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Complicated Case

Exit forum ID Forum Discussion Complicated Case

This topic contains 3 replies, has 3 voices, and was last updated by   Carl Nottoli, DC August 7, 2019 at 12:50 pm.

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    Doc Nina

      38 year old Female
      HX car accident in August 2018, after which her SX started:

      Did have MRIs after accident: Cervical C5/6 disc bulge with annular tear and mild left foraminal stenosis, and nerve impingement. Lumbar MR was also done after her accident which demonstrated annular tears at the L4/5 and L5/S1 discs with only mild IVF narrowing bilaterally at those levels.

      CC of bilateral hand pain and numbness with prolonged use – NOT involving the middle finger.
      Right hand is more bothersome, so that is where I have started.
      Right hand pain/numbness is 5/10 on average, and can be as bad as a 10/10 with use, and after a while patient reports she experiences shooting pain into her fingers, again NOT the middle finger.

      SA: 3f bilaterally, approximately 70% function
      Right WE+FE: 90 + 5 with moderate pain and severe pulling from anterior forearm to hand.

      Brachial cords tension test: Positive bilaterally
      Roos test: reproduced bilateral dorsal hand numbness (not including the middle finger), and moderate tension in the axillary region.
      Ulnar N tension test: Positive bilaterally
      Fromits paper test: Positive bilaterally
      Pinch test: Positive on the left
      Prayer and reverse prayer reproduced pain in the anterior wrist bilaterally, but did not produce numbness
      Grip strength was weak for her age bilaterally but worse on the right

      Diagnostic palpation:
      Right infra: 3+
      Right Tm: 2+
      Right subscap: 3+
      Right brachial cords: 3+/intolerable
      Right GH capsule: 1

      Diagnosis from the upper extremity standpoint was that of Brachial Plexus nerve entrapment, with moderate-significant adhesion in the other shoulder tissues.

      At first treatment: Pain reported as a 5/10 in the right hand with numbness, again NOT involving the middle finger, patient was able to tolerate Right Infra and Tm MAR with a post TX SA: 2f on the right. No change in symptoms.

      Second treatment: pain reported as a 5/10 in the right hand with numbness and pain NOT involving the middle finger (same as first visit). Patient pre-tx SA: 1F on the right. Right infra, subscap, and brachial cords at subscap MAR were done. Patient was barely able to tolerate treatment, and reported significant shooting pain at the end range of brachial cords at subscap MAR. Post tx: 0F on the right.

      After second treatment it was suggested that I move on to treating the forearms/hand so I did. There is significant adhesion in the superficial flexors, deep flexors, moderate in the palmar fascia, FPL, and moderate Ulnar N at FCU BILATERALLY. Pain and numbness is as always reported as worse on the right, so right is what I focused on.

      After 3 treatments on these tissues of the right forearm and hand: patient has reported feeling worse. There is a slight improvement in the range of motion tests, which are sustaining between treatments.

      Recently an orthopedic surgeon “scared her” regarding needing to undergo cervical spine surgery for her disc.

      I had the map conversation with her at the end of last week, and explained that we are achieving ROM changes in the positive direction, but that I understand that her pain and symptoms are not improving, but getting worse. We discussed discharging her from care, however she wanted to continue.

      She is always very very hyper sensitive to treatment. Even jumping up off the table at one point when I was doing IAR on the palmar fascia. There is a lot of adhesion to clean up, but she tolerates little, and is never better symptom wise.

      She is up to 15 degrees finger extension from 5 degrees at the start, but when I extend the fingers during treatment I am getting them back greater than 40 degrees – with no complaint.

      I know that Dr. Joe who treats her neck is also at a loss, as he has gotten good range of motion changes, but no change in patients symptoms ever. At this point, she wants to continue care, but I feel there is a very significant psychosocial aspect to her pain, and I am not really sure the best way to go about dealing with it.

      Of course approaching the subject of mental health can be tricky. I have gotten her to open up about a few aspects of her life which cause stress, including the fact that she “can’t go back to work until this is resolved” and the car accident which precipitated this was nearly 1 year ago now. She is also recently married, and her spouses family has no clue about it.

      Her general affect is always glum. I think its insensitive to simply tell a patient they need to seek out a mental health professional, and being blunt in that way can send people over the edge when they are already straddling it. However, in her case I think it will be extremely beneficial. What would you do?

      Further, after achieving no good symptom relief after treating the right forearm and hand, should I make the decision to move back to the right shoulder tissues, specifically the cords as that was my primary diagnosis to begin with? Any help/thoughts would be welcomed!

      Cheers! Doc Nina!


      Carl Nottoli, DC

        Her symptom location is extremely unique and if it were neuro MSK it would have to include C6 nerve root, C8 nerve root, but NOT C7 nerve root. If it were peripheral nerve problem it would likely would include the middle finger as well. Annular disc tears can be very painful as you know, but follow sclerotogneous patterns and don’t have a neurological quality in nature.

        If all of the adhesions are reducing and ROM is improving, but sx are the same, then it’s not MSK.

        Here are some important points from your data as well:
        “I had the map conversation with her at the end of last week, and explained that we are achieving ROM changes in the positive direction, but that I understand that her pain and symptoms are not improving, but getting worse. We discussed discharging her from care, however she wanted to continue.” Along with other points you posted about her psychosocial well-being, this is highly suggestive as the pain generator.

        Not addressing the elephant in the room is the last thing she needs. I know you want to help her and this is how you can do it. Stress from these life events can manifest as pain if her brain needs a distraction from dealing with it. Some people are addicts and some people overtrain, etc. It’s all a coping mechanism. But if she doesn’t address this problem she will never get better. If she does it will changer her life. It’s just like when patients with true MSK problems find us and it changes their lives.

        I have had patients like this in the past and have one currently that I will be having this same conversation with on Thursday this week.



        Jamie Hansen

          Hi Carl,
          I treat the above mentioned pt as well and i do agree with both you and dr nina that as she is improving in ROM, the pain for the most part has stayed the same. There is without a shadow of a doubt a psychological component to her pain.

          I do believe that she wants to get better, but there is a deep rooted fear that i think her pain mgmt dr has implanted in her brain and she’s just unable to get that out of her head. The dr gave her this image about a wk ago that her annular tear is causing her disc to “leak like a jelly doughnut and the jelly in irritating all her nerves and unless she undergoes surgery it will continue to leak out.” This is obviously not the case and Nina and I went over her MRI with her again and explained that this does not happen given her injury, and this is fear tactic.

          This will be an uneasy conversation to address with her, do you suggest that Nina and I do it together as we are both treating her or do you perceive that as “teaming up” and may make her shut down

          Thanks again for your input on this!



          Carl Nottoli, DC

            Teaming up can have plusses and minuses. For example, a male and female tandem that has a respectful and trusting relationship can be useful. If there is any wavering between either of your judgements that will be harmful. There may also be the perception of an “intervention” but this is a very important thing. Overall have the mindset of delivering a MSK diagnosis. You do this with confidence, clarity, and understanding of objections.

            You all want her to get healthy again–including her. So you can help her realize that this is the best path for that to happen. It will take effort to find a good therapist just like it took effort to find you guys. But as a MSK and soft tissue specialist, she is no longer in your wheelhouse.

            She absolutely doesn’t need surgery either. Assure her that this is nothing to be afraid of, but it’s understandable that the whole situation is scary and murky. You are all narrowing down what’s unnecessary to find the truth.

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