Treatment for a 28 year old male who presents to the Harris Health System with a C7 cervical disc herniation.
Diagnosis of a cervical disc herniation was made based on:
- +ive C7 Dermatomal and Myotomal testing
-Specific strength testing of musculature innervated by C7
-Visual inspection/palpation of triceps atrophy and wrist extensors
-Pattern of pain
-Confirmation with MRI findings
Additional important testing performed:
-Cervical range of motion testing was within normal limits with pain at end-range bilaterally
-Shoulder range of motion was within normal limits.
-Joint Mobility: Upper cervical mobility assessment was within normal limits; lower cervical mobility opening restrictions were present from C4-C7; 1st rib hypomobility bilaterally; middle and upper thoracic extension restrictions
-Muscle testing was performed using a hand-grip dynamometer.
Triceps: L: 33, R: 15.4
Middle Trap: L: 23, R: 20
Lower Trap: L: 19, R: 16
Hand Grip Dynamometer (average of 3): L: 95, R: 75 *Patient is R hand dominant
DNF (Kendall MMT): 8 seconds
Patient's Goals: Return to weight lifting, playing basketball, and full duty at work as a waiter.
A Look at the Literature
When looking over different interventions, management of individuals with cervical disc herniations is lacking in the literature. Furthermore, there has been even less published regarding the usage of both manual therapy and the cervical unloader (traction) for management of these patients. A 2007 article found that 67% of patients diagnosed with cervical radiculopathy responded positively to thoracic spine thrust manipulation (Cleland 2007). The clinical practice guidelines for neck pain recommend thoracic manipulation (Grade C evidence) for both pain and disability. Regarding traction, the guidelines recommend (Grade B evidence) mechanical intermittent traction be combined with other the use of other interventions (exercise and/or manual) therapy for individuals with neck and arm pain (Childs 2008).
Based off his initial evaluation, I knew scapular strengthening as well as triceps strengthening were essential components of my treatment. Additionally I wanted to normalize cervical and thoracic joint mobility. Finally, I wanted to incorporate the use of a cervical unloader to optimize the patient's success.
Thus far I have performed 4 treatment sessions on the patient. Each treatment is structured as:
1. Supine Thoracic Manipulation and Cervical Segmental Mobility
2. 10 minutes on the Cervical Unloader + Upper Body Ergometer (progressive resistance)
3. Cervical Unloader while performed progressive resisted Tricep theraband extension (3-4 sets x 10 RM)
4. Scapular strengthening exercises (standing theraband T's, prone T's, prone Y's (3 sets x 15 reps)
5. Postural Education
His reassessment results have been positive. Joint mobility has normalized, static sitting posture has improved, muscle strength has improved, and pain (not stated above) has significantly decreased. So far his outcome measures (NDI and FOTO) have not met the MCID.
Specific muscle strength as reassessment (using dynamometry):
Triceps: L: 34, R: 19
Middle Trap: L: 34, R: 29
Hand Grip Dynamometer (average of 3): L: 95, R: 82 *Patient is R hand dominant
At reassessment he reported 65% improved and has returned to shooting basketball, lifting, and working full duty.
I am continuing to treat this gentleman as of today. He reports 90% improvement. I have progressed to only using the cervical unloader during the warm-up and decreased manual therapy interventions. Final treatments are addressing plyometric aspects of sport and maximizing strength. From this single case experience I have found that using a multi-modal approach of manual therapy, cervical unloader with therapeutic exercise, and standard exercise has been effective in treating a young male with a C7 disc herniation.
Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Phys Ther 2007;87:1619–32.
Childs J, et al. Neck Pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the APTA. JOSPT. 2008: Sep (9): A1-A30.
Today's case discussion, again, is nothing incredibly unique, but I decided to bring it forward due to some potential considerations for treatments. I should note that my student Britt did most of the evaluation, so several tests and measurements were left out that I normally perform. I did proceed to add specific tests I deemed essential to the evaluation throughout. Our patient is a 41 year old male with a referring diagnosis of neck pain and RUE weakness. The patient reports he developed neck pain on 1/11/14 while working out at the gym. It then began to get worse and progressed to RUE pain and weakness. The patient had sought out multiple physician specialities for treatment in the following 2 months. The patient was then referred to physical therapy as a last-ditch effort before surgery. The patient presented on the day of evaluation with constant pain, numbness, and tingling beginning at his R shoulder and traveling down to the elbow. The neck was feeling slightly better that day per patient report. Pain was currently rated 6/10, 3/10 at its best, and 9/10 at its worst according to the VAS. His pain is increased by standing, running, walking, and driving. It is decreased when laying on his side and with his head fully flexed and supported. Patient also reports he has a headache, but denies any TMJ pain or clicking. Patient denies any significant changes in weight over last 6 months, S&S of cauda equina syndrome, night pain, nausea, vomiting. An MRI showed C6-7 lateral disc protrusion. The patient had had an injection in his neck that helped some with neck pain (so did Arnica gel), but has not helped besides that. Patient works from home on a computer, but also has to do lots of flying and driving for his job - several tasks with prolonged sitting. His Neck Disability Index is 38%.
