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Examination of the Shoulder
Published in J. Terrence Jose Jerome, Clinical Examination of the Hand, 2022
Muscle bulk is next assessed with direct visualization. Wasting of the musculature within the supraspinatus and infraspinatus fossae, trapezius, deltoid and pectoralis major is assessed. Peripheral neuropathies of the shoulder may be difficult to detect on clinical examination alone. Nerves such as the suprascapular nerve lack sensory components or reflexes, and symptoms may be difficult to discern from additional shoulder pathology such as rotator cuff tears.3 If there is concern for neuropathy based on further examination, an Nerve Conduction Velocity/ Electromyograph (EMG) may be obtained to further the diagnostic workup.
Neurodegeneration, ataxia, and retinitis pigmentosa (NARP)
Published in William L. Nyhan, Georg F. Hoffmann, Aida I. Al-Aqeel, Bruce A. Barshop, Atlas of Inherited Metabolic Diseases, 2020
William L. Nyhan, Georg F. Hoffmann, Aida I. Al-Aqeel, Bruce A. Barshop
Some patients have been impressively hypotonic [9]. Others have had localized proximal muscle weakness but, as recognized in the initial series, the weakness is neurogenic. Muscle biopsy does not show ragged red fibers or abnormal mitochondria [1–3, 9–12]. There may be evidence of denervation, lipid droplets, or variation in fiber size diameter. The electromyogram (EMG) is normal.
Clinical Problem Solving
Published in Walter J. Hendelman, Peter Humphreys, Christopher R. Skinner, The Integrated Nervous System, 2017
Walter J. Hendelman, Peter Humphreys, Christopher R. Skinner
The electromyogram (EMG) is a technique for investigating peripheral neuromuscular disease by recording electrical activity directly from muscle, using either needle or surface recording electrodes. Using this technique, it is often possible to distinguish between myopathic and neuropathic causes of muscle weakness.
Applying a clinical decision-making model to a patient with severe shoulder pain ultimately diagnosed as neuralgic amyotrophy
Published in Physiotherapy Theory and Practice, 2022
The patient went to urgent care that day and received a diagnosis of “shoulder pain” and was referred to an orthopedic surgeon. Three days later, the orthopedic surgeon found moderate weakness of the right shoulder in all directions and pain with ROM. A diagnosis of labral tear was given after the apprehension, relocation, load and shift, and grind tests were positive for pain. Radiographs taken were normal. Differential diagnosis included: inflammatory arthropathy; posterior impingement; and large effusion. The patient was instructed to perform ROM/strengthening exercises at home and was told to call back if symptoms persisted. When asked about the possibility of NA, the orthopedic surgeon responded that it was very unlikely. Pain improved significantly over the following weeks but because the patient reported persistent weakness, an MRI was ordered by the orthopedic surgeon and performed 3 months after onset of symptoms. The magnetic resonance imaging revealed diffuse intramuscular edema within the supraspinatus and infraspinatus, which was consistent with NA (Figures 2 and 3). Due to continued reports of shoulder weakness, a referral to a neurologist was ordered and electromyogram (EMG) performed 4 months after onset. EMG revealed positive sharp waves and fibrillation potentials in the right serratus anterior, infraspinatus, and supraspinatus. Reduced recruitment and an increased proportion of high amplitude, long duration polyphasic motor unit action potentials were seen in the supraspinatus (Table 4).
Slow progression of amyotrophic lateral sclerosis in a Chinese patient carrying SOD1 p.S135T mutation
Published in Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 2022
Hanhui Fu, Kang Zhang, Xunzhe Yang, Libo Li, Liying Cui
Physical examination revealed no signs of cognitive impairment or bulbar palsy. Prominent atrophy was observed in her four limbs, more severe in the first dorsal interosseous muscles bilaterally. The Medical Research Council (MRC) grade of her right limbs was 2–3 and the left side was 4. Tendon reflexes were not elicited and bilateral pathological reflections were absent. No sensation disturbance was found. Nerve conduction velocity was normal. Needle electromyogram (EMG) revealed fibrillation and fasciculation potentials, as well as signs of neurogenic impairments in the cervical, thoracic, and lumbosacral segments. Routine hematological examinations, cerebrospinal fluid testing, brain and spinal cord MRI were unremarkable. Considering the long survival time that is different from the classical ALS phenotype, we conducted whole-exome sequencing (WES) for the patient and her family members. A missense mutation SOD1 c.404G>C, p.S135T was detected in this patient, but not in any other family members. (Figure 1(A,B)).
Unusual presentation of thoracic disc herniation
Published in British Journal of Neurosurgery, 2021
Thomas Zambelis, Andreas Polydorou, Evangelos Anagnostou, Pavlos Angourakis, Sofia Vassilopoulou
A 57 year-old man developed transient pain in the upper back during heavy weight lifting. Five days later he noticed painless right lateral abdominal wall swelling (Figure 1(A)). A possible hernia of the abdominal wall was initially suspected, but ultrasound and Magnetic resonance imaging were normal. We saw the patient one month later. With the exception of the abdominal wall bulge, more evident in the upright position, physical examination was normal. Magnetic resonance imaging (MRI) disclosed a right T11–T12 extruded disc with migration medial to the T11 pedicle, (Figure 1(B)). Concentric needle electromyogram (EMG) disclosed spontaneous activity (fibrillation and/or positive sharp wave potentials) in the thoracic paraspinal muscles (TPM) at the T11, T12 and L2 level on the right side, in the right external oblique muscle (needle inserted in the bulge) and in the right Rectus abdominis at the T11 level. No spontaneous activity was observed in TPM at the T8 level on the right side and at the T11 and L2 level on the left side as well as in the left 1st dorsal interosseous and right Tibialis anterior. Motor and sensory nerve conduction velocities were also normal. On re-examination, four months later, the abdominal wall bulge was still present, but the patient was feeling better with no back pain and conservative treatment was recommended. After four more months the bulge was significantly subsided (Figure 1(C)) and EMG showed a few fibrillation potentials only in the Rectus abdominis.