Case Study: Radial Nerve Tension w/ CT Junction Mobility Deficits

Patient’s primary complaint
48 y.o. male with Left elbow and upper extremity pain with upper extremity activity

Physical Therapy Diagnosis
Radial Nerve Tension with CT junction mobility deficits

Subjective History
General: On 10/1/14 the pt. presented to a PT clinic with L elbow pain during L elbow movements following a work related injury. He reports reaching to grab an object falling off a shelf weight approximately 10 lbs. Pain intensity was 4/10 and described as sharp and localized to the elbow. Work/Social: He has two jobs, primarily working at Lowe’s. Job duties include a range of tasks from prolonged desk work to lifting up to 30# in the different aisles. Other: Non-significant PMH, past surgical history. Denies taking any medications. From 10/1-10/6, he received two physical therapy treatments for the medical diagnosis of lateral epicondylitis. The original PT treated his lateral elbow pain with wrist stretching and strengthening exercises. The patient did not report any benefit and stopped attending PT.

I first saw this patient on 12/2/14. He presented to my clinic with Left elbow pain and occasional referral from his common extensor mass to the lateral deltoid and down the arm to the dorsum of the wrist. Pain intensity was now 8/10 with arm and shoulder movements. He reported, “I thought I would give PT another try because my pain is so intense right now it is affecting my entire lifestyle- working, home activities…and sleeping.” Subjective history revealed his symptoms increase with elbow extension, wrist extension, pronation and shoulder flexion. His worst pain occurred with resisted elbow flexion and supination. Symptoms increase throughout the workday after using his arm. Additionally, he was now taking 200 mg Ibuprofen and Naproxen for pain management. This patient is L hand dominant. 

Objective Findings
Postural Assessment: Forward head posture. Rounded shoulders with the L shoulder anteriorly displaced. Mini-CT junction hump with cervical hinging at C5-C6. Mild thoracic kyphosis. Left scapular protraction.

Active Range of Motion: Cervical spine: WNL all movements, excessive hinging at C5-C6 with extension; Thoracic spine: decreased thoracic extension with no reversal of thoracic curve from T6-T8. Right UE: WNL. L UE: Shoulder Flexion, Abduction, Extension: WNL; Rotation (supine, arm abducted to 90 deg): ER: WNL, IR: grossly decreased. Elbow and Hand: WNL 

Passive Range of Motion: WNL all movements

Joint Mobility: Hypomobility with right sideglides at C6-C7; Hypomobility and pain with PA assessment of T1-T3; Hypomobility with PA assessment from T6-T8. Hypomobility with posterior glides of GHJ; Hypomobility PA of the humero-radial joint.

MMT: Deferred at initial evaluation (time constraints)

Neurovascular screening: Vascular deferred (not applicable). Neuromuscular: Normal dermatomes and myotomes; +ive radial nerve tension test. 

Special Testing: +ive Cozen’s, +Mill’s Test, +ive resisted supination.

Movement analysis (demo’ed with 5x shoulder flexion): cervical extension with shoulder flexion >120 degrees. Excessive scapular abduction during shoulder flexion, no reversal of thoracic kyphosis with shoulder flexion, decreased and poor coordination of L scapular retraction and downward rotation on return from flexion. 

Asterisk Signs
(12/2) Elbow flexion, supination AROM pain with movement: Pre-treatment: 8/10. Post-Thoracic and CT junction manipulation: 6/10. Post-C6-C7 mobilizations with radial nerve glides: 4/10. Post-treatment: 4/10.

(12/5) Shoulder flexion pain with movement: Pre-treatment: 5/10. Post-treatment: 1/10

First Choice Intervention (with rationale)
Manual Therapy: Supine Thoracic Manipulation- localized over T6-T8
-Neurophysiological Effects- reduction of neural tension, reflexive inhibition of periscapular muscles, hypoalgesic effects, decreased areas of activation in brain regions associated with pain (anterior cingulate, frontal cortex & sensory motor cortex)
-Biomechanical: restore joint play and ROM within the thoracic spine, quick stretch of tight joint capsules
-Psychological Effects- subjective report of relief with manipulation in the past.