-Dermatomes: cervical intact bilat throughout
-Reflexes: C5 2+ bilat, C7 2+ on L and 1+ on R
Posture: patient sits with FHP and downwardly rotated scapulae (R>L)
Cervical ROM: Flexion DN, Extension DN, Rotation DN bilat, Sidebend FN to L and DN to R
Shoulder ROM: WNL bilat
Shoulder Strength: Abduction, IR, ER all 5/5 bilat
Elbow Strength: Flexion 5/5 bilat, Extension 5/5 on L and 4/5 on R
Wrist Strength: Flexion 5/5 bilat, Extension 5/5 on L and 4+/5 on R
Scapular Strength: Rhomboids 4+/5 on L and 3+/5 on R, Mid Trap 4+/5 on L and 3+/5 on R, Low Trap 3+/5 on L and 3/5 on R, Serratus Anterior 5/5 on L and 4-/5 on R.
Segmental Mobility: C1-0 lateral flexion FN bilat, C1-2 rotation DN bilat, Flexion-Rotation test L limited more than R, C4-7 sideglides to L hypomobile compared to R.
Special Tests: (-) Transverse Ligament Test, (-) Alar Ligament Test, (-) VBI Test, (+) Distraction Test, (-) Compression Test, DNF Endurance Test 9 seconds (norm=39 seconds for male).
As you may have guessed already from the subjective and examination findings, the patient is suffering from signs and symptoms of cervical radiculopathy. The combination of forward head posture during prolonged sitting/standing for work with imaging findings, reports of neck/upper extremity pain and neural symptoms and upper extremity weakness increases our desire to confirm the suspicion of cervical radiculopathy. Had I performed the examination, I would have preferred adding the Median Nerve ULNT and Spurling's Test to utilize the Cervical Radiculopathy cluster. Something we must also consider is why the patient developed the pathology. The initiation of disc herniation is often due to some form of hypermobility, whether it be traumatic or repetitive stress. With lack of a specific mechanism of injury, it can be assumed that a repetitive stress is the likely culprit. Now why did the repetitive stress occur? We have already identified a pathological posture that the patient was consistently in, but we must remember the patient also showed hypomobility in the upper cervical spine (C1-2 rotation). When the patient performed standing cervical rotation, he was only minimally dysfunctional, however, during the C1-2 rotation breakout pattern, there were noted severe limitations in mobility. This suggests that the patient may have become hypermobile inferiorly (where the disc herniated) as a result of the superior hypomobility. While this is just a hypothesis, it is something that must be considered during our treatment plan.
-Manual Therapy: Grade V manipulation to T6.
-Therapeutic Ex: This was the makeup of the patient's HEP. supine chin tuck 5sec x10, supine on half foam roll with BUE horiz. add/abd and reciprocal flex/ext 5sec x10 each, standing wall shoulder shrugs 10sec x10. Samples of select exercises will be shown below.
-Mechanical Cervical Traction: 10 minutes 12# max 30:10 on:off ratio - resulted in a slight improvement in pain
Treatment 2: Neck feels a little better each day. Patient states he thinks the exercises are helping.
-Manual Therapy: Grade III mob for AA rotation bilateral followed by contract-relax for AA rotation bilat 6sec x3. Grade V manipulation to T6.
-Exercise: supine deep neck flexion (DNF), supine chin tuck with rotation, quad rock back with chin tuck, wall shoulder shrug with lift, standing chin tuck with rotation, prone TY exercises, wall push up plus. DNF added to HEP.
-Mechanical Cervical Traction: 15 min 16# max 30:10 on:off ratio.
Treatment 3: Pain is worst with prolonged standing/sitting but more centralized now. Weakness persists.
-Manual Therapy: Grade V manipulation bilaterally for AA rotation, grade V manipulation to T6.
-Therapeutic Ex: added quadruped alternating arm flexion with chin tuck, prone hands behind head scapular squeeze, body blade in flexion and abduction, serratus punches.
