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Referral: Brachial Plexitis
Demographics: 63 year old male, works full time as optician
PMH: May 2014 triple bypass surgery requiring median sternotomy
Chief complaint:
• intermittent burning/ “heat” in entire L hand (both palmar and dorsal surfaces, all fingers)
• intermittent, variable, “dull, achy, nagging” pain and muscle knots underneath and medial to L scapula
• patient states that two areas seem unrelatedHistory of Present Complaint:
• Onset 10 days after triple bypass in May 2014 when dc’ed home
• Burning symptoms have generally decreased in intensity since onset and now can only be immediately reproduced when gets into reclined sitting, does not inc. or dec. in intensity once in position with any typing, reading, etc.
• L peri-scapular pain notices throughout the day when sitting for long periods of time at work, can linger for 10-15 minutes at a time
• Easing factors:
o Burning sensation immediately dissipates upon upright sitting or standing
o No burning during walking, sitting upright, lying on either side
o Scapular pain decreases with “pressure” to scapula from behind and massage
• Unable to lie flat on back due to increased wheezing for past several weeks – started with change in blood pressure medication and is currently being monitored by physician. Has not experienced difficulty breathing since surgery. His chief complaints have not changed since the wheezing began.
• Used to have intermittent L medial upper arm numbness (just above elbow, nothing into forearm or hand) but subsided last winterHypothesis after Subjective Examination: Hand – Thoracic Outlet Syndrome; Scapular – Costovertebral facet/Myofascial
Reproducible hand symptoms in non-dermatomal pattern with positional changes. Positional changes cause compression or tension of brachial plexus (inferior trunk/medial cord) and shortening of tissues (pec minor, scalenes, UT, etc.) that has developed after median sternotomy.
Rule Out: cervical radiculopathy, brachial plexitis, visceral referral (diaphragm, heart, lungs), carpal tunnel syndrome
Physical Examination “Asterisks” Signs/Symptoms
Observation:
• Position for comfort: L hand on hip with scapula in excessive protraction, anterior tilt, and internal rotation
• Standing resting position: mild scapular protraction, anterior-faced glenoid, rounded shoulder L>R, forward head
• (-) neurological examination except (+) L median ULTT by -25 degrees elbow extension (inc. pain with contralateral cervical sidebending)(-) cervical screen EXCEPT sustained cervical extension caused slight numbness in palmar surface of bilateral hands but no finger involvement (this was NOT the same description and distribution the burning symptom in L hand)
• Reproduction of burning symptoms when placed in reclined sitting, arms down by side, burning intensity did not change with UE movements although decreased in intensity after STM to pec minor, scalenes
• TTP at L UT, rhomboids, latissimus dorsi, serratus anterior, subscapularis, pec minor, scalenes.
o This fits with the positional and postural changes of L UE and scapula, but does not relate to sensitivity of any nerves. No TTP along route of median nerve down L UE.Joint Mobility
o Hypomobile and painful 1st rib inferior glide B, L>R
o Hypomobile L scapulothoracic accessory motions in retraction, posterior tilt, ER
o Hypomobile posterior and inferior GH glide B, L>R
o Decreased L C6-T3 rotation PAIVMs• Limited ribcage expansion during inhalation and increased use of accessory respiratory musculature. Requested not to lie in supine due to increased wheezing. Reclined position did not cause wheezing at 45 degrees incline, but patient requested not to be reclined any lower due to belief that he would start having difficulty breathing.
Red Flags: central cord compression (stocking glove distribution?, sustained cervical extension causes bilateral numbness in palms)
Discussion Questions:
• Have you found a common clinical pattern with patients who have a recent history of sternotomy?
• How would you address thoracic and costovertebral joint mobility in a patient with preference to sitting, reclined sitting, and side-lying positions only?
• What other tests would you consider to further evaluate the bilateral numbness with sustained cervical extension?
• How would you differentiate between cervical radiculopathy, thoracic outlet syndrome, and brachial plexitis for the burning hand symptoms?
• What are the disadvantages of a RCT that uses therapeutic ultrasound as the comparison intervention?
• Do you think there was any presence of bias in the inclusion criteria towards participants who would benefit from soft tissue mobilization?
• What about the soft tissue mobilization set-up was different than the ultrasound intervention set-up? Could this difference potentially confound the study findings?
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Thanks for the post Laura, seems complicated for sure. Nice choice.
Another diagnosis that comes to mind that I may have treated in the past but did not know it because it wasn’t on my radar, is T4 syndrome. I don’t believe there’s much research on the pathology, although I certainly need to do more investigation. With a complaint of “whole hand burning and numbness”, that’s something that comes to mind along with TOS, brachial plexus. Given the fact that his symptoms seem to change with thoracic mobility going from slumped posture to upright posture, perhaps the symptoms could be changing due to movement in the thoracic spine affecting the sympathetic chain. Again, I’m certainly no expert on this pathology, nor do I know if it would change, but I think it would be worth mobilizing the thoracic spine in a seated position with his arms crossed, cervical spine neutral and scapula supported and neutral to see if that changes his symptoms.If anyone notices anything about the subjective history of this case that would not make them think T4 syndrome, please let me know. Has anyone ever seen T4 syndrome?
