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Old 26-07-2011, 09:25 PM   #1
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Default What would cause this?

Had a patient today. Otherwise healthy 30 year old male. Presents with shoulder pain and "twitching" around the shoulder.

He essentially has noticed the muscle twitching getting worse and his friends started to notice and ask him what the heck is going on.

He reports falling in May and grabbing a bar overhead to prevent landing face first. He had some shoulder pain then but it quickly settled down and he had full shoulder range of motion and no pain by mid June. Then in the past three weeks, he started to notice the twitching and general pain when raising the arm overhead.

He does have shoulder pain with abduction but it was very hard to test anything really as his shoulder would go into rather large convulsions( almost like he was hooked up to a muscle stimulator).

I attempted to test glenohumeral stabilty by placing the arim in 90 degrees abduction/external rotation and performing an anterior push. This caused what the patient describes as a "locking" sensation and his arm went into these large muscle twitches.

Even if he is just sitting there answering questions you can see the muscles twitching under his t-shirt.

Can shoulder instability cause this sort of involunatry muscle spasm( large convulsions)?

Any insights/past clinical experiences appreciated.
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Old 26-07-2011, 09:53 PM   #2
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Did he have an episode of instability at the time of the injury? Seems like shoulder instability should be worth investigating. Able to assess the shoulder at all other than what you've noted?
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Old 26-07-2011, 09:57 PM   #3
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Does the twitching include the neck? Does the twitching include the forearm?
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Old 26-07-2011, 10:04 PM   #4
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Can shoulder instability cause this sort of involunatry muscle spasm( large convulsions)?

I would think so, especially in the face of triple crush syndrome. Referred pain from neck, and wrist as well as the shoulder.

An ortho sx showed me how to do an instability assessment with out all the pain of abduction, external rotation. Simply have the pt lean foward, arms unsupported, (knuckles to floor gorilla style), and feel the gaps at the anterior shoulder between the humoral head and tip of glenoid fossa. Knuckles shouldn't touch the floor of course. Probably easiest done standing.

Good luck

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Old 27-07-2011, 01:30 AM   #5
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Quote:
Originally Posted by Jason Silvernail View Post
Did he have an episode of instability at the time of the injury? Seems like shoulder instability should be worth investigating. Able to assess the shoulder at all other than what you've noted?
Not that he is aware of. He had a little shoulder pain after the incident, but it settled quickly and he felt he was fine. It was the suden onset of extreme twitching that started 3 weeks latter that alerted him that there was a problem.

It did seem like instability to me however I was a little taken aback by the magnitude of the muscle spasm around the shoulder. Even when the shoulder wass at rest down by his side his muscles were just convulsing away like I had hooked him up to NMES at turned the dial up full...

Quote:
Does the twitching include the neck? Does the twitching include the forearm?
no....only around the shoulder( teres minor/major/deltoid)

Have any of you come across this with shoulder instability? And if so....I'd have to gather we are talking some pretty wicked instability likely requiring surgical intervention?
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Old 27-07-2011, 01:47 AM   #6
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Here are some possibilities.

Any findings that make you think it is something more sinister?
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Old 27-07-2011, 02:00 AM   #7
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My first hypothesis would be minor injury to the axillary nerve.
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Old 27-07-2011, 03:10 AM   #8
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were you able ti identify which muscles were "twitching" in the shoulder?
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Old 27-07-2011, 03:50 AM   #9
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I agree with Jon. Seems like a medical work up for some neurological issue. Referral to neurologist, possible NCV/EMG to assess health and function of various nerves/plexus.

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Old 27-07-2011, 04:52 AM   #10
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I would agree with Gilbert. Axillary nerve, quadrangular space, tunnel syndrome.
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Old 27-07-2011, 06:37 AM   #11
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I agree with Gilbert and Diane re the axillary nerve.
If nothing changes in presentation, a medical neuro workup could be the way to go.

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Old 27-07-2011, 02:05 PM   #12
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Quote:
Originally Posted by garydiny View Post
I agree with Jon. Seems like a medical work up for some neurological issue. Referral to neurologist, possible NCV/EMG to assess health and function of various nerves/plexus.