-Mechanical Cervical Traction: 15 min 18# max 30:10 on:off ratio.
Day 4: Neck feels better each day and is centralized to one spot in neck. No pain with sitting on airplane any more. Scapular pain occasionally occurs but no longer down the arm. Weakness persists.
-Manual Therapy: Grade V manipulation for AA rotation bilaterally, grade V manipulation to T6. Lower cervical spine sideglides normal throughout.
-Therapeutic Ex: added quadruped cervical flex/ext eccentric, cervical retraction followed by extension, lateral wall walks using hands with yellow theraband.
-Mechanical Cervical Traction: 15 min 20# max 30:10 on:off ratio.
Treatment 5: Pain only when driving for prolonged periods; weakness in RUE persists.
-Manual Therapy: Grade V manipulation bilaterally for AA rotation, grade V manipulation to T6.
-Therapeutic Ex: added seated cervical extension with hands on ipsilateral shoulders, prone ITY exercises, swiss ball walkouts, standing straight-arm lat pull-downs, quadruped rolling ball side to side. Cervical retractions added to HEP.
-Mechanical Cervical Traction: 15 min 22# max 30:10 on:off ratio.
Treatment 6: Pain is more localized; strength is improving. Patient states retractions work better and he only has pain when driving.
-Manual Therapy: Grade V manipulation for AA rotation bilaterally, grade V manipulation to T6, grade V manipulation to C-T junction (no cavitation), IASTM to bilat suboccipitals/scalenes/upper traps.
-Therapeutic Ex: added plank lateral walk-overs. Cervical retraction with upper thoracic extension added to HEP.
-Mechanical Cervical Traction: 15 min 22# max 30:10 on:off ratio.
Treatment 7: No pain when driving. Working out at gym now. Patient reports he is 95-98% improved.
-Manual Therapy: Grade V manipuation bilaterally for AA rotation, grade V manipulation to T6.
-Therapeutic Ex: added prone row with ER.
-Mechanical Cervical Traction: 15 min 22# max 30:10 on:off ratio.
As you can see, I took a very multi-modal approach. It is commonly accepted that some form of therapeutic exercise is necessary in the treatment of neck pain. Often that exercise progression focuses around the "core of the neck." This is initially begun with supine chin tucks to develop awareness of activation of the deep neck flexors - longus colli, longus capitus, rectus capitus anterior, rectus capitus lateralis. It is then progressed to a supine deep neck flexion while maintaining the chin tuck. Following that, the same exercise is performed in alternate positions (standing, sitting, etc.). Just like the multifidi need to be trained in low back pain, so do the small cervical extensors. This can be done in quadruped, while maintaining a chin tuck. Movement can be trained by switching between these positions and adding flexion/extension, rotation, sidebend.
Manual therapy is an intervention that is commonly used with discal injuries (Boyels et al, 2011). However, some people are under the impression that a herniated disc is a contraindication for manipulation. In the acute stage, it is reasonable to assume that the end range positions for a manipulation can be detrimental to the healing of the irritated tissues. However, that does not mean a manipulation elsewhere may not prove beneficial. There has been significant research performed on the benefit of a thoracic manipulation to alleviate neck and shoulder pain (Cross et al, 2011; Masaracchio et al, 2013). We discussed some of the reasoning behind this in an earlier post. However, what about a cervical manipulation. While it is controversial, there have been studies showing the benefit of a cervical manipulation being more successful for neck pain compared to thoracic (Puentedura et al, 2011). An obvious application of this is to free up the hypomobile segment, so that the hypermobile and injured segment no longer has to compensate. This can be done with a cervical manipulation (as done to free up the restricted C1-2 in this patient). While this may be off topic for this particular case, I would like to discuss the need to manipulate the level of the herniated disc. A healthy set of spinal segments rotates around a point in the disc that disperses stress equally throughout (general interpretation). If a facet becomes "locked," that focal point shifts to one side, causing increased stress on parts of the disc - leading to possible herniation. While you still would not want to manipulate that segment in the acute stage, once the patient enters the subacute stage, it may be necessary to manipulate the joint in order to restore normal arthrokinematics, shifting the focal point of rotation into the proper position.
As many of you may have realized by now, I am not often an advocate of using modalities. However, when there is sufficient evidence to show the benefit of a specific modality for a pathology, I don't hesitate to trial incorporating it into my plan of care (I may also trial it if the patient shows any biopsychosocial implications that it would help them). There have been numerous studies to show how the addition of cervical traction to manual therapy and therapeutic exercise can improve outcomes (Fritz et al, 2014; Jellad et al, 2009).
