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Case: Can’t Hold Up Arm + Cervical Disc

Exit forum ID Forum Discussion Case: Can’t Hold Up Arm + Cervical Disc

This topic contains 3 replies, has 2 voices, and was last updated by   Christopher Stepien June 16, 2016 at 9:11 am.

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  • #2091

    Christopher Stepien
    Participant

      I have a 21 year old female with right anterior and posterior shoulder pain, rated as an 8/10 at rest + described as sharp/stabby.

      HX:

      • Trauma – In Dec 2014, she was cheerleading + had a girl land on her head/shoulder, causing a tractioning injury of the brachial plexus on the right.
      • In Dec 2014, she had right-sided neck pain, the same shoulder pain she has today, and right arm tingling that was present all of the time.
      • Most of this pain got better except for the right shoulder pain and movements that provoke the tingling.
      • 3 months ago, she was working out with upper body and noticed entire right arm, forearm, and hand “tingling” about 10 minutes into a CrossFit workout.  She also noticed “Stabbing/throbbing” at her right brachioradialis/radial n. @ supinator concurrently.

      EXAM:

      • Posture: Her left hand was holding her right arm. When she dropped her right arm, her right posterior pinky, ring finger, and hand along 4th and 5th MCs went tingly.
      • UCF: 36.9 – midline upper thoracic “pulling” + both scapula elevated.
      • CF: 1.5 fingers from full – “9/10 Pain” midline T3-T7.
      • CTF: Didn’t measure standing.  Noticed she’s quite flat in whole upper T-Spine. She mentioned one trauma during gymnastics where she landed on upper T-spine as teenager and was significant.
      • SA: Left – Full.  Right – approximately 120 degrees and very slow. Felt right medial scapular symptoms and same tingling in pinky + ring finger.
      • Interestingly, she couldn’t provoke the CCx.  She said if she were able to do a bunch of push-ups, the shoulder pain would get worse.
      • Provocative: She sleeps face down.  If her arm is right next to her side during sleep, she’s OK. If it’s anywhere else but next to her body, the tingling comes.  If she sleeps face down and is leaning on it, it goes numb.

      TESTING/IMAGING:

      • MRI (without contrast) 6/2/16 – tiny partial thickness tear in spraspinatus.
      • MRI (without contrast) 3/24/16 – entire teres major muscle is markedly enlarged, thickened, and edematous.  6 x 5 cm in its axial dimension.  “Mass effect” on quadrilateral space and the exterior nerve, whatever nerve that is.  Of note: This is a couple of weeks after she started CF’ing.  She has since continued CF’ing without using her right shoulder.
      • EMG/NCV testing 12/12/14 (1 week after trauma) – no findings.
      • MRI of C-spine 11/21/14 (before trauma) – no findings. I asked her about this MRI beforehand.  She said she had some back pain, but couldn’t describe it more than that.

      INITIAL DIAGNOSIS:

      1. Lower cervical disc pathology with right nerve root involvement.  Supported by need to hold her arm and C8 nerve root involvement.  I’m thinking that if she cannot hold her arm up without her other arm’s help, the load on cervical disc cannot handle any exterior load on the right hand side.  Not sure though as I haven’t seen this before?

      What am I missing?

      #1763

      William Brady, DC
      Participant

        Plenty of nerve symptoms means nerve involvement. Severe symptoms means a big problem. So she has a big problem with a nerve. Distribution is consistent with C8 nerve root. Shoulder MRI is negative (without contrast 80% reliable). The next step would be a cervical MRI. You have to diagnose what is causing such severe symptoms and limitations.

        Adhesion may be part of her problem, but I’d bet it’s not most of her problem. Look for the big pathology that causing the big symptoms.

        #2108

        Christopher Stepien
        Participant

          Will do.

          Is there any other conclusion I can extrapolate from the “Arm holding” phenomenon?

           

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