgeon first. The only cysts I've aspirated had typically been in an older population referred back from the surgeon. Either they're not a good surgical candidate or they want to try and defer that for a time. Yeah. Sure. And we can mess around with the cyst as much as we want, but if we don't fix the underlying problem, it's just going to recur, likely. Yeah, and also just monitoring the chat box here, people have mentioned that, you know, if he's coming from a far, far away distance, maybe the PT is inadequate, you know, comparatively, and it's not as good as maybe where you're at here. So other factors, but yeah, I mean, this kid was sent to a surgeon, they decompressed the cyst and repaired the labrum. And three months later, after further physical therapy, was back to throwing at a high level and did well. So that's this case here. Let's move on to the second, third case in the respective time here. So I've got a 55-year-old Microsoft programmer with acute two-day onset of severe left upper trapezius and periscopic pain, but no radiation to the forearm nor hand, no recent trauma. Pain is rated nine out of 10, and he prefers to be slumped forward with his neck flexed. Any upright posture or surgical extension worsens his pain. He's got a past medical history of hyperlipidemia and hypertension. No weakness in the upper extremities though, with manual muscle testing, normal sensory exam, normal upper extremity reflexes, negative Hoffman's, normal gait, he's got active shoulder motions do not cause pain. So I'm gonna throw this to Dr. Aaron Yang. What are your thoughts here? Anything else you wanna know on the history, differential? Yeah, so basically I would first think about his age. First of all, thinking, what is most common at his age group? I mean, he's in between, so he's not very young, but also would say not in the 80s. I would also just wanna know if he's ever had a history of axial neck pain before. Sounds like he does not have any neurologic symptoms, but also wanna know where he's tender on examination. It sounds like there's nothing really provocative that I could do per se that would make his pain worse. But just hearing sort of what he's mentioning without radiation into the extremity, I would think possible facet mediated, possible disc, possible myofascial pain. Those are some of the three things that come to mind in the top three differential. And I think someone said this and I said this yesterday, but the mystery is in the history. And the fact that they're coming in with severe acute pain, I think some things rise higher up in the differential in terms of pain generators. I'm not thinking myofascial pain. Again, thinking about the whole comprehensive history, I'm not necessarily thinking facet mediated pain. I know a lot of times my trainees say, oh, it's axial, it's probably the facet joints. Well, again, if you think about it, I tend to see that more as a slower process and not an acute exacerbation of pain. Yeah, I agree. I mean, when I think about like this acute, like sudden onset, I'm thinking facet's kind of more, you know, indolent, I'm thinking more disc herniation, but at least that's kind of what gets the top, something that's acutely just causing some compression or inflammation right there, right? Clyde, you, anyone else? I see a couple of comments. I was going to address it real quick. Two are Parsonage-Turner cervical radic, absolutely cervical radiculopathy is at the top of my list, to be honest, considering the acute presentation. Parsonage-Turner, I gave a talk yesterday about this differentiating this and cervical radiculopathy. I'm thinking more acute shoulder pain with distal arm symptoms in Parsonage-Turner, as opposed to acute neck pain without arm symptoms, which is, that's the case here. And we'll maybe talk a little bit more about it as the case goes on. Great, yeah. So I'm glad you mentioned the cervical spine. I'm just going to pop up this guy right here. Kind of the point of this case I'm sure to highlight is that, yeah, I mean, you, whenever I think about sort of posterior shoulder, upper back symptoms, this acute onset, I also am thinking about cervical radic. And you can see C6, C7, C8, the dermatome patterns can go that area. Certainly they go more distally down into the fingers. And if they go down to the fingers, like the thumb and they've got a pair of seizures, then I'm thinking cervical radic much higher. But I've had cases where I've had patients and it's just into this area right here and nothing more distally past the shoulder itself. I mean, have you guys seen that too as well? Yeah, absolutely. So I think someone mentioned in early radicular pain patterns, they could have a more proximal pain, especially periscopular pain. That can be very common. The other thing I didn't mention is actually I had a case where a patient presented with periscopular pain in absence of significant neck pain, a little bit of neck pain, but again, neck pain prevalence is very common. So for someone to have neck pain in general can be high, but that patient ended up having a Pankow's tumor because when he came back, he wasn't getting better with therapy. He eventually got an MRI and had an apical tumor. And by the time he came back and saw me, his symptoms were starting to radiate into the extremity. So initial presentation was just periscopular pain. Not saying we have to image everybody, but again, it's an unusual presentation. Yeah, and then just