Proximal Median Nerve_JOSPT Resident Case Study

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    • #7998
      Eric Magrum

      Have a read, post some thoughts on differential diagnosis, clinical decision making in this case.

      Have a great weekend

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    • #8000

      I really enjoyed reading this case problem. It showed how systematic we can be to come to a very reasonable conclusion. Very sound reasoning to rule in and out hypotheses. This will definitely help my approach to similar issues. Seeing all the results play out puts what we’re doing into perspective.

      One thing I found interesting from this case was the nature of pronator teres syndrome and how it typically presents with negative findings on NCV tests. To me this really speaks to the nature of the pathology. Perhaps the absence of these findings in known cases points to this being more of an exertional entramptment as opposed to being associated with nerve damage that can be identified with these tests.

    • #8001

      Definitely a great review for anatomy of the forearm and hand.

      One area that could have been more specifically broken down due to his previous shoulder injury was rotator cuff referral, so quickly adding in some resisted testing for ruling that out could have been something that was also done. Overall I feel like they did a good job with differential diagnosis and describing their thought process with ruling out, as well as addressing areas they might not have thought about initially in the discussion.

      Treatment wise adding strengthening of the entire upper quarter was a good place to go, especially with a previous shoulder injury that potentially could have contributed to overuse in this area with the increase in activity. Also incorporating trunk and lower extremity mechanics into functional movements to decrease UE strain could also be another place to look at.

    • #8002

      I agree with Anna that this article was a great review of the anatomy of the forearm and entrapment sites of the median nerve. I thought the author did a great job of narrowing down the differential list and then utilizing diagnostic tests to systematically rule out entrapment sites of the median nerve.

      I liked how the article really broke down the author’s thought process of the treatment approach as well as the differential process. I like how the author discussed the pros and cons associated with some of the manual soft tissue techniques that may have been less helpful immediately, but more beneficial in the long run, and I feel like I catch myself in that same circle sometimes with some of my patients. Definitely a great resource for a less common diagnosis and how to approach it in a more direct fashion.

    • #8003
      Steven Lagasse

      That was a humbling article. It did a great job of shedding light on the gaps in my current knowledge and clinical regarding peripheral nerve entrapment. I have found evaluating neurogenic pain (outside of radiculopathy) rather difficult. Unlike radiculopathy, there isn’t a very clear easily cluster. With that, I enjoyed being able to see the thought process and logical flow behind the clinician’s evaluation. I also enjoyed how their special questions drove their objective tests to rule out certain structures, and ultimately rule in supinator teres syndrome.

      Although my logical flow and clinical reasoning are getting better, it is still something I struggle with regularly. Did anyone else have a similar feeling while reading this article?

    • #8005

      Yes, Steve! I was really impressed by the resident’s clinical reasoning skills and how they walked through the process in the article. I still feel like I really struggle with having a flow for my thought process and examination…

      I thought this article was a good example of the use of clustering signs/symptoms from subjective and objective to make a diagnosis in the case where special tests aren’t great. I also thought it was a good example of diagnosing by ruling everything else out, instead of trying to rule in the suspected diagnosis. And as Lauren and Anna mentioned, a great review of the anatomy of the forearm and possible nerve entrapment sites – something that I definitely could stand to review. In terms of treatment, I tend to want to address all the deficits I see rather than hone in on the real issue first then incorporate everything else later. The author first focused on soft tissue to address the main cause of the symptoms, then gradually incorporated strengthening the surrounding areas.

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