This patient responded extremely well to the multi-modal approach. Whether it was just the accumulative effects of all the components that led to the 95-98% improvement on that last treatment session or the addition of IASTM in the previous treatment session, I cannot say (I decided to trial it after viewing several videos on the OMPT Channel of The Manual Therapist). As I have written before, initially I was only using IASTM to treat neural symptoms of my patients, with good success. After watching several videos on the OMPT channel, I decided I would try to incorporate it on other patients for different reasons. So far I have found it very successful for treating neck and foot/ankle pain in general when combined with my other treatments. It's definitely something I look forward to developing patterns for patient application.
Boyles R1, Toy P, Mellon J Jr, Hayes M, Hammer B. (2011). Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011 Aug;19(3):135-42.
Cross K, Kuenze C, Grindstaff T, Hertel J. (2011). Thoracic Spine Thrust Manipulation Improves Pain, Range of Motion, and Self-Reported Function in Patients with Mechanical Neck Pain: A Systematic Review. J Orthop Sports Phys Ther. 2011; 41(9):633-642.
Fritz JM1, Thackeray A, Brennan GP, Childs JD. (2014). Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial. J Orthop Sports Phys Ther. 2014 Feb;44(2):45-57.
Jellad A1, Ben Salah Z, Boudokhane S, Migaou H, Bahri I, Rejeb N. (2009). The value of intermittent cervical traction in recent cervical radiculopathy. Ann Phys Rehabil Med. 2009 Nov;52(9):638-52.
Masaracchio M, Cleland J, Hellman M, Hagins M. (2013). Short-Term Combined Effects of Thoracic Spine Thrust Manipulation and Cervical Spine Nonthrust Manipulation in Individuals With Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop. Sports Phys. Ther. 2013 March;43(3):118-127.
Puentedura E, Landers M, Cleland J, Mintken P, Huijbregts P, Fernandez-De-Las-Penas C. (2011). Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients with Acute Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys. Ther. 2011 April;41(4): 208-220.
The patient reports he has had a chronic history of low back pain that would increase and decrease over the last 10 years, but increased significantly 3 months ago with no mechanism of injury. Additionally, the patient reports he has had some numbness and tingling over his L distal leg & foot that he believed to be associated with the back pain. In 1986, the patient reports he fractured his lumbar spine playing football, which he associates with his current state. The patient reports he had an MRI that showed L3-5 HNP, L5-S1 spondylolisthesis, and "nerve root pinching." The back pain the patient currently has is a constant dull ache that sometimes has sharp increases. The back pain and LE N&T all increased with standing, walking, and prolonged sitting. Heat and stretching decrease the pain slightly. The aggravating factors in cases like can be confusing, because standing and walking pain are commonly associated with stenosis and sitting pain is often associated with discogenic pain. SIJ pain or the combination of stenosis and discogenic pain can manifest in all these situations. That leaves us with an interesting set of hypotheses. An additional one that should be considered, however, is that of lumbar hypermobility. A common report for this last one is that of pain in sitting, standing, and walking. These patients frequently have to change positions due to the development of pain. Why do they develop pain with prolonged positioning? Creep. With a joint positioned for an extended period of time one way, the tissue begins to stretch and eventually signals pain.
Multi-Segmental Flexion FN
Multi-Segmental Extension DN
Supine Lat Stretch Hips Flexed FN
Prone Press-Up DN (hinging at L3)
Thomas Test DN bilat
FABER DN on R and DP on L
Multi-Segmental Rotation DN bilat
Seated Trunk Rotation DN bilat
Prone Hip Rotation FN bilat throughout
Seated Hip ER Active/Passive FN bilat
Seated Hip IR Active/PAssive DN bilat
Single Limb Stance DN bilat
Hip ROM: flex 85 on L and 90 on R, ext 0 bilat, IR 30 on L and 35 on R, ER WNL bilat.
Hip Strength: WNL throughout bilat except ext 3+/5 bilat.
Knee Strength and ROM: WNL throughout bilat.
Ankle ROM: PF WNL bilat, DF 10 on L and 15 on R
Ankle Strength: DF WNL bilat, PF 23/25 on L and 25/25 on R.
Neuro Screen: dermatomes intact bilat throughout except L5-S1 on L diminished; (+) Slump Test on L; (-) SLR bilat.
Special Tests: (-) Ober Test bilat, (-) SIJ Compression/Distraction Test bilat, (-) Hip Scour bilat, (-) POSH Test bilat, (-) Sacral Thrust Test.