to jump in on that, you mentioned facets too. So this is the facet referral patterns that can occur based on Dwyer's work many years ago here. Definitely on the differential. All right, so you're saying kind of axial-ish neck pain, but maybe some radicular symptoms. At this point in time, would you get any kind of imaging in the clinic? You know, without neurologic symptoms, I always ask what is the utility of the x-ray? Is it going to change my management? Is the x-ray, am I expecting to see something on x-ray that's really gonna blow me out of the water and change up what I do? And to be 100% honest, I'm not sure an x-ray in this time where there's no neurologic symptoms, axial neck pain in a 55-year-old, I would have to ask how would that change my management? So maybe in this case, I would not jump to an x-ray, but if you have it, I think it's always helpful for reassurance for the patient too. In that sense, he is 55. So again, I would say, you know, if you have it, great. Yeah, I mean, I always joke that sometimes the therapeutic x-ray I'm getting in the clinic here. So I'm gonna put up a therapeutic x-ray right here. Yeah, yeah. What are your thoughts? So, you know, again, we have a AP and lateral view here. You know, as I like to always do with trainees, I always like to think about the ABCs of reading an x-ray. It's always just good to have systematic way of doing it. So again, starting with A, again, this is not really a flex, it's just a still image, but A is for alignment. And again, I don't really see significant amount of spondylolisthesis just right off the bat. B are for bones. I wanna make sure, I don't know if you can see my air, it might be yours, but looking at the cortices and just integrity of all the corners of the vertebral bodies to see if there's any vertebral body breakdown. I can't really see the cord, that's for C. D is for disc. You do have a little bit of spondylosis here. One, two, three, four, five, five, six. So those two levels have a little bit of disc-based narrowing as opposed to other levels. E are for exiting nerve roots. Again, more helpful for MRI. F are for facet joints. And so in terms of this view right here, again, just really looking, and it's really hard to always assess the facet joints in this view, but just looking for any major asymmetries on the right versus the left. And maybe right here, there's a little bit of asymmetry. But again, based on this x-ray, just sort of as I thought prior to, I don't think it really changes my management. Again, it's more of that reassurance here. Yeah, anyone else? Sounds like you're good, man. Okay, great. Yeah, so what's your treatment then set based off of this then? Yeah, so I probably would obviously start off with physical therapy first. You'd have to think about controlling his pain because it sounds like he's coming in with nine out of 10 pain. Again, leaving this sort of as we are, maybe thinking more of a disc, even though he doesn't have the extremity symptoms. So I would consider a strong anti-inflammatory. I do think there's some moderate evidence for muscle relaxers in the acute phase. So that can always be a start. Just again, it really has to gauge where the patient is at. If they're in really severe acute pain, maybe some neurologic symptoms, I may consider a course of steroids. But I would start off with physical therapy. So yeah, I agree with sort of someone in the chat box. Steroids are definitely in the option there, just depending on what the evaluation shows. And then- In terms of you doing a MedDRAL dose packs, you're doing like a course of 50 milligrams of prednisone for five days. Like what's kind of your choice? To be honest, I just do a traditional MedDRAL dose pack. So that's what I would start off with. But I know people have their own different formulations in terms of different dosages. And then in terms of therapy, I personally, if I'm thinking of the disc, I would try to send them to someone who's McKenzie trained to see if there's some type of directional preference. I would also consider some general traction, manual therapy. Yeah, and someone's also bringing up, it's a great point. I mean, there's not a lot of great literature in terms of use of oral steroids for radicular pain. Uh, most of the studies are based in the emergency room, not in a typical outpatient setting like ours, but I'll tell you, I mean, again, anecdotally, I mean, if, if someone's in severe pain and I give them a meloxicam and a flexoril, I'm probably getting a call back in a couple days that they're not doing better. And just anecdotally, steroids tend to do better for patients and not trying to throw steroids to everybody. But in this case, um, I would consider if they're nine out of 10, it's hard for me to look at someone who's nine out of 10 or 10 out of 10 and say, here's some muscle relaxers and an aproxine. And so, um, you know, we may talk about role of opioids, um, again, really, I personally would, depending on their medical history, lean more towards steroids than doing short acting narcotic medicines. Yeah. And I would, I would agree with that. And then we'll get a lot of comments in the chat box here. So I'll, um, I'll say this, let's say, for example, this guy, um, you give him the initial course of, uh, medications, like say steroids, you know, PT, like one or two weeks has gone back and now, and I use Epic at the university of Washington. I know you guys have, but we have this feature