Weekend 5 Case Presentation

[jeffpeckins]

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[Cameron Holshouser]

1.What are your top three diagnoses based on the subjective information? (ranking order)
– c/s radiculopathy
– 1st rib dysfunction
– Rotator cuff tendinopathy

2. Based on the subject info, what would be your top priority objective tests and why?
– rule out non-MSK due to hx of cancer and insidious onset
– Differentiate between shoulder and cervical spine
– radiculopathy cluster

3.What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)

– Upper crossed syndrome (posture, job, (SCM p! with activation / stretch, better with unloading), tight post capsule, no MOI, negative radic, wide range of pain, cuff related weakness with minimal pain)

4 What subjective and objective information do you feel is missing and would have been helpful to assess with this patient? (Key information, keeping in mind this is a one hour eval)

– 1st rib tests
– scapular exam (posture/palpation/movement/associated strength/re-positioning)
– work related ergonomic questions
– patient’s age
– cancer related questions
– cranial nerve exam
– dermatomal testing / DTR / UMN
– imaging
– patient goals

5.What would you test in the next follow-up treatment session?
– 1st rib
– scapular vs cervical spine driven with upper crossed syndrome

6. What would you have given patient for her initial HEP?
– posture education
– ergonomic recommendations
– seated scap retraction
– posture stretching / relaxation techniques

[Erik Kreil]

1.What are your top three diagnoses based on the subjective information? (ranking order)
– c4/5 radiculopathy
– 1st rib dysfunction
– TOS

2. Based on the subject info, what would be your top priority objective tests and why?
– TOS testing, first rib spring test, tinel’s, hand dynamometer, Spurling’s, scalene length
– functional observation of assumed desk posture or how she chooses to push an object
– determine catastrophization of her sxs (reports 10/10 pain in the last 24 hours, but sxs are achey and numb?), determine how she views her problem, its origin, what she feels like will improve her problem, and her relationship with pain in the past.

3.What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)

C4/5 radic:
– R UPA to these segments generating familiar paresthesia
– R rot (closing down) and L SB (tensing nerve) painful –> UT slackening improves this … could also be interpreted as slackening nerve group in the upper quarter
– Left forward quadrant painful (tensing nerve), Right forward quadrant painful (closing down d/t SB and rot)
– + spurlings, ULTT 1
– myotomal weakness to C4/5 related mm groups
– structural observation of TS kyphosis… could also mean lower CS in extra extension closing down?

4 What subjective and objective information do you feel is missing and would have been helpful to assess with this patient? (Key information, keeping in mind this is a one hour eval)

– Observed functional testing that may lead to better understanding of how her body is choosing to move
– TOS testing
– hand dynamometer to determine if it’s a purely sensory deficit distally

5.What would you test in the next follow-up treatment session?
– 1st rib or TOS
– Scapular performance
– reflexes
– DNF endurance

6. What would you have given patient for her initial HEP?
– Explain pain video (she works 60hr weeks and is describing 10/10 NPRS pain.. could need to destress and push education)
– nerve gliders
– Picture of a basic ergonomic set-up to model her work station after

[Matt Fung]

1. What are your top three diagnoses based on the subjective information? (ranking order)

• Cspine radiculopathy
• TOS
• RTC pathology
2. Based on the subject info, what would be your top priority objective tests and why?
• Cspine radic cluster (Cspine rot, ULTT1, Distraction, Spurling’s)
• UE neuro screen (myotomes, detmatomes, DTR)
• 1st rib
• TOS
• Resting posture/work ergonomics
• Grip strength
3. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)

• Mechanical Cspine facet dysfunction R C4-5 with dural irritation
i. LSB and R rot painful & b/l front quadrants painful
ii. Pain w/ R UPA and CPA C4-6
iii. Myotomal weakness C5
4. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient? (Key information, keeping in mind this is a one hour eval)
• 1st rib assessment
• TOS assessment
• Work ergonomic observation
• Hand dominance?
5. What would you test in the next follow-up treatment session?

• 1st rib and TOS
• DCF endurance
• Functional testing (wall push up or push object – agg factor)
6. What would you have given patient for her initial HEP? 

a. Postural education
• Work ergonomic recommendations
• Scapular retractions

[Cameron Holshouser]

I did not read the “denies/negative” title so please ignore my cancer related comments. After re-reading the case along with Erik and Matt’s comments, the primary pain driver to the patient’s recent symptoms seems to come from the cervical spine specifically in the right C5/6 region.

Erik, what type of nerve gliders would you give this patient on the first day?

[Erik Kreil]

Hey Cam –

It’d depend on the patient’s irritability level, but I think a safe bet would be either upper limb tensioners reflecting the positive obj test on the contralateral side or a glider/ slider on the affected side with the hopes of decreasing nerve tension and improving nervous irritability. What do you think?

[Jon Lester]

1. Cervical radic (lower cerv levels), Cervical facet/multifidus referral, R SAI/RTC irritation
2. Radiculopathy cluster, ULTTs, dermatomes, myotomes, DTRs
3. C5 radiculopathy with associated myotomal weakness
– myotomes, RUPA for distal symptoms, pain with closing down on nerve root or lengthening nervous system structures
4. Age, more specifics on quality/frequency of each symptom, Tsp mobility, grip strength, DTR
5. C5 myotome, DTR, symptoms with L SB/R rot, CPA/RUPA C4-6
6. Self Tsp mobs if appropriate, SNAG to L or supine L rot over towel, rows or similar to work on positioning of Csp/Tsp

[Author]

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