Palpation: L anterior inominate, R posterior inominate, L3 shifted anteriorly
I used many of the core stabilization exercises that you learned in school for the appropriate low back pain category, starting with education of anatomy/pathology/Transversus Abdominus activation. The transversus abdominus muscle wraps around the spine and acts like a corset to provide stability to the base activating before we see movement in the extremities. It has been shown that in those with low back pain, the transversus abdominus muscle has a delayed firing. Exercises training this muscle are progressed from positions like supine/sidelying/prone to seated to standing and then to more functional activities. Additionally, extensive time was spent educating patient on maintaining a neutral lumbar spinal position with upright activities (the patient responded well to postural corrections with a TA wall slide exercise that corrects posture). Throughout the treatment sessions, the patient would occasionally present with SIJ pain that was then immediately alleviated with manual therapy. The previously mentioned core stabilization exercises were essential for maintaining these gains. Manual therapy was also used to increase the hip mobility bilaterally. This is essential as decreased mobility in the hips with gait can transition to excessive mobility in the lumbar spine. In addition to normal exercise and manual therapy for lumbar stenosis, Whitman el al found that the inclusion of a body weight supported treadmill training program can prove beneficial. This patient in particular began with 75# unloaded at 1.3 mph and was progressed to 40# unloaded at 2.2 mph for 10 min. The patient expressed some relief with the harness placement alone (mimicking the corset-like feature of the transversus abdominus muscle) but reported no symptoms after the treadmill training each session. This intervention does exactly what the name implied: unloads the spine while allowing exercise without pain or decreased dysfunction. This type of intervention is more integral than traction for patients with lumbar hypermobility, because the unloader simply decreases the weight on the spine, while traction's goal is to lengthen tissue - not ideal for hypermobility. Additionally, I did trial IASTM over the patient's L foot once and the patient reported an immediate significant improvement in his foot N&T but they returned after treadmill training that day. The patient was discharged after approximately 10 treatment sessions as he reported feeling greater than 100% improved. For this patient, there was an expectation that back pain was a normal development with aging. With reports of feeling better than he has in over a year and being able to be pain-free with regular performance of his HEP, the patient was ready for discharge.
Upon looking back at this case, I think I should have included some thoracic manipulation as well as this can have a significant impact on the neural symptoms, as discussed previously in another post. Additionally, this case really opened my eyes to the applicability of BWSTT for patients with low back pain. My initial thoughts on it were that no significant changes would be made due to the return of normal body weight afterwards. After seeing the results of it with this patient, when combined with the appropriate exercise, manual therapy, and of course education. If anything, I think I learned just how underutilized BWSTT is used.
Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, Garber MB, Bennett AC, Fritz JM. (2006). "A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial." Spine (Phila Pa 1976). 2006 Oct 15;31(22):2541-9. Web. 9 Feb 2014.
I performed this evaluation prior to taking the SFMA course and many of the residency lectures, so it is not exactly how I do my evaluations presently, but it is still an interesting case I wanted to present. This individual had a referral that indicated upper extremity numbness with the patient being a female in her upper 50's. With upper extremity numbness, there are several sources we should immediately start thinking of: pathologies affecting peripheral nerves, nerve roots, or potentially within the spinal cord. Obviously this means checking cervical, thoracic, and complete upper extremity involvement. What stood out immediately to me with this patient was her excessive thoracic kyphotic and forward head posture. With society's attachment to the computer screen, this is a common finding in all patients, so posture is commonly addressed. However, this individual would be placed beyond this "norm."
As usual, the subjective interview should play a large role of your examination. Here you typically gain about 90% of the information essential to your evaluation. This patient's primary complaints were bilateral numbness & tingling down the entirety of both arms and "Carpal Tunnel Syndrome," both of which had increased in frequency and intensity over the last few months. The patient's job involves about 8 hours of computer work each day. Her symptoms were increased by working and decreased by rest. The patient had also been seeing a hand therapist at another clinic to treat her "Carpal Tunnel Syndrome." The treatment there was consisting of using wrist splints at night, wrist stretches, and some massage to her hands according to the patient's reports. The patient reported to me that she had not seen any results from the hand therapy yet and was skeptical about physical therapy in general at this point. The patient told me she had even been considering some type of surgery, because it was affecting her so much. The patient denied any S&S of cauda equina syndrome, B&B changes, significant changes in weight over the last 6 months, or night pain. With the finding of bilateral involvement, we do need to be cautious due to the risk of central involvement - this can be associated with serious pathology. With the combination of thoracic kyphosis/forward head posture and bilateral symptoms (and lack of non-musculoskeletal symptoms), my primary hypothesis was a form of postural dysfunction resulting in Cervical Radiculopathy. Some other potential hypotheses included: Thoracic Outlet Syndrome, T4 Syndrome, and bilateral peripheral neuropathy. Thoracic Outlet Syndrome, like Cervical Radiculopathy, can be related to abnormal posture due to the effect thoracic kyphosis and protracted scapulae have on shrinking the thoracic outlet, compressing the brachial plexus. T4 Syndrome was included in my hypotheses because a common symptom is bilateral non-dermatomal neural symptoms. Peripheral neuropathy is pretty self-explanatory as to why it was included.
