Parsonage Turner Syndrome — The Sports Medicine Review

Due to the nature of the diagnosis,  it may go unrecognized and treatment may be difficult. Treatment options are dependent upon the stage of PTS, although there is no preferred or best treatment option.  Options for nonpharmacologic treatment are based on small studies and anecdotal evidence. Current treatments involve physical thearpy, osteopathic manipulation, therapeutic modalities and acupuncture.  Physical therapy can be challenging and the goal should be to maintain range of motion and prevent loss of function. The timing depends on pain, weakness and degree of intervention. An overly aggressive approach can overload muscles that are weak and athletes should not lift outside of physical therapy [1,10].  The mainstays of therapy include stretching, range-of-motion, and therapeutic exercise. Nerve stimulation and acupuncture may play a role in pain relief, though only small case studies exist [1].   

Pharmacologic options also exist for symptom management.  Severe pain in the acute stages are often treats with nonsteroidal anti-inflammatory medications (NSAIDs) and opioids.  Anti-epileptic medications such as gabapentin or tricyclic antidepressants like amytriptyine are used to treat neuropathic pain that lingers after the acute stages.  Patients with a history of viral infection are sometimes treated with antivirals. Cervical epidural injections are sometimes doen for diagnostic and therapeutic reasons.  The evidence supporting these therapies is limited, however. One study suggests early treatment with oral prednislolone at 1 mg/kg for the first week and tapering during the second week [4].  Another treated several patients with a two week course of 60 mg prednisolone in the first week and taped the second week at 10 mg per day and a faster recovery was noted [11]. One case study showed improvement in symptoms following immunotherapy after developing peripheral neuropathies [13].  More randomized controlled trials are needed to determine best management for PTS.

Despite challenges with diagnosis and pain, prognosis is good for most cases [2].  The best possible outcome involves around one month of symptoms that responds with conservative management.  One large study reported 89% of patients had a full functional recovery at 3 years based on functional strength, with only 36 percent showing “excellent” recovery after one year [14].  No long term studies that document full EMG recovery exist and most estimates for reinnervation are between 6 and 12 months. Another study with 246 patients reported around one-third of patients continue to experience chronic pain of persistent functional deficits after 6 years [11].  Prolonged pain and weakness are associated with poor prognosis and patients may also have subsequent attacks.

In summary, Parsonage Turner Syndrome is a rare and underrecognized condition with limited high-quality evidence in regards to treatment.  Diagnosis should be considered in patients with abrupt onset of upper extremity pain that is non-traumatic in most cases. Muscle weakness and atrophy may follow an acute painful phase.  An antecedent event occurs in around half the cases. Although many theories exist in regards to pathophysiology, a common unifying cause has not been established. EMG studies after three weeks can show specific abnormalities that can aid with diagnosis.  No specific treatments have been proven to reduce neurologic impairment and most modalities are to control symptoms or maintain functionality. Most patients are treated with a multidisciplinary approach including physical therapy and pharmacologic treatments.  

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