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Chronic Upper Back Tightness

Exit forum ID Forum Discussion Chronic Upper Back Tightness

This topic contains 10 replies, has 7 voices, and was last updated by   Carl Nottoli, DC August 19, 2019 at 3:34 pm.

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    Jamie Hansen

      Hey everyone,
      I wanted to know if anyone see’s anything that im missing with this case.
      1st order HX
      SX Loc; Bi-Lat upper trap R>L
      SX; Achy, tightness
      SX Intensity; Current 6/10, Avg 5/10, Worst 8-9/10, Never a 0/10, Best 0/10
      Provocative; CPU/iPad, laying on right side in bed, “trying to stretch”, instantly feels the discomfort when waking up in the am and before bed after the day.
      Pall. Deep Massage (24-36hrs) minor relief.

      2ndary HX
      20+ yrs of this discomfort, progressively worse over the past 4-5 yrs
      Moderate Stress level
      No HX of headaches or head trauma
      No imagining
      **Pt noted that about 6 months ago he started getting “cramping sensations” in both hands which he described to feeling like arthritis in his hands but in his mind the cramping “resolved” abt 2-3 months ago.

      Exam Findings:
      UCF- 10, Pain bilateral C5-T4 moderate (6/10) deep pull
      CF 52, Sig pain bilateral C4-T4
      CTF 69, Sig pain bilateral C4-T4
      Rot: L- 63 mod tight left LS
      R- 53 mod tight right LS
      Lat Flex – R 10 Mod P inc. with shld dep
      L 15 mod P inc. with shld dep.
      After 5 visits:
      UCF improved to 19/25
      CF improved to 58

      He mentioned that even though his ROM is improving he has not seen any sustained relief in the discomfort he is experiencing. After yesterdays visits we spoke about 3 options:
      1) he get an MRI to rule out any structural damage and to make sure nothing was missed.
      2) we stop care if he is not happy with how tx is going and refund him the rest of this case.
      3) we continue with care
      His response was interesting in the sense that a) he is open to the MRI b) he expressed that he knows hes “a little bit better” to some extent in his words ~15%, but sleep is getting a little bit better so he knows something is working, but his “trap tightness” has not improved much (his CC).

      My questions to everyone:
      1) am i missing something?
      2) has anyone encounter something similar?
      3) overall thoughts?

      Thanks for everyone feedback!



      Doc Nina

        I think that an MRI is a logical next step, given his age it is reasonable to assume there may be some spinal degeneration. Considering his reported “moderate” stress this may also play into his pain, similarly to our other patient who gets improved ROMs but never improves their pain. Maybe he also has shoulder dysfunction which is contributing to his pain? Just some thoughts.


        Scott Glidden

          IMO I think you’re on the right track. Focus on the fact that you need to follow certain steps to ensure that this problem stays fixed and you haven’t really gotten to his main issue yet.

          How is max cervical compression on the R vs L? What about lateral flexion/anterior flexion?
          It’s possible that CTF structures/rotatores/joint capsules could be the source of his pain, especially since C6/7 refers to the trap and you haven’t yet treated joint capsule/rotatores yet.

          Explain that and then refer to MRI only if symptoms persist once you hit a wall with those measurements.


          Seth Schultz, DC

            I would not give up on this case at all. You still have half the tests to work through and you’ve made good functional changes. This needs to be communicated to him so he knows the path forward as this condition has been chronic for half his life! What was your initial diagnosis? Great job with collecting all the data


            Michael Vibert

              How are things in terms of load management? Don’t forget that LM is 1/3 of treatment and if he is loading it up all day the angry tissues can’t heal. My top DX would be low cervical disc derangement.? I often personally find LM the hardest part of my job, identifying the problems postures, positions and activities and then having patients comply with instructions.


              Seth Schultz, DC

                Any update with your differential dx Joe?


                Brandon Cohen DC, CSCS

                  I’m with Seth here. Great functional improvement and you haven’t even addressed the tissues in the area where he is having symptoms. What is the dx? I’ve made some assumptions below.

                  We don’t have palpation findings, but if he has significant findings in his Accessory nerve, CT erectors, Levator, or Serratus, that could clean up a lot.

                  I think the hand symptoms might be a distraction.

                  Focus on the communication piece here, depending on your diagnosis.

                  When people have symptoms like this, I might say, “I know you are feeling pain in this area, but we need to go in proper order to best relieve your symptoms. We start up at the top and work our way down. Sometimes, just treating the tissues higher up completely resolve the pain lower down, and sometimes it doesn’t.”

                  That conversation maybe is a little bit in the past now, so I might go from here.
                  “We have made great progress on your flexibility and range of motion (give numbers, show pictures). This means your neck is objectively healthier than it was before. We are done with 2 of the 4 ranges of motion that you need to have a healthy neck. The next one focuses right in the area where you have pain, and you have (a nerve stuck there, or a ton of adhesion, or whatever is going on), so I’m excited to see what progress we make over the next couple of weeks.”


                  Jamie Hansen

                    THank you everyone for the feed back,
                    He will be in today and i will post an update later on today!

                    Thank you all!


                    Carl Nottoli, DC

                      What’s the diagnosis? The updates are important for sure, but it needs to be done in light of a complete diagnosis.


                      Jamie Hansen

                        D/X were:
                        1) Degeneration of lower cervical spine (this was based off of the cramping that he had received in the past)
                        2) Adhesion

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