Gary
Hi Gary,

I appreciate the support but I didn't really say anything to agree or disagree with. I simply supplied a list of presentations which have *fasiculation* as a presenting feature. As the link notes, the majority of the time fasiculations are benign. I also asked whether there are any other details that may lead proud to think there is something more sinister going on.

That said, twitching that doesn't go away with active movement (and possibly gets worse with it) does seem more suspicious than twitching that does go away with active movement.

What are your thoughts proud? Keep us updated on his progress.
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Old 27-07-2011, 02:30 PM   #13
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Magnesium deficiency can also cause this, i've had it numerous times and magnesium almost always has helped.

The shoulder instability may have already been there.
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Old 27-07-2011, 02:44 PM   #14
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CDano, magnesium deficiency with only one location of effect?

I agree with a deeper neuro-issue like axillary nerve; "twitching" or fasciculations are quite different from what appear to be all-out contractions of the whole muscle(s).
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Old 27-07-2011, 04:43 PM   #15
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Quote:
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CDano, magnesium deficiency with only one location of effect?

I agree with a deeper neuro-issue like axillary nerve; "twitching" or fasciculations are quite different from what appear to be all-out contractions of the whole muscle(s).
This is purely my personal experience. When i get twitches, its only in one place, it sticks around for weeks, and magnesium has helped. This last conclusion, is open for discussion of course, maybe its just been a coincidence.

After the twitch has gone, the next time it comes back can be a totally different location, but its always one, or at most two locations.
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Old 27-07-2011, 05:53 PM   #16
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Quote:
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I agree with a deeper neuro-issue like axillary nerve
How would/could one differentiate this?
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Old 27-07-2011, 07:21 PM   #17
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Are you sure about the teres major? Been obsessing about it.
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Old 27-07-2011, 07:45 PM   #18
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If it were axillary nerve, given the large amplitude of involuntary muscular activity, wouldn't sensory symptoms be expected as well? I'd check pinprick in the axillary nerve distribution and compare to the other side. The muscular activity may interfere with this, I'm not sure.

Both Butler and Shacklock describe a similar method of tension testing the axillary nerve in their books.
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Old 27-07-2011, 11:58 PM   #19
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One could easily deduce that axillary nerve was involved by knowing beforehand the nerve that innervates deltoid, i.e., axillary. It also provides cutaneous supply via cutaneous branches. It would be unlikely to be any other nerve, if deltoid is fasiculating.
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Old 28-07-2011, 12:42 AM   #20
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Quote:
Originally Posted by Diane View Post
One could easily deduce that axillary nerve was involved by knowing beforehand the nerve that innervates deltoid, i.e., axillary. It also provides cutaneous supply via cutaneous branches. It would be unlikely to be any other nerve, if deltoid is fasiculating.
Of course. Nothing strikes you as more sinister requiring referral back to the Physician?

I did not pick up anything in the history that would cue me to believe so...although through 15 years of clinical practice( and TONS of patients)...I've yet to come accross a presentation even remotely similiar.

Docjohn:

Quote:
Are you sure about the teres major? Been obsessing about it.
Quite certain. Why are you obsessing about it?

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Old 28-07-2011, 01:17 AM   #21
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I agree with Diane.


"twitching" around the shoulder.



It could be the neck or the axillary nerve.


Differential Dx


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Old 28-07-2011, 01:27 AM   #22
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I've had a patient recently with something of the sort in her levator scapulae. But nothing so intense as you describe it Proud. I too would suspect the axillary nerve. The «trauma» mechanism could implicated it if the pt vigourously contracted his terez muscles thus affecting the nerve in the quadrangular space. So are there sensory symptoms or not?

It could be fatigue related ? If these muscles are always strongly contracting in a protective fashion, it could induce this fasciculation after a while maybe. Or, the twitching could be present when he tries counsciously or not to stop the contractions.