Cervical ROM: flexion 35 degrees, extension 45 degrees, rotation 55 degrees bilateral, SB 30 degrees on L and 20 degrees on R.
Shoulder ROM: WNL bilateral except 80 degrees of IR on L and 45 degrees on R.
Shoulder Strength: 5/5 bilateral except 3+/5 flexion and 4/5 ER bilat.
Wrist Strength: 4/5 flexion and extension bilat.
Neural Screen: C3-4 dermatomes intact bilaterally. C5-T1 dermatomes diminished bilaterally. C5 reflexes 2+ bilat. (+) Radial/Ulnar/Median ULNTs bilat.
Joint Mobility: Hypomobility noted throughout thoracic spine, especially at mid- to upper-locations.
Special Tests: (+) Spurling's Test, (-) Cervical Distraction Test, (-) Painful Arc Sign, (-) Infraspinatus Test, (-) Hawkins-Kennedy Test, (-) Vertebrobasilar Insufficiency Test, (+) ROOS Test, (+) Costoclavicular Test.
My examination actually did not narrow down my hypotheses to one alone. With 3/4 positive tests in the Cervical Radiculopathy Cluster, there is a +LR of 6.1 that Cervical Radiculopathy is a contributing factor: (+) Spurling's Test, (+
) Median ULNT, (+) < 60 degrees rotation to affected side, and (-) Cervical Distraction Test. While the Thoracic Outlet Tests do not have any diagnostic accuracy reported that we are aware of, the positive findings of the test combined with the significant thoracic kyphotic and protracted shoulder posture keep Thoracic Outlet Syndrome as a possibility. While T4 Syndrome typically has some reports of a mechanism of injury such as lifting an object awkwardly, the combination of non-dermatomal paresthesia and hypomobile mid-thoracic spine keep T4 Syndrome as a possibility as well. This often happens where we are unable to pinpoint the true "diagnosis"; however, what really matters is that we identify the primary impairments contributing to the problem and treat those! In this case my most significant findings were: abnormal posture (forward head/thoracic kyphosis/protracted shoulders) - consider the weak postural muscles associated with this, hypomobile thoracic spine, neural tension, and decreased shoulder IR ROM. Another factor we definitely need to consider is the patient's job that requires 8+ hours of computer work a day as this will definitely impact our prognosis.
Same Day Treatment:
Having recently completed the IASTM Technique course prior to this evaluation, I was eager to trial some IASTM on this patient due to the significant neural tension findings. The patient was extremely skeptical at first (she actually referred to the EDGE Tool as my "belt buckle." I told her I would only perform it on one UE, so that she could judge the effects compared to no treatment on the opposite side (other than the HEP I was going to distribute). I performed IASTM on her dorsal/ventral forearm and medial upper arm. The HEP I distributed to the patient included supine chin tucks to strengthen the deep neck flexors, and hourly cervical retractions and scapular retractions to improve posture/relieve tension on overstressed structures while working. Of course, the patient was educated regarding proper posture and the effect excessive computer work has on posture and the patient's symptoms, as well.
At the second visit, the patient reported she noticed a significant reduction in numbness & tingling on the side IASTM was performed compared to the opposite side. Additionally, the patient reported some relief with the performance of HEP. This is huge, because I now had patient "buy-in." This treatment session I performed the same IASTM treatments to both upper extremities, some cervical and shoulder mobilizations to improve mobility, manipulations to thoracic spine, and some general postural strengthening exercises.
