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Diagnosis problem

Exit forum ID Forum Discussion Diagnosis problem

This topic contains 3 replies, has 2 voices, and was last updated by   Carl Nottoli, DC February 2, 2018 at 7:26 am.

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    Andrew Wengert

      46 year old female. Pain in the right medial brachialis/biceps region and deep forearm flexors and into the hand. The patient’s hand started swelling 1 week after the initial injury.  Pain is described as a bruised feeling. Currently rates it a 5/10 and a 7/10 at its worst.  Provocative is any movement with the arm overhead. Palliative is not having the arm overhead or flexing the elbow when the arm is overhead.

      Pain started after locking out a thruster.  On examination, shoulder abduction recreated the pain at 90 degrees and increased pain to 135 where it stopped. More motion was achievable if the patient flexed her elbow. Neck testing was all in the 90% function.

      Palpation of brachial chords at subscap was extremely tender.  Palpation of the bicep and forearm reveal a hypertonic band deep in the area of complaint.

      I have a diagnostic problem.  Based on the tests I am thinking nerve entrapment, but the range of motion seems severely limited in a short period of time for nerve entrapment.  The nerve entrapment also does not explain the swelling in the hand.

      The patient had gone to the ER prior to seeing me due to swelling in the hand.  Fractures and clots were ruled out.


      Carl Nottoli, DC

        Nice job with the case so far and thinking through the details. Nerve entrapment is still high on the list of diagnostic suspects. There is also an acute injury component to this as well.

        With prolonged nerve entrapment that continues to get worse and is put under high load and explosive movements, the surrounding tissues will constantly engage in protective tension. Over time this could create a partial tearing in the tissues surrounding the nerve entrapment. Think of the hamstring “pull” video Dr. Brady did some time ago. The swelling from the injured area will follow gravity and end of near the hand.

        Look for any bleeding or bruising and if warranted do an MRI or Dx Ultrasound in the suspected region of tearing. If it’s difficult to tell, imaging may not show it except for inflammation. In rare cases, neuromuscular entrapments can get so bad that it can impede vascular flow. It doesn’t sound like this as it was more of an acute onset.


        James Phipps

          Would there be any value in doing arm abduction passively then adding elbow flexion, or doing resisted elbow flexion or shoulder flexion to help diagnose the tear?


          Carl Nottoli, DC

            Absolutely! Great additional diagnostic testing JJ.

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