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Picture

What is the Diagnosis?

8/26/2016

8 Comments

 
Picture
​A patient recently presented to my cash-based clinic (Heafner Health) with the pain diagram seen above. The patient had a three-year history of left upper extremity pain that has been limiting almost all daily activities. From the picture alone, my first three clinical pathoanatomical hypothesis' were cervical radiculopathy, ulnar nerve peripheral neuropathy, or a double crush syndrome (thoracic outlet syndrome could be included in the double crush category). Additionally, due to the chronicity of his symptoms, I knew the patient would have some degree of central sensitization.
 
During the initial evaluation, he presented with the movement impairment syndrome of left scapular downward rotation and depression. Primary impairments included decreased left thoracic rotation, decreased scapular upward rotation, hypomobility in the CT junction and mid thoracic spine, poor serratus anterior and lower trapezius strength, and a positive ulnar nerve tension test. Additionally, the patient was unable to maintain cervical stability with any shoulder movement above 90 degrees.
 
Following the objective examination, manual treatment included a supine thoracic manipulation, Grade IV CT junction mobilizations, IASTM to the left upper trapezius and scalene muscles, and active assistive sidelying scapular upward rotation. Following the OPTIM treatment paradigm, the manual interventions were followed with corrective exercises. These included seated upper trapezius shrugs (with arms resting on a pillow), serratus anterior presses with the shoulders at 90 degrees, and seated chin tucks with upper thoracic extension. We attempted ulnar nerve tensioners, but I did not feel comfortable prescribing them as part of his HEP. The patient was given education on chronic pain (told to watch ‘understanding pain is less than 5 minutes’ and the ‘Lorimer Mosely TEDx Talk’) and ergonomic set-up. Following the treatment session, the patient's upper limb tension test had improved by nearly 40 degrees. 
 
What other initial diagnoses were you suspecting based on the pain diagram? Anything else you would add to the initial treatment? 

-Jim Heafner PT, DPT, OCS
8 Comments
Felipe Baeza
8/29/2016 05:21:05 am

I would add a cervical (articular) assesment and if it is necessary make cervical manipulación. And excercises for cervical stability. And find trigger points.

Reply
El
8/29/2016 06:18:32 am

I feel you have done too many things at once -if he returns better or worse you won't know what did what and will have troubles to diagnose and rehabilitate appropriately.

Reply
Steve
8/29/2016 07:35:00 am

Does it really matter if he "did too many things at once"? The patient feels better and is presenting better. That's what counts.

Reply
chad
9/6/2016 10:45:31 am

I agree w/ El, perhaps to many things all at once. But the end goal is to decrease pain as rapidly as possible and it sounds like this was accomplished very well. I generally perform one movement and look for a change & prescribe as hep (mostly because patient are non compliance), but also that way I can be more confident it what will and will not help the patient.

Reply
Jim link
10/8/2016 06:22:11 am

I curious to see what you mean by doing too much El! I always try to find the top primary impairment(s) and address those issues. For this case, each one of those interventions were successful in the clinic so I want them to be part of his home program. Addtionally, all 3 exercises in the HEP focus on improving upward rotation (or meet a requirement that is necessary for upward rotation)

I often find patients have impairments in multiple areas and only addressing 1 thing leads to a slower prognosis. I definitely see the point of not over testing and over treating. However at the same time, my interventions were not blindly chosen.

Anyhow, always appreciate the discussion and thank you for the comments! Would be curious to hear more too. -Jim

Reply
Richard Field
12/16/2017 09:22:55 am

In absence of a palpatory exam of cervical and thoracic spine I diagnose a facilitated segment at C2/3 Left. Together with same at C6/7 Right. This may be as result of lateral scoliosis D/L concave Right.

Reply
Border Free Health link
5/16/2024 11:50:44 pm

In the intricate realm of healthcare, the pursuit of an accurate diagnosis is paramount. Amidst the complexity of symptoms, tests, and medical histories, clinicians navigate the terrain with precision and empathy. Within this framework, the concept of "Border Free Health" emerges, emphasizing inclusive, accessible care for all. Whether deciphering the subtleties of a mysterious ailment or unraveling the layers of a chronic condition, the diagnosis becomes a beacon of clarity and hope. It signifies not just a label, but a pathway to understanding, treatment, and ultimately, healing.

Reply
The Well-Being link
9/30/2024 08:47:13 am

The Well-Being encompasses a holistic approach to health that integrates physical, mental, and emotional aspects. It emphasizes the importance of balance in life, promoting healthy habits such as regular exercise, nutritious eating, and mindfulness practices. Engaging in activities that bring joy and fulfillment is essential for enhancing overall well-being. By prioritizing self-care and building strong social connections, individuals can foster resilience and cope better with stress. Embracing The Well-Being philosophy encourages a healthier, happier lifestyle, ultimately leading to improved quality of life.

Reply



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  • Home
  • About Us
  • TSPT Academy
  • Resources
    • Newsletter
    • Orthopedic Blog
    • Featured Articles
    • Research Articles
    • Residency Corner
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test