Is it twitching when he sleeps?
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Old 28-07-2011, 01:45 AM   #23
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What I would do, as a manual therapist, is see if treatment targeted at axillary nerve would help with the symptoms/signs. I would be less inclined to worry that it was the neck, because if it was the neck, say, at C5 level, a bunch of other stuff that C5 supplies would also act up, somehow. Would it not? Not to say it couldn't be both, say small percent neck and large percent posterior axilla/quadrangular space. Double crush.

If treatment judicisously applied to axillary nerve/its receptive field(s) did NOT help, then I'd swiftly assume red flags/move to send the patient forward for medical testing.
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Old 28-07-2011, 01:57 AM   #24
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Quote:
Originally Posted by Frédéric View Post
Is it twitching when he sleeps?
Good question...never thought to ask.


Quote:
So are there sensory symptoms or not?
No. Although I repeatedly had to ask as he was constantly making a fist in similiar fashion you usually see when people have either pain, pins/needles in the hand. He indicated that he does that just because this seems to help relieve some of the "tension" in his shoulder.



Diane,

Could you describe some DNM you might apply here?

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Old 28-07-2011, 02:09 AM   #25
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Quote:
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Good question...never thought to ask.

Diane,

Could you describe some DNM you might apply here?
Nothing too complicated. Side lying, comfortable, neck support. Lift arm carefully up into abduction, stop at first hint of resistance, prop arm up (so patient doesn't have to hold it up, especially if it's twitchy. Treat lateral cutaneous nerves first, as they are most superficial. Then, very gently, very slowly, with nice flat hand contact on skin over lateral border of scapula, push skin and scap together, medially, down toward the floor. Go slow so that no resistance is provoked by you. Stop at the first sign of inherent resistance. Wait for it to go away. Continue. This will create an opportunity for the brain to
1. let go of "too much" motor output into the borders of the quadrangluar space, i.e., the three muscles that along with the humerus make up the 4 sides; teres major, minor, and long head triceps.
2. allow descending modulation to occur in response to mechanically induced vascular response (leading to oxygenation) within the nerve/neural tunnel of axillary nerve. Also subscapular nerves and suprascapular nerve. Probably some stim of deeper nerves such as long thoracic and thoracodorsal and dorsal scapular; medial and lateral pectoral and intercostobrachial.
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Old 28-07-2011, 02:13 AM   #26
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Quote:
Originally Posted by Diane View Post
Nothing too complicated. Side lying, comfortable, neck support. Lift arm carefully up into abduction, stop at first hint of resistance, prop arm up (so patient doesn't have to hold it up, especially if it's twitchy. Treat lateral cutaneous nerves first, as they are most superficial. Then, very gently, very slowly, with nice flat hand contact on skin over lateral border of scapula, push skin and scap together, medially, down toward the floor. Go slow so that no resistance is provoked by you. Stop at the first sign of inherent resistance. Wait for it to go away. Continue. This will create an opportunity for the brain to
1. let go of "too much" motor output into the borders of the quadrangluar space, i.e., the three muscles that along with the humerus make up the 4 sides; teres major, minor, and long head triceps.
2. allow descending modulation to occur in response to mechanically induced vascular response (leading to oxygenation) within the nerve/neural tunnel of axillary nerve. Also subscapular nerves and suprascapular nerve. Probably some stim of deeper nerves such as long thoracic and thoracodorsal and dorsal scapular; medial and lateral pectoral and intercostobrachial.
Thank you. Sounds quite similiar( I think ) to the DNM for the suprascapular nerve?

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Old 28-07-2011, 02:18 AM   #27
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Well, I think you could treat suprascapular in lots of different positions. My fave for that particular nerve is prone, with arm straight or flexed and in different angles, and rotations, including hanging straight down. I think arm in 90 degrees abd, 90 degrees external rotation, puts that nerve in its slackest situation. But it would be nice to be able to visualize various nerves in various positions with ultrasound or something, some day. Until then, who knows for sure? We guess based on improved motor and decreased pain output, which are, as we all well know, wildly variable and subject to descending modulation secondary to expectancy.
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