called my chart, right? My chart messages and patients send them all the time. Let's say this guy's sending you two messages a day saying he's in severe pain, can't work. He's thinking about fine for disability because it's that bad, can't sleep, right? At this point in time, like two weeks out, are you doing anything else? And we kind of mentioned medications a little bit, but are you going to be more aggressive? I'm just kind of wondering at what point do you say, Hey, no, Hey, hold, you know, hold the pattern. Let's keep going. This is just going to get better over time. Or are you that image? Yeah. Yeah. I mean, considering your patients, Brian up in Seattle, it seems like everyone comes back and they're really mad after one visit if they're not better. So, um, yeah, you have a lot to balance, you know, the question of role of imaging. I mean, if he's still in severe pain, I would, uh, consider an MRI, especially if he can't even participate in physical therapy and he's in severe pain. We're really limited in options, right? I mean, yes, you could give him strong enough medicines to where he's comfortable, but he may still not be very comfortable participating in physical therapy. So at that point I would consider, um, obtaining an MRI. Okay. So your luck. We get an MRI here. Okay. Uh, this is only one slice. I'll, um, I'll, I'll give you another picture here, but just general thoughts about this. Yeah. Just briefly again, ABCs, just going through that this time we can see, uh, the cord again, you have some slight flat, uh, flattening of the ventral, uh, CSF, but again, not significant cord signal changes. I think what you're really trying to point out is one, two, three, four, five, between C5, six, um, again, it's somewhat hard to see the exiting nerve root, but for the sake of this case, um, you may say there's some moderate foraminal stenosis on the left at five, six, he's got left axial neck pain again, thinking all things being common C5, six, C6, seven. So I'll give you another picture here, another slice, just a little bit above that level. Um, yeah, so, you know, I'm thinking, um, C5, six, C6, seven being the most common levels. Um, I think it fits that pattern. And so, you know, based on that, I would think maybe that could potentially be the pain generator here in terms of him with the axial neck pain on the left. Yeah. So we, we, so I don't necessarily say that you've got the diagnosis, but maybe more evidence that it's, it's cervical, right? Cervical spine, not something else. And, and maybe like Redick here, let's say he's got now, now he kind of declares himself a little bit more. He's got more pain that radiates down his arm, right. to the, the dorsum of the hand and maybe even to sort of the, the thumb region here. Um, what, uh, what would you do next? Is there anything, would you just say, okay, look, you've got the MRI, it's reassuring. You don't have any myelopathy concerning like terribly neurologic. You still got good strength, right? No, uh, negative Hoffman's no reflex changes. Would you do anything else, uh, from a treatment standpoint? Yeah. And I was going to get on this. I don't know if you're going to ask later, but really can a patient come in with cervical radicular pain or cervical radiculopathy in the absence of arm pain. And I'm only circling back to that because it can absolutely happen. Um, and I'm bringing up a study because I just presented on it yesterday and it's a great study in 2018. I'll put it in the chat box, but basically they took 239 patients who had a single level ACDF and had 75% relief at six months. So that was their standard and it was a retrospective cohort. And so in this case, what they did see is that about 50% of those patients who underwent successful surgery had dermatomes that followed the netters, like textbook that we all learned in medical school about 50% of the time. The other interesting thing was that even at C five, six, about 17% of them had axial neck pain without radicular arm symptoms. So can it happen? Absolutely. And we have numbers from a study that show that. And so it's much more common at the upper cervical levels, like at C three, four, where about 60% of them had just axial neck pain and some shoulder pain. So in this case, like it fits some of the, it may be that 17% cohort that this patient falls into. Um, and sometimes they may not have more radicular symptoms, but sort of to get back on track with this, I mean, considering the level of pain, I would consider a cervical epidural steroid injection. If they still cannot participate in therapy, if they're still, you know, I can't, I still have severe pain. Um, we've tried medicines, have tried a course of steroids or tried anything else. Um, I would, again, I think it would be helpful for that patient to get into therapy, but how can we get that patient to therapy is what I'm thinking about. And injection might be something to consider. So again, the, the individual got a cervical, uh, interline epidural injection. Um, obviously we talked about this being kind of on the, on the left side, and this is kind of more right paramedia. And this is just kind of an image that I had had to get it from my files here. Um, it was 50% improved at two weeks after this injection here. Um, so that's kind of what happened here. Um, I guess if you did more PT after this, right, how, how, how much longer would you let this go before you would send someone to a surgeon? Yeah. I