PM1078: Parsonage-turner Syndrome in a Baseball Pitcher

Introduction: Parsonage-Turner syndrome is an inflammatory, immune-mediated axonal brachial plexopathy affecting the upper trunk or single peripheral nerves, specifically long thoracic, suprascapular, or axillary nerves. It rarely affects the pediatric population. There is no literature regarding prevalence in youth athletes. Presentation consists of sudden, severe shoulder pain followed by painless weakness and potential muscle atrophy/sensory deficits. Diagnosis in pediatrics is often delayed due to its’ rarity and nonspecific presentation.

Case Description: 13-year-old male baseball pitcher presented with 1 month of right posterolateral shoulder pain after he was throwing in the bullpen and developed sudden, severe, radiating pain followed by weakness and difficulty swinging a bat and pitching. He endorsed intermittent numbness at the right anterior forearm and fingers. Severe pain persisted for 3-4 weeks before evolving to a dull, ache. Pain was aggravated with pitching, hitting, and shoulder abduction/extension. He denied any prior shoulder injuries, trauma, or recent illness/vaccination.

Non-tender cervical palpation with full, non-provocative active range of motion. There was mild atrophy of the right periscapular muscles, deltoid, and biceps and tenderness at acromioclavicular joint, supraspinatus tendon insertion, posterior scapular spine, and proximal biceps tendon. On passive range of motion, there was compensation to achieve near full shoulder flexion and abduction. Strength significant for weak shoulder abduction though decent strength against resistance, 3/5 elbow flexion, 3+/5 flexor pollicis longus, 3/5 abductor digiti minimi, and 5/5 abductor pollicis brevis. Positive Hawkin’s, Neer’s, empty can, and O’Brien’s tests. No scapular winging with wall and regular pushups. Sensation was diminished at lateral shoulder, lateral/medial elbow, and digits 1/3. 2+ reflexes at bilateral upper extremities.

Normal right shoulder x-ray and brachial plexus MRI, NCS/EMG demonstrated chronic reinnervation changes without acute denervation in the right serratus anterior. He was prescribed PT focusing on postural correction, periscapular and core stabilization/strengthening and OT for hand strengthening. All pitching activities were stopped until pain subsided. Over 7 months, there was improvement in strength and resolution of sensory symptoms/pain. Once strength returned and pain was gone, a return to play program was initiated.

Discussion: Parsonage-Turner syndrome has a good prognosis in pediatrics with most recovering fully in a shorter period compared to adults through a multidisciplinary approach of PT with a focus on periscapular and core stabilization/strengthening and postural correction, therapeutic modalities, and pain management. There is a dearth of evidence-based guidelines for return to sport. As strength returns and pain subsides, a return to sport program can be initiated with the guidance of sports medicine, PT, and athletic training.

Conclusion: Return to sport guidelines in pediatric athletes with Parsonage-Turner syndrome are not well-established. There is a need to develop specific return to sport protocols in youth athletes to tailor treatment and better educate athletes, parents/guardians, and coaches/trainers on safe return to sport.