Hey guys, I evaluated a patient on mentorship last week that I would like to get some input on. Thanks for any assistance you can provide!

Subjective:
Pt is a 59 yo male presenting with 1 month history of right sided scapular, posterior arm and hand sx. He states that although he does not have neck pain, neck movements seem to make his symptoms worse. He denies MOI, but that his sx have worsened over the past month until his MD prescribed prednisone, which has helped with his sleeping. His scapular and posterior arm sx are dull achy, but his hand sx are a tingling in the volar aspect of his middle right finger. He believes his sx are related to one another. His sx are worse in the AM, then intermittent throughout the day and evening. He denies loss of strength, history of neck pain, difficulty lifting/reaching overhead. He denies elbow or forearm sx. He has had some hand NT previously when he “wakes up and sleeps on it wrong”. He works for VDOT, which entails working on a computer, in heavy machinery, driving and working out in the field. He also cares for his cattle and garden.

AGGS: sleeping on L side (preferred sleeping position), turning neck, looking up, looking down and to the left, shoveling (**aggs are in reference to his scapular and posterior arm sx, he was unable to provide specific aggs for his hand sx)
EASES: prednisone, propping neck up when laying on L side, topical ointment, avoidance of aggs
GOALS: sleeping, working with decreased pain, functional activities with decreased pain

QuickDASH: 14%
NDI: 6%
NRPS: current- 1/10, best- 0/10, worst- 3/10

PMH: skin CA, CAD, DM, Thyroid disorder, HTN, previous R sided RTC with CSI that resolved on its own
XR: arthritis in neck

Objective:
Shoulder clearing: (-)
Posture: moderate FHP

Cervical ROM:
-Cervical ROM grossly limited (R>L)
-Flexion, R Rotation, RSB and R Flexion quadrant reproduce scapular and posterior arm pain
-L Flexion and R Extension quadrant both produce scapular, posterior arm and hand sx**

Traction:
-L flexion quadrant: worsened sx
-R extension quadrant: worsened sx**

Palpation: first rib, paraspinals, infraspinatus, scalenes, triceps, median nerve tract all (-) for tenderness or sx provocation; R upper trap mild tenderness noted

Accessory mobility: hypomobile cervical CPAs, R UPAs, R PPIVM/PAIVM testing (no sx provocation); hypomobile thoracic spine CPAs

Neuro:
-dermatomes: equal and intact bilaterally
-myotomes: equal and intact, non-fatiguing
-DTR: R triceps absent (L normal), brachioradialis and finger flexors diminished bilaterally, biceps normal

Neurodynamics:
– L ULTT: reproduction of R sided posterior arm sx with lacking 50 degrees of elbow extension, worse with RSB, improve with LSB
-R ULTT: Reproduction of R posterior arm sx with full wrist extension+ radial deviation with GH ABD and 90 elbow flexion
-L Radial: Reproduction of R sided posterior arm sx with GH IR and wrist flexion, unclear differentiation
-R Radial: deferred

(-) Tinel’s at Carpal Tunnel
(-) Phalen’s

Treatment provided at eval:
-R UPAs
-HEP: banded scapular retraction + GH ER, cervical rotation on pillow

Discussion Questions:
1. What would be your differential diagnoses for this patient?
2. Are there any additional tests/measures you would have performed (or would like to perform) with this patient?
3. What do you make of this patient’s neurodynamic findings? What about the worsened sx with both flexion and extension quadrant traction?
4. In regard to his bilateral neurodynamic symptom provocation, what would be your starting intervention and progression of treatment in addressing his impairments?