mean, I think that's a tricky question. It really depends a lot on the patient and their sort of tolerance to sort of where they're at, you know, ideally, obviously we want to make sure we have exhausted all conserved options. If you go back to therapy, I would probably set up a follow-up because at that point they're starting therapy and they're 50% better. I'd give them at least three to four weeks and follow up and gauge where they're at. And especially in absence of severe arm symptoms or numbness or weakness, you know, again, I mean, it really depends on the patient's preference, right? We still have to listen to the patient at the end of the day. Otherwise, no one's going to come to me because I'm just forcing them to just tough it out, right? Because pain is something that they live with, not what I live with. So I think you really have to sort of gauge, um, where there are, um, someone mentioned about EMG nerve conduction. Um, you know, I think in this role, again, in absence of significant weakness, numbness, um, or reflex change, the pretest probability of a needle EMG showing something maybe low, right? And then I find that it causes a lot of confusion for surgeons because they don't understand that you could have radicular pain without a positive EMG. So if I have a normal EMG and a patient has questionable symptoms, it really doesn't help the surgeon much because they're thinking, well, that's a normal EMG. They don't have radiculopathy. And I'm reminding them a lot that you absolutely can't have radicular pain without positive EMG findings. Yeah, yeah. No, I agree with that too. I don't typically go to EMGs anymore for these. I mean, I clinically feel like I have the diagnosis and I don't necessarily know that it changes my personal management, but I'm open to, you know, obviously hearing different opinions and suggestions, right. Cause y'all got practice a little bit differently. Um, I was just going to chime in one, one thing real quick. There's been some discussion of partial niche Turner in the, in the chat, like can affect the, the, the spinal accessory nerve. But fortunately that's like not as common as the other manifestations. But again, we would see more like profound weakness atrophy and like, uh, they're winging in some regard if that really was the case. So, yeah. And again, you know, with parsonage Turner, um, yes, you're the pretest probability by the time you get an, uh, um, an EMG on someone with parsonage Turner would be high because they have profound atrophy. And I shared a case where a patient came in and they had severe shoulder pain followed by resolution of their pain, but they almost have this painless weakness. And so it just depends on where you catch them. But the chance with atrophy, obviously the chance that you needle that muscle, you're going to find something is pretty high. So, um, again, I think that parsonage Turner can be a consideration, but for this specific case, it's not as common. Yeah, I agree. I mean, just mentioning it to keep that in the differential, right? Because we always start off with a working diagnosis and I always tell patients it's a working diagnosis and that things can evolve and change over time. Yeah. All right. Uh, in the interest of time, I'm going to use case four here. Hopefully you can get to at least the end of this case here. Apologies here, but, um, I've got a 30, uh, year old Paya chef. Okay. Uh, presents for evaluation of diffuse bilateral upper back, thoracic and periscopic pain intermittently for the past three to four years has periodic flares typically brought on after upper body workouts, but lately more frequent flares without having worked out at all. Periods where he doesn't have any pain, but recently flared is he was getting his catering business started and was cooking more, so using his shoulders and arms, but admits he has also been stressful starting his business describes the pain is this kind of burning dull, constant pain has had some radiation to the left lateral shoulder posterior arm, but nothing below the elbow tried a total lack purse PCP and has been seeing a chiropractor doing massage therapies for two months, both continued pain. Notice he's very anxious. Uh, he's like really nervous about having, uh, this pain and he's worried that he has a tumor or mass in his spine. So past medical history, none review of systems. The only thing that he mentions is that he's been a little bit slightly feverish, um, and, but no night sweats exam wise, he's got this kind of head forward, rounded shoulders, posture, uh, as tenor palpation over the bilateral upper traps, kind of diffusely middle traps, paraspinals, uh, and his PCP happened to order x-rays of the thoracic spine. So Dr. Uh, Miron, I'm going to pick on you here. What are your thoughts about this case? Um, so this is a common, um, and not totally clear case, but I think on my differential, this is chronic pain. Um, it would include myofascial pain secondary to those postural abnormalities that, uh, we're seeing all the things we mentioned, like thoracic and cervical radicular pain around the differential referred cervical facet pain. Um, it's, it's bilateral. So you could consider PMR in the diagnosis. Um, but I think given his age is 30, that would be a lot less likely. Um, hearing that he's a little feverish, I think without objective findings, it's, it's hard to say, but it has me thinking about infectious, um, inflammatory conditions, um, like