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
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