Disclosures: Jared Astrow, DO: No financial relationships or conflicts of interest

Case Diagnosis: A 59-year-old female with past medical history (PMHx) of Cervical Dystonia (CD) presented with acute left shoulder (LS) pain after botulinum toxin injection (BoNT).

Case Description: Patient has a PMHx of CD, chronic neck pain, managed with BoNT injections in bilateral cervical muscles. One month after BoNT injections she noted left shoulder pain, arm weakness and burning pain in the volar forearm, first, and fifth digits. She denied trauma or inciting event. Physical exam was positive for anterior LS tenderness, limited LS active/passive range of motion due to pain. Ultrasound imaging of the LS performed in the clinic demonstrated a bursal-sided partial tear of the supraspinatus tendon with increased subdeltoid bursal fluid. Referral was sent to Sports Medicine and MRI of the LS and cervical spine was ordered.

Setting: Outpatient Neurotoxin ClinicAssessment/

Results: LS MRI revealed low grade bursal sided tearing and interstitial tearing of anterior fibers of the supraspinatus tendon, moderate subacromial/subdeltoid bursitis with a 2.4×2.9×0.5 cm body within the bursa suspicious for calcific tendinosis. C-spine MRI was unremarkable. She was then referred to physical therapy and prescribed NSAIDs.

Discussion: CD, a neurological disorder characterized by involuntary activity in cranio-cervical muscles, causes pain and abnormal movements/postures involving the neck/head. Secondary problems may arise including C-spine arthritis, and radiculopathies. This case provides insight into CD highlighting the importance of ultrasound imaging, a broad differential, and taking a detailed history.

Conclusion: Point-of-care ultrasound offers a safe, quick, and real-time evaluation of anatomy allowing for swifter intervention/treatment. Patients with dystonia and or those receiving BoNT may present with symptoms whose origin may be neurological or musculoskeletal. It is critical that clinicians maintain a broad differential diagnosis, as in this case, where our patient’s symptoms were unrelated to BoNT injections and caused by two distinct but unrelated problems.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/the-role-of-ultrasound-imaging-for-evaluation-of-acute-shoulder-pain-following-botulinum-injections-for-cervical-dystonia/