discitis or an abscess. I think it's a lot less likely, um, given the time course of this, but, um, always just want to keep that on my differential. And then, you know, you mentioned that he's feeling very stressed as pain seems to come on with stress. I'd want to make sure to do, you know, a complete history to hear about anxiety, depression, sleep disturbance. Um, cause we all know, you know, mood can contribute to pain and pain can contribute to mood. So we just want to make sure we're addressing those things as well. Yeah. And I agree. I mean, I, I, I, I try, you know, to see if we can probe into any anxiety, depression history. I think that can be helpful. Um, even though sometimes we have limited time in clinic, but I think it's from a physiatric approach and we're physiatrists, right. Uh, pretty good for us to sort of ask all that stuff here. Great. So I'll pop the x-rays of the spine here just quickly here. And, um, you know, what are your thoughts? Yeah, there's a, uh, mild scoliosis. I'm otherwise the alignment looks good. Um, disc heights look good. I don't see a compression fracture, um, or any other fractures. So generally pretty normal, nothing concerning on these x-rays. Yeah. And most times, again, this is kind of like a therapeutic x-ray, right? I mean, you don't have a history. He's 30 year old guy. It'd be unlikely to have compression fractures or fractures in the absence of trauma here. Just so you know, like in our clinic, we get x-rays on these patients that come in to anyone that has pain greater than three months or an acute trauma. They're going to get x-rays automatically in our clinic. So I'm often reviewing these and I do find it's very reassuring to be able to go through it with them. And then one, one short story, since I know we're low on time. Um, we had a patient when I was in residency who came in with, um, periscopular pain, that was a lot more focal than this, but, um, we did end up getting x-rays and there was actually a speculated lung mass that was causing like pleuritic irritation. That was, um, yeah. So glad we got the x-rays and sometimes you can find things you don't expect. That's great. Um, so, so for this guy, I mean, you have pretty normal looking x-rays, kind of diffuse pain. Uh, would you do any further workup at this point? I mean, at this point, I think if the, you know, like you said, we're talking to them, we're hearing, um, you know, how they're responding to the, going over the x-rays. So if he's reassured by the x-rays, um, and I'm reassured by the x-rays, I think I'd go to treatment and, um, do a course of physical therapy for, um, you know, posture positioning, periscopular strengthening, you know, right in clinic, I'll often demonstrate some like heart opener stretches to stretch the pecs and some, uh, scap periscopular strengthening exercises just so they can get started right away. Trigger point injections. No. And I, I, my comment is if, if obviously if the, if they're getting the sense that the patient isn't necessarily reassured by what you've gone over, I wouldn't be open to getting more advanced imaging at that time to help with assuring his anxiety. I would say like the two and a half months of physical therapy, doing what you had asked him to do, Dr. Miran, and, um, he has MRIs, right? He's pushing hard for MRIs. So you get MRIs of the thoracic spine and while you're there, you might as well throw in an MRI of the cervical spine cause he's got great insurance and he's also sending you five, my chart messages, right. Um, and insurance will pay for it. Cause he's got great insurance here. So what are your thoughts here? Um, yeah. So again, disc heights look normal. Canalex, Peyton. I don't see any disc bulges. We have only a couple of slices here, but on the ones I'm looking at, I don't see foraminal stenosis or central stenosis. Definitely. The point of putting these up is that they're normal. So now you've kind of reassured him. He doesn't have a tumor. He doesn't have a mass, no, no core injuries. Neurologic exam is good. Um, and he's done PT, chiropractic care, massage therapy, like any treatments that you would consider. I guess specifically I'll ask you, would you start him on any medications? And he's still pretty anxious kind of guy and he's never seen. Yeah. I think at this point is when I start considering medications, again, have the conversation about, you know, reassurance, everything, your spine is strong, you're stable. It's okay to do activities. I think like giving patients permission to do physical activity can be really helpful in these cases because especially someone who's very anxious, um, might be scared to do something. So having the guidance of the physical therapist to help them through that has not worked to this point. So I think at this point I would consider, um, medications. Um, I tend to go to duloxetine in this case, if they're not already on an SSRI, I think it can be helpful for both chronic musculoskeletal pain, which is approved for, um, and some of the mood component of this. So I typically start at 30 milligrams for a week and then if they're tolerating it, um, particularly the GI symptoms, um, go up to 60 milligrams after a week. Yeah. I mean, duloxetine is something that I will use decently frequently. Um, it's FDA approved for chronic musculoskeletal pain, fibromyalgia. Right. And so that, um, I also sometimes will use, uh, pregabalin or Lyrica, um, you know, for, you know, it's