The patient again reported significant improvement in her numbness and tingling by her third visit, so much so that she stopped hand therapy for her "carpal tunnel syndrome" because she felt my treatment was having a more significant impact and she didn't want to waste her insurance visits with the hand therapy. I should note that I have been putting Carpal Tunnel Syndrome in quotations, because I was never certain the patient had that at all. Even though this patient did have prolonged computer work associated with the pathology, I have found that it is often over-diagnosed and the origin of the pathology may be located proximally. She may have had the diagnosis; however, she was already being treated for this by the hand therapist so I was going to focus more proximally. The patient was treated a total of 12 visits with similar treatment sessions to the second day; however, I would gradually alter the ratio of manual treatment to exercise (increasing exercise) to make the gains more permanent. By the 8th visit, the patient had no symptoms, but the patient wanted a few additional visits to "lock in" the changes. The treatment plan was lengthened compared to what I originally planned due to a couple additional development of symptoms. The patient came in a couple times with "upper trap pain" and L buttock pain. The upper trap pain was found to be an elevated 1st rib and was treated with a seated anterolateral grade III mob. Cervical retraction with sidebend was used to lock in the changes. The left buttock pain was found to be sacroiliac joint dysfunction that was negative on all provocation tests. Following a couple muscle energy techniques, pain was completely eliminated. Additionally, the patient fractured a toe one day between sessions. Needless to say, this patient had a lot going on; however, at discharge she was completely symptom-free and independent with her HEP to hopefully stay symptom-free!
As with any case, you should begin formulating hypotheses based on a referral. Even though this is a useful process, not every script is accurate or even that descriptive. This upper 60's male patient had a referral of "knee pain." As you know, there are many different pathologies that can refer to the knee. We must consider the back, SIJ, hip, knee, and foot/ankle at the very least.
After meeting the patient in the waiting room, I noticed several key things with the patient's posture and gait. The patient stands and walks in about 45 degrees of external rotation bilaterally in the lower extremities. As you might imagine, this can easily stress the tissues located medially along the knee. Also, with the patient wearing sandals, I was able to notice significant pes planus bilaterally as well.
With the subjective interview, I learned that the patient's pain was located generally on the left knee medial to the patella both in the distal thigh and proximal tibia. The patient was unable to identify any mechanism of injury but the pain began intermittently about 2 months ago and become relatively constant 2.5 weeks ago. Again, the patient was unable to explain the change to constant pain. The patient then reported that pain was more prevalent in knee flexion and squatting, but alleviated by extension or manual pressure. No history of joint locking/catching, but the patient did state his knee sometimes gave way. Other than that, the patient couldn't link any specific activities to knee pain and denied any numbness and tingling. All other red flags were negative as well. At this point, due to the patient's age and aggravating/alleviating factors, I had several hypotheses. Meniscal tears/osteoarthritis were easy targets due to the location of the pain and age of the patient. Saphenous nerve irritation or medial retinacular fiber irritation were possibilities due to the location of the symptoms and potential for stress as a result of the patient's gait pattern. MCL injury was possible but unlikely due to the pain location but with the lack of a mechanism of injury seems unlikely (even though postural stress can irritate it as well, so I still wanted to inspect it). At this point, lumbar, SIJ, and hip must still be ruled out as the source of pain.
Lumbar ROM: WNL and pain-free. Repeated flexion and extension negative as well.
Hip ROM: extension and external rotation WNL bilaterally. Internal rotation decreased significantly bilaterally (L > R). Hip flexion was moderately limited bilaterally. All motions without pain.
Knee ROM: extension was WNL, however overpressure resulted in pain. Flexion was WNL but pain was intermittent throughout the motion with no pain at end range overpressure. Hamstring length was moderately decreased bilaterally. Tibial internal rotation was essentially non-existant bilaterally, and the patient was sitting in tibial external rotation as well. Both tibial internal and external rotation recreated pain.
Ankle ROM: plantarflexion WNL and pain-free bilaterally. dorsiflexion limited bilaterally (L > R) with no pain.
Strength of bilateral extremities was strong and painless throughout, including quadriceps contraction. This is important to note, because this decreases the likelihood of retinacular fiber involvement.
