One patient I recently saw presented with cervical radiculitis. She had a long Hx of cervical pain and distal numbness/tingling in 4th and 5th digit of RUE. Her sxs had been exacerbated by an UE traction injury at work when attempting to catch a heavy object that fell from her work bench. Her sxs at IE included BL neck pain from mid Csp into her shoulder. She described a pulling sensation at R elbow and increased numbness and tingling in her 4th and 5th digit. These sxs were worst when sleeping. My diff Dx included cervical radic, disc dsyfnc, facet dysfnc TOS, rotator cuff pathology, and trigger point of lev scap/rhomboids.
Objective findings included neck pain with R rotation and extension, R back quadrant increased shoulder and elbow sxs. Distraction eases UE sxs. Rotator cuff was not fully assessed at IE, but ER lag and belly press were negative. Patient was unable to raise RUE from side. Shoulder PROM was WNL, she limited end range flexion and ABD BL. Neuroscreen showed increased C5 and C6 reflexes on R compared to L. Sensation screen WNL and myotomes unable to assess due to pain. At follow up visit pnt had positive findings during ULTT for median and ulnar nerve. Median reproduced elbow pain and ulnar reproduced numbness and tingling in hand.
At this point I was confident that cervical radiculitis was the primary pathology with a probable peripheral traction injury present. I was also keeping an eye on shoulder sxs to monitor for rotator cuff injury. After 3 weeks her neck pain had subsided an her shoulder pain was minimal. She could modulate her sxs at home with head positioning in supine and sidelying positing. I continued to treat postural and cervical impairments, however mild shoulder and elbow sxs remained. Upon reassessment I found supination limitation and radial head restrictions with reproduction of elbow sxs. With functional lifting it was apparent she was compensating for the lack of supination with shoulder protraction and ADD. We treated the radial head restriction for 2 visits and she was back to work without issue. I should have reassessed earlier in the rehab process. I do not think I would have been able to discern any local elbow dysfunction at IE, but radial head dysfnc with a described traction is not uncommon. This was a case of me having my blinders on early on.

One thing that jumps out to me when reading your cases and reflecting on my own below is the importance of reassessment/reflection and getting a second pair of eyes on the case when needed. I know with my case especially it was something that I should have picked up on earlier and would have if I did a reflection of the case. This is the true benefit of a residency program. It forces us to use tools like the clinical reasoning form for reflection and provides mentorship for complex cases. Keeping this in mind as this rez year comes to a close, it will be important to continue to use the tools/skills learned over the last year and to keep in touch with you guys when a tough patient comes along. I think back to what Eric Kopp said about his time “treating on an island” and can see the difficulty in that when compared to my clinical experience over the course of this program.

Great reflection Justin and Erik

I think you both hit on great ideas about bouncing ideas off other therapists. Putting your ego aside and knowing that you do not have all the answers is key. Being able to listen to the patient and hear that they are actually till having issues is the first step.
You both did a great job figuring this out and going to another mind to get other ideas.

Keep strong clinical reasoning and reflecting in-action and on-action as you move on in your careers.

I don’t have any dazzling examples like you all, but I do have one that highlights the importance of this concept. For several months I have been seeing an 18 yr old male high school pitcher who has had IM 1 yr h/o L anterior shoulder pain and decreasing velocity with throwing. I saw him after he had taken 3 weeks off and his shoulder was minimally irritable, with only an uppercut motion and palpation of the biceps tendon reproducing even minimal soreness. He had ~20 degree loss of total shoulder rotation and had rotator cuff weakness in IR and ER. At the IE I looked at him do L SL balance and a SLS and unsurprisingly he had deficits: compensated trendelenburg, dynamic knee varus into valgus. It wasn’t until I watched a video of him pitching the next session though that I realized I needed to look further into his hip motion. He was 10 degrees shy of neutral hip extension and had only 15 degrees hip ER on his L. With sprinkling in some hip mobilization, self mobilization, and stretching he now has hip extension to neutral and his hip ER is symmetrical. While he isn’t pitching at game speeds he has been doing well with his interval throwing program and has been able to increase his distance and then velocity without symptoms much more successfully than when he had tried in the past. I think I would have missed out on a lot of important secondary factors if I had only focused on the upper quarter.