more for, you know, diabetic peripheral neuropathy. Right. But, uh, I mean, it could be used for myofascial pain, fibromyalgia. Right. So easier to titrate than gabapentin. Um, and if you guys also use any other medications, TCAs, anyone would use TCAs here, I would also consider maybe a non-medication option, you know, in, uh, some of my colleagues we could potentially consider doing acupuncture for this patient, that might be another option. Um, it'd have to be, you know, certainly any of these options in line with what the patient feels comfortable with since anxiety and like his, um, his feelings are certainly driving a lot of this and it should drive the treatment, right? He should feel comfortable with it. So if acupuncture is something that they're not keen on, um, you know, I've definitely patients who are not keen on needles, uh, but if they are, I think it could be a helpful thing as well. Yeah. People have mentioned the chat box, trying lifestyle changes, biomechanics, right, and breathing techniques. And certainly, yes, this is, this is, these are things that we should all, I think, mention to the patient. Um, I've tried a lot. I mean, I live in Seattle, Washington. So there are a lot of folks who are very, I'll say it's natural or would gravitate more towards non-pharmacological, non-interventional procedures. And we try that, um, they get to a point where they're still not better. And so, yeah, I think that medications might be a consideration at this point in time. Um, great. Um, so this person, yeah, we actually put them on duloxetine. And, uh, after about two months of being on this mood was much better. It was less anxious. Pain was completely resolved. He actually tried a course of acupuncture, um, didn't help. Um, and, and, and also tried rolfing rolfing out of you guys are familiar with rolfing or structural integration, right? So a really deep tissue guy massage. So these are just kind of other things to consider. Um, I think we had two minutes left here. Um, I just have some other cases that I don't think we have time to go through them, but I want to sort of mention to people in case you guys have seen the slides, this case five here, um, was meant to sort of highlight compression fractures to keep on the differential. So something, thoracic compression fracture, and given this patient's history of breast cancer and depression, why don't you guys just keep in mind that, um, you know, it might be osteoporotic stress fractures, but it could also be pathologic. So things to sort of think about too. Um, so this is the thoracic spine imaging for this patient here, compression fractures at the T4 and T10. And then, uh, the case six that we have here, this is meant to sort of highlight, um, someone who's talking about having shoulder pain and they've got a history of hypothyroidism. So thinking about, is this shoulder like adhesive capsulitis issues, uh, rotator cuff issues, or is this person also suffering from potentially polymyalgia rheumatica? And, um, you know, we didn't mention anything about, uh, in the case here about getting out of a chair, having difficulty, but that's something I'll ask anyone over age of the 50, who's got this sort of diffuse shoulder pain. Uh, and periscopic pain is whether or not they're having a difficult time getting out of a chair, having pretty proximal hip girdle weakness, uh, and then thinking more closely about things like lab work. So yes, our CRP. All right. Um, I think we're running out of time. So I just want to see, uh, you guys have great, uh, comments in the chat box. Sorry, we didn't get to all the cases in full. I really appreciate everyone being here for the panel and everyone's comments in the chat box as well. Um, thanks so much. And, uh, let us know if you have any questions. Thank you all. That was great. Take care.
Video Summary
The video discusses several cases involving shoulder and upper back pain. In the first case, a 21-year-old football player experiences burning pain near the scapula border after a game. The panel suggests a thorough shoulder evaluation, including imaging such as an x-ray or ultrasound, to look for any tears or injuries. Physical therapy is recommended, with a focus on scapular mechanics and strengthening exercises. If the patient does not improve after therapy, an MRI may be considered to assess the muscles and labrum. In the second case, a 17-year-old baseball pitcher has pain and weakness with throwing. The panel suggests a full shoulder evaluation, including imaging such as an x-ray or MRI to look for any issues with the rotator cuff or labrum. Physical therapy is recommended, along with a possible scapulothoracic bursa injection. The third case involves a patient with acute upper trapezius and periscapular pain. The panel considers cervical radiculopathy and suggests physical therapy and medication options such as anti-inflammatories or muscle relaxants. If the pain persists, an MRI may be considered. In the fourth case, a patient with chronic back pain is reassured by normal x-rays and the panel suggests physical therapy and stress management techniques. In each case, the goal is to assess the patient and tailor treatment accordingly, considering imaging, therapy, and medications as appropriate.
Keywords
shoulder pain
upper back pain
football player
scapula border
shoulder evaluation
imaging
physical therapy
strengthening exercises
MRI
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