Patient Case Discussion

[Tyler France]

Hey everyone! My student, Caitlyn, and I evaluated a patient recently and we could use some thoughts on diagnosis and treatment.

Pt is a 33 YOF who works as a scheduler in the OR who presents with 3 week history of L upper trap region and deltoid region pain as well as numbness and tingling in the forearm extending into the 3rd, 4th, and 5th digits. She also reports perceived grip strength changes. The pain began suddenly 3 weeks ago with no specific mechanism. She reports that she had a tetanus shot the day before her symptoms began, but she is unsure if this contributed. States that she has had some cervical tightness previously at work, but no other similar symptoms.

Aggs: Numbness and tingling is aggravated R cervical rotation, cervical flexion, and L shoulder IR. Shoulder pain is aggravated by shoulder elevation, washing her hair, and generally increased activity at work.

Eases: Numbness and tingling is eased by placing her arm across her body. Shoulder pain is eased by heat and placing it across her body with the elbow supported. She has not experienced relief with muscle relaxers or Naproxen.

Posture: Moderate FHRS

Cervical ROM: Limited motion in extension and R SB. L rotation, L extension quadrant, R rotation, and R sidebending provoked L sided neck and upper trap region pain.

Shoulder ROM: Shoulder IR increased tingling in forearm and hand. Flexion/scaption/abduction limited to ~90 deg actively by pain. Able to achieve 100 deg of elevation passively with empty end feel. Mild shoulder pain relief with scapular assistance, but no change in ROM.

Neuro Screen: WNL

Spurlings: (+) for L sided upper trap region pain

Distraction: (+) for reduction In L upper trap region pain

ULTT A: (+) for increased tingling in L forearm and hand

First Rib Springing: (+) for local pain and increased tingling in the arm

Soft Tissue Assessment of Scalenes/Upper Trap/Pec Minor: increased turgor. Palpation increased L forearm numbness and tingling.

Grip Strength Average: 14 kg on R UE, 2 kg on L UE

**Pt did not tolerate supine positioning well as it caused her L sided upper trap pain as well as her forearm tingling, even when the table head was placed more into flexion. Limited information was gathered in supine.

Before her first follow up visit, the pt had acupuncture performed and reported mild relief in symptoms. Treatment focused on postural exercises with diaphragmatic breathing at that visit because the pt could not tolerate manual tx.

QUESTIONS:
1) What would be on your differential diagnosis list for this pt?
2) Considering the pt’s irritability and her inability to tolerate supine positioning for more than a minute or two, what tests/measures would have you prioritized?
3) What assessments would you have performed in other positions?
4) When treating patients who are highly irritable, how do you determine how much discomfort (in this case, increased numbness/tingling) you are okay with during manual techniques?

[Katie Long]

Wow Tyler, interesting case.

1) I think given the rib and scalene findings with neurogenic sx, I would have TOS on my differentials. I also would have some sort of peripheral nerve entrapment or double crush on my differentials.

2) Regarding her irritability, I think a lot of my evaluation would have been spent getting a few key objective findings, as you did, but then trying to find ways for her to relieve her symptoms. I wonder if you have tried some of the neurodynamic positioning that Kristin talked about? I wonder if she would be better able to tolerated a supine position with elevated LE or tensioned contralateral UE with her affected UE slackened?

3) I wonder about trying some MWM UPAs on the CT junction in sitting with her rotating towards the right (or left)? Seeing if that changes her numbness? Did you assess cervical ROM with UT slackened?

4) I think this depends on the patient and how much they buy into what you’re trying to sell them. I have had patients that are completely down with trying anything and I tend to push them a bit more to see what we can change in regards to their symptoms. But I also have patients that are very cautious and are not completely sold, so I don’t tend to push them quite as much. But this is hard, and something I am still struggling with. What does your patient think about what is going on? What did you “sell” her? and does she buy it?

Good luck! Keep us posted!

