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Patient with significant chronic ache/pain at R TL junction.

Exit forum ID Forum Discussion Patient with significant chronic ache/pain at R TL junction.

This topic contains 5 replies, has 5 voices, and was last updated by   Scott Glidden January 28, 2019 at 9:14 am.

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    Scott Glidden

      I’ve got an interesting one for you guys.

      60 year old male

      Pain R lateral T12/L1 rib area. 4/10 avg. 2/10 best, 8/10 sharp pain at worst.
      P+ laying prone, heavy activity, rolling over in bed, sitting a lot, R arm overhead
      P- walking, light activity, supine position

      Believes it was caused falling from 20ft high 17 years ago.
      L1/L2 compression fracture from fall.
      MRI is apparently clean– “The doctor says he wishes everybody had my discs”

      TF: 3″ Flat T9 down. Mild adhesion R erectors (1) with hypertonicity
      TR Left: 52%/6-7 (effort/tension) Mild adhesion of R T9-10 rotatores (1), mild adhesion of T8-10 intercostals bilaterally(1)
      Right: 49% rotation/5 (effort/tension) Mild adhesion of L T9/10 rotatores (1)

      SLR: L 70/6-7 tension +D basically no adhesion. Maybe sciatic @ext rot (1)
      R 55/6-7 tension (sharp into R ribs too) +D Also minimal adhesion

      SHF L 0Fingers/2-3 ant hip pinch. add magnus (1)
      R 3Fingers/5 (as hip extends in R ribs) add magnus (1) hip capsule (1-2)

      QLF 21221 Adhesion at R L1/2 multifidus (1-2), L L3 longissimus (2) R L1 iliocostalis (2)

      KHE L 9.5″/2 (sore across lower back)
      R 10″/2 (same)

      SLPF: 75%, with pinch in lower back on way back to standing (uses hands on thighs to get back up)

      DDX: #1 L1 Disc #2 R parathoracics #3 R SHF

      After 4 treatments I corrected TF to 2″ flat, Rotation to 65% bilaterally and corrected QLF to 21222. No change in symptoms.

      On treatment 5 I thought, “maybe he has something unusual” so I thought about his diaphragm. I palpated some firmness at the most lateral part on the right side, had him exhale, took a posterior/superior tension (not particularly deep), and told him to breathe in. I felt and HEARD a “clunk” like I broke through some brittle piece of something and he had a brief wince in pain. Afterwards his rotation dropped 20% bilaterally. I also thought about his lat. SE/D was 2″ on L and 1.5″ on right with pretty minimal adhesion. Went to 2″ after some tx.

      What could go clunk there? What am I missing? Could anything in SHF affect sensation that far above the hips? What the hell went “clunk”?


      Brandon Cohen DC, CSCS

        1. I’d want to see the image.  Good lumbar discs? What about thoracic discs? Could this be a lower thoracic disc symptom? Does he have a thoracic and lumbar MRI? After a trauma like that you could get a lot of compression in different areas.

        2. I don’t know what SE/D means, but congrats on making it better, also, I don’t know if 2″ is good, but you seem happy with it.

        3. Does rotation dropped 20% bilaterally mean it went to 30%? Did he have increased/decreased symptoms with it?

        4. Does the KHE and SLPF symptoms correlate with his CC?

        5. Did you treat lat? Does he have limited shoulder abduction? It seems like you would have to have specific trauma to have adhesion in the lat at that area, especially if it doesn’t limit shoulder abduction.


        Scott Glidden

          1. I believe he has had imaging of both thoracic and lumbar spine, but I will check.

          2. SE/D= Shoulder Elevation/Depression.  Worked on his R lat a bit and there wasn’t much there, but I did get it to improve from 1.5″ to 2″.

          3. Rotation dropped to ~42% bilaterally after the “clunk”.  He had ‘weird’ symptoms after treatment, so I want to say it didn’t reproduce his problem.

          4. KHE and SLPF symptoms do not correlate with his CC

          5. I treated lat, but his R shoulder was no worse off than his left, I was just thinking “what tissue runs through that area” and thought I would see how functional it was with SE/D.


          Carl Nottoli, DC

            Sounds to me like this dude has bad discs. The questions are how bad, at how many levels, how much facet arthritis is also present, and how healthy is the actual vertebrae.

            SLPF that needs support to return to neutral with pain is pathognomonic for disc inflammation. KHE can also be painful with disc inflammation and actively inflamed facet arthritis.

            Don’t get distracted by the diaphragm or the weird clunk right now. You need eyes on the images as all signs point to structural pathology.

            In addition, your DDX should be after the consultation so you can purpose build your examination. After the examination, you should have a complete diagnosis that’s reverse compatible. Use the diagnostic sheet. This will help in difficult cases like this.


            Scott Glidden

              Noted. I will have him bring in imaging the next time I see him.


              William Brady, DC

                My diagnostic worksheet is attached below (I also pasted it but I’m not sure that will show up well). I could spend an hour on this case if it were a coaching call.

                The short story is that the compression fracture may have progressed and is responsible for his symptoms. This is highly reverse compatible with the history and exam (see below).

                I would need the timing of his symptom onset or flare up (I’d assume he hasn’t been in pain for 20 years).

                Thoracic Rotation: adhesion was 1 (mild) but his ranges were only 50%

                Look at the diagnostic sheet and post your thoughts. Thanks

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