Another test I may have added would be cervical distraction in extension after it produced symptoms, as well as testing in cervical extension quadrants to assess change, if you hadn’t done that.
As far as differential diagnosis of C/S radic, TOS and brachial plexus: I would refer to the suggestions of the C/S radic CPR looking at rotation, distraction, ULTT, and Spurling’s to rule that in or out first, as well as reproduction of symptoms with cervical mobility testing. Then I would move on to TOS, which doesn’t have the best test metrics. I’ll have to do some research on brachial plexus.
I’m going to move on to your article now. Thanks for the post!
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• How would you address thoracic and costovertebral joint mobility in a patient with preference to sitting, reclined sitting, and side-lying positions only? I have never had a patient post sternotomy but I have had patients who could not lay down due to vertigo. One way I found to assess thoracic motion in sitting is having the patient go through cervical full AROM while observing upper thoracic motion. I also palpate between the SP to see how much thoracic movement the patient has. Side-lying is great for assessing the spring mobility of the costovertebral joints. It’s also possible to do a PA force down the thoracic spine to assess provocation/ joint end feel.
• What other tests would you consider to further evaluate the bilateral numbness with sustained cervical extension? Did you place the patient into different SB quadrants and see if the symptoms changed?
• How would you differentiate between cervical radiculopathy, thoracic outlet syndrome, and brachial plexitis for the burning hand symptoms? Thoracic outlet syndrome we know has a vascular component special test like Adson’s , costoclavicular, etc. would help rule it in/out. Checking changes in radial pulse are vital during these special test. Cervical radiculopathy is typically segmental with changes in a specific dermatome/ myotomal patterns. If it’s truly a cervical radiculopathy I don’t think the patient shoulder have a whole hand burning sensation. Brachial plexitis is typically multisegmental. It depends if the patient has a peripheral presentation or a cord compression presentation. For example, if the patient has a posterior cord compression then I would check MMT tricep, wrist extensors, sensation loss in a radial peripheral pattern. I would also see if there is atrophy present. I don’t know if a burning sensation is common symptom for this, but I would definitely check all the other test and see if that changes symptom.
I have yet to read your article, but I will soon.
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Great case Laura! I am impressed with the comprehensiveness of your exam, and certainly it is a very interesting case to discuss.
– I cannot recall ever treating anyone who had an onset of musculoskeletal symptoms following a sternotomy. I certainly have seen individuals post CABG, however have never found this procedure to contribute in some way to the patients pain. It certainly makes sense that it would lead to anterior muscle tightness and myofascial restrictions.
– Manual mobilizations to the T spine and ribs in the positions you mentioned might be difficult. However, I do think you have a fair bit of therex at your disposal if you think it might be appropriate. Seated retraction over a towel and sidelying open book stretch both fit the positional descriptions and might help to improve the mobility in the area. If he is okay with quadruped, you could also do a thoracic rotation exercise from that position as well. Here is another quadruped thoracic extension mobility exercise that I occasionally use with patients – also helps to stretch the latts: https://www.youtube.com/watch?v=qovO0ysEpuc
– I am supposing that cervical quadrant was negative bilaterally? Spurlings as well? Was the sustained cervical extension active or passive? If active, I might try and do it passively, then add distraction and see if his symptoms abate (what Sean said).
– As you seem to hint at by your last question, one of the main disadvantages I noted about the use of US was the patient positioning. In the STM group, the intervention was performed with the patient in a neurodynamically lengthened position; whereas in the US group the neural structures were on slack. I would be curious to know what, if any, treatment effect occurred from the mere 15 minutes of positioning in a nerve-tensioned positioned.
– I completely agree with your picking up on the inclusion criteria that might bias towards individuals who would benefit from STM (i.e., tender points in various muscles). However while I think this does add some bias to the inclusion criteria, in the end I am not sure how much it would have limited the patient population; that is, tender points are highly likely to be found in this group of patients. If you removed this from being part of the inclusion criteria, I doubt very many patients, if any at all, would have been removed from the study.
– Never seen T4 syndrome and can’t say I know anything about it. Might need to find a PDF…unless you have one at your disposal Sean?
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Hey guys,
Your posts continue to be though provoking. This weekend we will cover some strategies to assess t-spine mobility and treat in sitting as well as other ways to examine neurodynamic mobility.
Laura, you stated that your neuro exam was negative. Was that a segmental exam only or did you include UMN testing. With bilateral UE symptoms in sustained extension you certainly want to utilize the myelopathy cluster to rule out cord compression.
I agree with several other posts, putting him in extension quadrants to see if you can reproduce his unilateral symptoms. However, with the distribution it does not appear to be root level.
If you feel comfortable placing him in sustained extension and there are nor VBI s/s you may consider testing UMN (ie hoffmans) in this compromised position.
