Patient Case Discussion

[Katie Long]

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?

[Justin Pretlow]

Hi Katie
I’m finding it challenging to make sense of his symptoms.
When you say ULTT reproduced symptoms does that mean it was the same quality – dull and achey?
Were CPA’s or UPA’s painful at any level or just hypomobile?
Did you happen to support his UE’s and recheck cervical AROM? or adjust his posture and recheck cervical AROM?

[Katie Long]

Hey Justin. Sorry for any confusion.

Yes, ULTT reproduced his arm symptoms with the same quality, although perhaps more intense. However, ULTT did not produce his NT in his hand.

CPAs and UPAs were not painful during any testing, just very stiff.

I did support his UE and re-checked his ROM, which did not alter his symptoms with ROM testing.

Hope this helps!

[Tyler France]

Hey Katie,

Interesting case. As far as the neurodynamic testing on the L UE reproducing his familiar R sided pain, I would take that as an indication that there is either something occurring centrally or that his system is a little irritated. Not sure what to make of worsening symptoms with traction in R extension and L flexion quadrants. That doesn’t really compute in my brain. As far as starting treatment, I would probably address joint mobility in the cervical region and see if symptoms change at all with improvements there. How did first rib mobility compare from side to side?

[Katie Long]

Hey Tyler,

I agree with having some trouble making sense of his presentation. It seemed very neurodynamically driven and seems like the whole system was a little irritated. I did look at his first rib mobility and it really wasn’t all that remarkable, not tender, not notably stiff and didn’t produce symptoms.

As an update: He came back after the evaluation with reports of no scapular or posterior arm pain, but continued NT in the hand. With ROM testing, he still got mild posterior arm symptoms with extension R quadrant (but no change in hand symptoms). His ULTT and Radial nerve tension testing was negative bilaterally for symptom provocation at full testing position. During Ulnar nerve tension testing on the right, he reported resolution of his R hand NT. We continued R sided cervical UPAs and added Elvy towards the right with the R UE in median nerve tension, then progressed the following session to Elvy away (to the left) with R UE ulnar nerve tension. We also incorporated some pec minor stretching and periscapualar strengthening for improved posture.

[Sarah Bosserman]

Katie!! my response was just deleted because I apparently was not signed in to post. However, I was thinking along the same lines as you in terms of first addressing the cervical stiffness and a trial of the Elvey technique to address the system irritability. You also addressed my 2nd main thought in that his worst pain is in the AM (gets better throughout the day) so addressing sleeping position may be beneficial. He sounds like he goes from sitting all day to some potentially heavy house/yardwork in caring for his garden/cattle and wonder if poor repetitive body mechanics may be playing a role (stiffness/poor posture/repetitive pushing and pulling) so would be curious to see the continued impact of posture re education/strengthening on his symptoms. Thanks for the post/update!

[Katie Long]

Thanks Sarah! I think I really need to focus on the postural components over the next few visits. His periscapular strength is okay, but his endurance is pretty poor. He gets fatigued easily and I think you’re right, that may be a large part in his current symptoms and a good way to address/prevent any future issues.

[Laura Thornton]

Hey Katie –

– Seems like there was a pretty significant chemical inflammatory component to his pain initially, with his response to the prednisone dose pack and quick decrease in pain over the past week. Could also explain his initial negative response to distraction in both flexion and extension. Does this initial response to distraction on day 1 deter you from looking at unloading strategies in the future?

– How did you modify/progress the UPA treatment from session to session, including grade, level, and positioning? Specificity with mobilization can help guide your manual treatment to gradually improve joint mobility and enhance what he can do actively during exercises.

– The resolution of tingling in the ulnar nerve tension position could potentially be a response similar to the shoulder abduction test for cerv radic. I wonder if this could be useful in educating him on arm positioning to relieve symptoms during the day, as you are building postural strength and endurance exercise program.

– Attached a recent review on clinical diagnostic testing for cervical radiculopathy in Spine. Food for thought when building differential diagnoses lists.

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[Jennifer Boyle]

Hey Katie! It seems from day 1 until his second visit he had some great improvements. I was wondering what you attributed these changes to (being the techniques you utilized day one or medication). Also, how long ago did he start/ end his dose pack. I ask because I had a patient like this a few months ago that had a very similar response to early treatment and steroid pack. As the dose pack wore off his sx returned almost to baseline. I was wondering what your plan was if this occurred and suggestions for what I could have done with my patient way back when I struggled with a similar presentation.

[Katie Long]

Laura- Good point about the shoulder abduction test, I hadn’t thought of that, but it makes sense. I have been continuing with UPA grade III-IV mobilizations to his upper and mid right sided cervical spine, which I initiated at the eval due to his symptom-free hypomobility. I then progressed my mobilizations to include Evly glides with neurodynamic positioning following his positive response after the eval.

Jen- He was almost finished with his dose pack by the time he got to me, I think he had a day left. By the time he followed up with me, he had completed it. I think a large part of his success with treatment is due to the dose pack aiding with management of any initial inflammatory process that was going on, which enabled me to perform my interventions to treat his impairments with relatively low irritability. The fact that he has had continued success throughout our time together without the dose pack tells me that, while the dose pack may have been helpful in decreasing his irritability, the interventions in PT and his HEP are aiding in his continued improvements.

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