Second Choice Intervention (with rationale)
Therapeutic Exercise: Radial Nerve Glides:
-Improve axoplasmic flow within the nerve, improve nerve vascularization, improve the mechanical properties within the nervous system, facilitation of nerve gliding.

First Treatment:
Manual Therapy: 12 min
-Supine Thoracic Manipulation: Grade V, T6-T8
-Prone bilateral CT Junction Manipulation: Grade V
-IASTM using Edge Tool: 8 minutes along radial Nerve Tract

Therapeutic Exercise: 15 minutes
-Upper Extremity Ergometer: x10 minutes (5 forward, 5 backward); Lvl 1
-Prone T’s: 3x15 reps*
-Prone I’s: 3x15 reps (given after unable to perform Y’s without pain)*
-Radial Nerve Glides: x15 reps, slowly*
       *Home Exercise Program

Education: 15 minutes
-Nerve anatomy and irritation
-Positions to avoid while at work and home
-Postural Education

SecondTreatment:
Manual Therapy: 10 min
-Supine Thoracic Manipulation: Grade V, T6-T8
-Prone bilateral CT Junction Manipulation: Grade V
-C6-C7 Right side glides, GIII oscillatory, with active radial nerve glides x10 min
-Prone IR Contract/Relax to end-range 3x30 sec

Therapeutic Exercise: 25 minutes
-Upper Extremity Ergometer: x10 minutes (5 forward, 5 backward); Lvl 1; focus on neutral scapular positioning
-Prone IR AROM from neutral scapular position x30*
-Prone T’s: 3x 15 reps
-Prone Y’s: 3x 10-15 reps (now able to perform)
-Bruegger’s Postural Exercise 3x10, hold 3 sec.

        *Home Exercise Program additions

Third Treatment
Manual Therapy: 20 min
-Supine Thoracic Manipulation: Grade V, mid-thoracic spine
-Prone Left CT Junction
Manipulation: Grade V
-C6-C7 Right side glides, GIII oscillatory with active radial nerve glides x10 min
-Prone IR Contract/Relax to end-range 3x30 sec
-Manual L UE radial nerve glides with active neck side bending x15 reps, slowly

Therapeutic Exercise: 20 minutes
-Upper Extremity Ergometer: x10 minutes (5 forward, 5 backward); Lvl 1; focus on neutral scapular positioning
-Prone IR ROM from neutral scapular position x30
-Prone T’s 1# DB: 3x 15 reps

Fourth Treatment
Manual Therapy: 8 min
-Supine Thoracic Manipulation: Grade V, mid-thoracic spine
-C6-C7 Right side glides, GIII oscillatory with active radial nerve glides x6 min
-Manual L UE radial nerve glides with active neck side bending x15 reps, slowly

Therapeutic Exercise: 20 minutes
-Upper Extremity Ergometer: x10 minutes (5 fwd, 5 bkwd); Lvl 3
-Prone T’s on swiss ball 2# DB: 3x 15 reps
-Prone Y’s on swiss ball: 3x15

  

Fifth Treatment
Therapeutic Exercise: 6 minutes
-Upper Extremity Ergometer: x6 minutes (3 fwd, 3 bckwd); Lvl 5

Therapeutic Activities: 14 minutes
-Push/Pull: Sled +35#: 10x 40 feet (pain free)
-Lift floor to waist: 15x 15# (pain free)

Education: 8 min
-Lifting mechanics

The patient has been on vacation for the past 3 weeks so I have not seen him since prior to Christmas. Assuming he is doing well, I am expecting 1-2 more treatment sessions for full return to work.  


Conclusions:
-We must perform appropriate differential diagnosis. The first PT improperly diagnosed his lateral elbow pain as lateral epicondylagia. The patient had months more duration of pain, increased medical cost, and time away from work. This could have been avoided with a proper differential. 
-Always assess the radial nerve in lateral elbow pain.
-Look proximal and central when addressing nerve dysfunction. Many of this gentlemen's symptoms were due to poor posture and spinal mechanics. 

Hope you enjoyed the case. Send me any questions you may have.


-Jim