Shoulder pain syndrome is an especially frequent challenge accountable for numerous medical professional visits annually. Coming on the heels of back pain, it is the 2nd most typical musculoskeletal complaint. Severe shoulder pain can have debilitating effects on one’s daily life. Your shoulder contains a wealth of nerve endings. Typically soreness or damage in one part of the body can be sensed in a different spot. This can called referred shoulder pain. https://www.theshouldercenter.com/resources/

1. How does EMG/NCV fit in a
Tertiary Care Shoulder Practice?
Vivek Agrawal, MD
The Shoulder Center
Carmel, Indiana

2. The Shoulder
• Present cases to
help highlight the
importance of
detailed shoulder
girdle/cervical
EMG/NCV for our
shoulder patients.

3. Case #1
• 84 y/o retired business owner
referred with persistent
shoulder pain/ debility.
• RIGHT TSA 10/2006
• RIGHT TSA revision and RCR
2007
• RIGHT shoulder arthroscopy
debridement and RCR 2007
• Peripheral Neuropathy
• TIAs

4. Case #1
• Right shoulder:
Neurovascular Exam: Anterior Interosseous
intact, Posterior Interosseous Nerve Intact,
Radial Nerve Intact, Ulnar Nerve intact, Median
Nerve Intact, Radial pulse present, Ulnar pulse
present.
Inspection: infraspinatous atrophy ;PREVIOUS
DELTOPECTORAL INCISIONS.
Sensation to Light Touch Normal.
Active ROM: Active FF/ER/IR (90)=30/20/10.
Active External Rotation Severely Limited.
Active Internal Rotation Dorsum of hand to
buttock.
Passive ROM: Passive
FF/ER/IR(90)=60/50/20.
Strength testing: Deltoid: +3/5.
Infraspinatus: +4/5.
Subscapularis (Belly Press): Positive.
Palpation: RENT Test Positive for Full
Thickness Tear.
• Cervical Spine C3-4
Spondylolisthesis GRADE I; C4-5
C5-6 C6-7 Advanced DJD
Multilevel Arthrosis
• EMG/NCV
• Supraspinatus: 2.3ms latency and
0.5mV amplitude
• Infraspinatus: 2.7ms and 0.2mV
and Temporal Dispersion
• Normal Axillary Nerve
• No evidence of Radiculopathy,
Plexopathy.

5. Case #1
• Based on Severe Suprascapular
Nerve Pathology but Intact Deltoid
performed:
• Right Reverse Total Shoulder with
Removal of Failed TSA in
September 2008
• Examination April 2010:
• Excellent Pain Relief and Overhead
Function
Right shoulder:
Inspection: all surgical wounds
healed.
Active ROM: Active AB=155.
Strength testing: Deltoid: -5/5.
Infraspinatus: -5/5.
Subscapularis (Belly Press):
+3/5.

6. Case #2
• 57y/o with persistent pain/debility
following hemiarthroplasty performed
Dec. 2007 complicated by
intraoperative spiral fracture
• Left shoulder:
Neurovascular Exam: Anterior Interosseous
intact, Posterior Interosseous Nerve Intact, Radial
Nerve Intact, Ulnar Nerve intact, Median Nerve
Intact, Radial pulse present, Ulnar pulse present.
Inspection: infraspinatous atrophy// left deltoid
atrophy present// all surgical wounds healed// no
scapular winging.
Sensation to Light Touch Diminished.
Active ROM: Active FF/ER/IR (90)=70/10/25.
Active External Rotation Hand behind head with
elbow held forward.
Active Internal Rotation Dorsum of hand to L3.
Passive ROM: Passive FF/ER/IR(90)=,
ACTIVE=PASSIVE.
Strength testing: Deltoid: +3/5.
Supraspinatus: +3/5.
Infraspinatus: +4/5.
Subscapularis (Belly Press): -5/5 (Break Away).

7. Case #2
• EMG/NCV-
• Posterior Deltoid 1+ fibrillation
potentials, 1+ positive sharp
waves, increased polyphasic
motor units with prolonged axillary
latency 6.6-7.8ms with amplitudes
5.8-7.7mV. Demyelinative Axillary
Neuropathy without Conduction
Block
• SSN-prolonged latency to SSN
7.0ms with low amplitudes 1.1-
2.6mV and temporal dispersion
• Cervical Radiculitis/Radiculopathy
at C6 and/or C7

8. Case #2
• Referred for primary
evaluation and treatment
of radiculopathy
• Had C6 and C7 selective
blocks and good
neurogenic symptom
control with multimodal
regimen
• Left shoulder arthroscopic global
capsulotomy and extensive debridement,
acromioplasty, distal clavicle resection,
suprascapular nerve decompression
(bony suprascapular notch) and axillary
nerve decompression

9. Patient #2
• Visit 15 months postop:
• Excellent Pain Relief
and below shoulder
level function with
ROM:
FF/ER/IR(90)=125/70/70.

10. Case #3
• 25 year old male presents with c/o pain Hx of
garage door falling and crushing cervical vertebrae
approx 1 yr ago had A&P cervical fusion , Location:
anterior and posterior radiates down arm to elbow ,
numbness and tingling, c/o weakness and atrophy. ,
Nature: dull in cervical area, sharp in shoulder ,,
reports popping with some movements that is
painful., Aggravated by: reaching overhead for short
periods of time, reaching across chest, twisting,
driving, lifting over # 5
• Right Shoulder Exam: Dynamic Scapular Winging
• Strength testing: Deltoid:, +5/5.
Supraspinatus: +4/5 improved to -5 with
scapula stabilized.
Infraspinatus: +5/5.
Teres Minor (Hornblower's): Intact.
Subscapularis (Belly Press): +5/5.
Subscapularis (Lift Off): +5/5.
Palpation: ACJ non-tender SLAP test
positive RENT Test is negative.
Tests: POSITIVE O'BRIEN positive
Yergason's.
Stability tests: post. apprehension positive.

11. Case #3
• EMG/NCV:
• SSN: Normal latency with severely low
amplitudes to both Supra and Infra with
significant conduction block
• Chronic C6 and C7 radiculopathy
• Normal Axillary Nerve Function
• Normal Long Thoracic and Dorsal Scapular
and Thoracodorsal Nerve Studies
• Referred for Diagnostic SSN block which
did not provide much relief (? Severe
conduction block)
• Mechanical Symptoms severe enough at
shoulder that wanted to proceed with
Arthroscopic Management.
• RIGHT shoulder arthroscopic capsular
shift with extensive labrum repair, type II
SLAP lesion repair, and suprascapular
nerve decompression

12. Suprascapular Nerve

13. Suprascapular Nerve

14. Neuralgic Amyotrophy
Neuritis (Mono or Multifocal)
• Significant number of
these patients have
concurrent shoulder
pathology/pain
• Frozen Shoulder
– Axillary and SSN
• Rotator Cuff Tear
• Unstable Shoulder

15. EMG/NCV
• Important to include
detailed objective
criteria for SSN and
Axillary Nerve
• Large differential for
parascapular and
shoulder pain with
significant Neurogenic
Contribution.

16. Click Link Below to Visit
The Shoulder Center
Thank You!