Special Tests: (-) Lumbar Quadrant Test bilaterally, (-) SLR bilat, (-) SIJ Compression, (-) SIJ Distraction, (-) POSH Test, (-) Gaenslen Test, (-) FABER Test, (-) Valgus Stress Test, (-) Knee Flexion Overpressure, (+) Knee Extension Overpressure, (+) McMurray's for clickling, (-) Joint Line Tenderness, (-) Patellar gliding
At this point, I'm relatively confident that the lumbar spine is not the source of the patient's pain. Even though there is no significant diagnostic accuracy to ROM, repeated motions, and the Lumbar Quadrant Test, all were full motion and did not reproduce pain. This combined with the negative SLR Tests helps to rule out lumbar disc related pain. SLR and Crossed-SLR Tests have good sensitivity and specificity respectively. I performed 4/5 tests in the SIJ Cluster and all were negative, so I was able to lower the likelihood that SIJ was the source of pain. With FABER and POSH Tests negative and hip ROM overpressure not producing any pain, I did not think the hip was the source of the patient's pain; however, with the ROM limitations, I did begin to suspect a contribution to the patient's pathology. Like I mentioned earlier, with no pain with resisted knee extension, I lowered the likelihood of retinacular fibers as the source of pain. Same thing with the Valgus Stress Test. If the MCL was being strained, it would have been painful.
With only 2/5 conditions met for the Meniscal Cluster, I was unable to rule in or out meniscus as the source of the patient's pain; however, I was leaning away from that as the patient described feeling "relief" with pressure. The vague description of the pain is more commonly associated with nerve lesions. Something I should have looked at the eval was potential for femoral head retroversion (I looked at this on his second visit thanks to a recommendation from my mentor) with Craig's Test. It did end up being positive bilaterally. Now that we know the source of the patient's pain, we must determine why it is painful. Let's go back to the original presentation of our patient: significant ER of the lower extremities bilaterally in both stance and gait. The patient likely ambulates this way for two reasons: femoral head retroversion and decreased dorsiflexion ROM. The lack of utilization of hip and tibial internal rotation over decades results in lack of ROM in those directions. As a result, the patient ambulates in external rotation which had been stressing the medial structures, in this case the saphenous nerve. My goal then was to increase hip and tibial internal rotation and ankle dorsiflexion ROM followed by gait retraining to take some stress off those medial structures.
So what other clues led to my determination that the saphenous nerve was the culprit? First of all, nerve pain tends to be a little more vague and harder to localize. Patients are usually able to point with one finger where their pain is. Now this is definitely not always the case, but it is common. The knee angle's effect on pain was difficult for me to fully comprehend initially as the patient had on and off pain with flexion and relief with extension. However, the patient had pain with extension overpressure. Well if you look at this picture, you will see the saphenous nerve actually runs posterior to the knee flexion/extension axis. This would indicate that extension would cause pain. While this is possible, I am more convinced that the patient's extension overpressure pain was the result of some meniscal lesions that are otherwise non-symptomatic (remember we had a few tests positive in the cluster). Every anatomical presentation tends to be different, so maybe this patient's saphenous nerve runs closer to the axis of rotation in the knee, thus causing pain in flexion. At this point I am speculating, but it is something to consider in your diagnosis.
Same Day Treatment
Having recently learned some useful techniques from The Manual Therapist for increasing mobility, I quickly put them to use for this patient. Regarding the loss of hip internal rotation, Dr. E uses mobility bands to increase the ROM as shown in the below video:
Following this technique, my patient's IR ROM doubled bilaterally. It still was not full, but I wasn't expecting to increase it to normal due to the retroversion. At this point I performed some IASTM to the distal medial thigh and proximal medial tibia along the path of the saphenous nerve. For the decreased tibial IR ROM and lack of ankle dorsiflexion, I wrapped the mobility band around the proximal calf in half kneeling and did some MWM rotating the tibia internally as the patient lunged forward. This increases both ankle dorsiflexion and tibial IR ROM. Check out the first part of the video below to see where the band is applied in the half-kneeling position. I added in the tibial IR MWM as a technique that Dr. E teaches elsewhere:
This resulted in both increased tibial IR and ankle DF ROM. The patient's HEP included this technique (minus the band), the windshield wiper stretch from the 1st video, hamstring stretch, and forefoot adduction with theraband. I added the last exercise because it has been shown to activate the posterior tibialis the greatest and is the primary medial arch supporter (remember the pes planus bilaterally). The patient described significant relief in pain following the evaluation and treatment that day.
Day Two Treatment
The patient came in a couple days later and reported reduced pain from a week ago. I performed the same treatments as described above. Once I had improved mobility, I proceeded to educate the patient on neutral subtalar positioning in stance and normalized gait. I had him perform some squats with his lower extremities in decreased external rotation and neutral subtalar positioning. I finished the day by training the patient's gait in less external rotation compared to his "normal" form. I do not expect to have the patient ambulate with his feet pointing straight forward due to the retroversion of his hips. The patient again expressed improvement in pain following treatment, especially with the tibial IR MWM in half-kneeling. With one or two more visits to focus more on maintaining our results and changing gait form, the patient should be ready for discharge.