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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.
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
4 Comments
chad
1/21/2015 11:40:36 pm
This case really highlights the importance of the nervous system's effect on patient's presenting with typical MSK dysfunctions. As an upcoming PT grad I am fortunate to be at a clinic that emphasizes the neural system and appropriate differential Dx to apply the correct treatment. I would think most PTs would see this type of patient for 10+ visits based on the Dx of "epicondylitis, so it is encouraging to see such an effective treatment strategy applied here!
Chad
2/13/2015 05:50:55 am
Hey Chad! 2/14/2015 12:23:52 am
great case study, do you use lubricant when treating the neural container or directly on skin?
Jim
2/14/2015 01:57:49 am
Thanks for the comment Kyle. I typically use a massage cream during my IASTM treatments. I find it to be easier on the patient's skin and allows me to feel the tissue better. When performing manual nerve mobilizations, I usually do not use any lubricant. Hope this helps. Leave a Reply. |
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