[Tyler France]

Hey Katie,

Thanks for the input. TOS is the diagnosis we have settled on based on the findings that you mentioned. We have not yet done any specific TOS special tests, and I am not sure what I would hope to gain by performing them. I had not thought of playing with different neurodynamic positioning techniques, but that is definitely something I will try to see if she can tolerate supine positioning better in order to perform other interventions. She had slightly decreased pain with cervical lateral flexion with the shoulder girdle passively elevated, though it was not significant. Incorporating MWM to the CTJ is definitely something that could be beneficial in this particular patient. Education is something that we likely need to do a better job of with her. I do not get the impression that she has a good understanding of our role in the recovery process. We likely need to do a better job of selling her on what physical therapy can do for her condition, and I think achieving some symptom relief with certain interventions could go a long way. Unfortunately, we have not made significant strides in this area yet.

Thanks for the input! Definitely some helpful ideas about different things that I can try with her.

[Sarah Bosserman]

Hey Tyler!

1. I would be thinking TOS for differential dx and also would want to rule out peripheral entrapment.
2. For objective measures, I would focus on the cluster of findings that would either reinforce or rule out my primary diagnosis (i.e cervical ROM, spurlings, distraction, etc) — it sounds like she is wary of treatment so spending the time on education and getting objective measures along the way may help with patient buy-in.
3. I like the ideas you had in using techniques that can be performed in seated, including MWM, postural/stabilization exercises, why she is more acute. In terms of manual techniques, I would just make sure I had a re test I could use to make sure symptoms are not worsening with my treatment.

[Justin Pretlow]

Hey Tyler,
Sorry for the delayed response. I have way more questions than answers. Did the proximal and distal symptoms have the same onset? Do you think the lower cervical, CT junction could be the primary issue? With an elevated rib or TOS contribution? In sitting, you could assess cervical rotation lateral flexion.
While performing ULTT A in supine, were you able to differentiate the impact of cervical positioning or contra UE?

[Eric Magrum]

TOS = description of sxs in a region that is dynamic (rib cage/breathing).

Vascular TOS (< 5%)- should be a red flag, and think anomalies versus Neurogenic TOS (> 90%) which you need to think of structures in the TOS region.

What are those structures to specifically asses?

What objective measures/”special tests” stress those specific tissues; and how can that information help you be more specific to guide treatment?

Please continue this discussion – always a challenging patient presentation with clinical reasoning/asses-re asses to guide specific treatment decision making.

[Jennifer Boyle]

I agree with Justin to look into 1st rib cervical rotation and lateral flexion is one way to further assess this potential structure at fault. That or looking at the ability of that first ribs mobility with palpation to B 1st ribs with inhalation and exhalation to assess potential movement restrictions. If these are positive and tolerance of supine is poor I sit the patient up and put the effected arm over my leg to put slack into the UT and then perform my 1st rib mobilizations with them SB toward that side.

Have you thought about a seated CTJ manipulation? I know this is more aggressive but I was unsure how she was progressing or if you think she would tolerate this. Maybe it would be enough of a kick start to allow you into the system and treat other impairments.

[Justin Pretlow]

I have a hard time picturing how to stress the specific tissues to gain helpful information when the patient is highly irritable. I tried using the ULTT as a gauge of irritability with this type of patient, but I was not able to figure out if the irritation of the nervous system was stemming from interscalene, or clavicle/rib, or subpectoral space. Has anyone else had success with this type of presentation?

[Tyler France]

Structues to Assess:

Ant and Mid Scalene: Palpation for hypertrophy or increased turgor/trigger points that may cause reproduction of distal symptoms. Can also perform Adson’s test if suspecting vascular TOS.

First Rib: Can perform cervical rotation-lateral flexion test or palpate for hypomobility with breathing. We probably should have checked CRLF in our patient, but we were scrambling a bit when she kept asking to change positions.

Pec Minor: Observation of scapular positioning at rest and palpation of pec minor for turgor.

GH Mobility: Palpating for position of the humeral head and assessing GHJ mobility, particularly posteriorly.

Has anyone used the prominent TOS special tests (Adson’s, Roo’s, Costoclavicular, etc) in their practice and do you feel that you can comfortably diagnose TOS without performing these tests?

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