One of your strongest ** seems to be decreasing his pain with STM to entrapment points of the plexus as well as opening the anterior rib cage. Not completely familiar with a sternomoty, but sounds traumatic and may be dealing with tissue adhesions. This may be contributing to his breathing difficulty.Easy with the T4 syndrome. There is a reason that there is limited evidence on it.
AJ -
Great discussion and interesting case!
Nick – You made some good points when answering the posted questions about the article. I will be interested to see additional discussion in relation to the questions!
Laura – How long does it take for the bilateral hand numbness to ease after produced with cervical extension. If it takes a long time to ease, would you still test quadrant? Also, did you ask about symptoms on the opposite side during the subjective? Now that you are aware of this area of symptoms, are there other areas you would like to ask about (‘clear’)? Other questions you want to ask? I agree with doing an UMN screen. Interesting that Spurlings was negative….
Great ideas for ways to treat the comparable clinical findings in positions of comfort. What clinical findings would you reassess to prove the value of added techniques?
Re: bilateral numbness with cervical extension, but reproduced with pressure on the palm during ADL’s….what other tests will you be doing to differentiate?
During the Upper Limb Tension Test, Median emphasis, what pain was reproduced?
This wheezing seems significant. Do you feel comfortable with how this is being managed/monitored? Are there specific tests that you feel would be important to monitor related to this? Besides blood pressure, have other medical tests been performed?
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Sean’s idea is great with increasing thoracic mobility, arms crossed over a pillow may help. As well, what were some of the sign’s and symptoms that made you think you treated a T4? It’ll be good for me to keep that in the back of my mind.
Nick- that’s a great video to increase thoracic mobility! Laura mentioned his surgery was 5/2014 and he’s 63. I think that’s a great progression. I’m excited to learn new techniques this weekend.
Something that Kristin is teaching me is to assume that the patient has every pathology present and my goal is to rule the most sever out. IE cervical myelopathy (good call AJ), UMN (reflexes, Babinski, Hoffman), you have a good list you wrote before. He had surgery last year, did he also have previous therapy? If so what did they work on? His wheezing is a concern of mine, I wonder when his BP meds were changed and if that’s when he started feeling the whole hand numbness more prominent?
You mentioned numbness when typing on his computer and driving his car (palm against the steering wheel). Where is his hand placement at 12, 3 o’clock or a little lower on the wheel? Is he at a desk when he’s typing/ how far away is the computer? My assumption is that he probably has forward head with a mechanical stress point at his mid cervical junction. How is his scapula positioned (abducted, downwardly rotated, depressed)?
Going back to your article, STM would be beneficial to tender spots. I agree with Nick, I highly doubt I would see a patient who does not have tender points in the upper quadrant. I also wonder why the sonation time was 50% as compared to a different dose? I also find it interesting that the neurodynamic placement was different between groups. The STM therapist also had the autonomy to spend time on any particular region based on his/her assessment whereas the US group has a strict 5 min cervical, 5 min UE. The article you selected was also from JMMT and I’m sure they would biased any manual intervention is better than a modality.
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Oksana- I mentioned the “T4 syndrome” because I essentially know nothing about it, I have read brief descriptions in things such as independent study courses the APTA has published. I wanted some input from others as to whether or not it should be considered, if anyone has seen a patient with neurogenic UE symptoms or whole arm and hand numbness that wasn’t thoracic outlet or cervical driven and if it is thought to exist in the first place. I had a patient last year that c/o bilateral UE whole arm and hand numbness that I could not explain despite testing everything I could think of and looking back I wondered if it were a possibility. You could ask your mentor their perspective, but don’t be surprised if they laugh at you ;)
I agree with you guys about the positioning of the patient’s. I also wanted to make note of the duration they spent on US. Seems there was a significant amount of time spent on STM addressing more global areas and the US was only applied to two small locations. If I were to implement US to achieve this goal, if I thought it would help, I would apply it to multiple tender points in a continuous fashion with the goal to heat the tissue to an adequate temperature to increase pliability (in theory). On a side note, I think it would be more applicable to study the differences in neural gliding vs STM. The disadvantage of using US is that it’s already shown to not be effective for much of it’s use. I hope by the end of our discussion to develop a better understanding of why they would use this modality for this study and not another intervention that has been shown to have some effect.
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Laura,
I would go through your myelopathy cluster first, including UMN testing. If you get nothing, you may consider testing a Hoffmans or a reflex in the compromised position. Need to be cautious when provoking cord s/s to assist in diagnosis.
Did Myra’s case presentation this weekend give you any new ideas of what else may be going on with this person?
AJ -
Hey Laura- I thought of you when I read this case study. Check it out.
“The patient also has a presentation of bilateral paraesthesia “The GP had performed blood tests including B12, ferritin and folate, which had returned normal. Vitamin B12 deficiency can result in paresthesia, peripheral neuropathy, and demyelination of the corticospinal tract and dorsal columns (Robert and Brown, 2003). The possibility of alcoholic sensory neuropathy was considered as chronic ethanol exposure can cause polyneuropathy characterized by axonal degeneration (Mellion et al., 2011). Recent studies have shown that ethanol exposure has direct neurotoxic effects on peripheral nerves.”
I thought this was interesting.
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