This topic contains 5 replies, has 5 voices, and was last updated by Anonymous September 21, 2016 at 10:20 am.
September 15, 2016 at 10:15 am #3599
I have a case I would like to share with the ID community. I brought it up with Dr. Lytle this past weekend, but I did not have all the information on the case so here it is in its entirety.
Patient is a 21yo male minor league pitcher that presented with a chief complaint of T3-T4 pain midline and out laterally about two inches on either side of the spine, bilateral Shoulder/trap area tightness that goes out to the AC joint, and some neck pain. This started in mid August. He also related that he was diagnosed with “tendinitis” in his right throwing shoulder 2-3 weeks ago and has been doing some prescribed exercises. His pain is made worse with sitting up in bed in the mornings, pitching (lifting right shoulder into extension and abduction), rotating neck to the right, and performing what would be a “wall angel” with his thoracic spine extending and his arm going up and back. Also he is not currently pitching, only doing the exercises for his shoulder.
He rates his pain at a 6/10 and describes it as achy and shooting and furtherrelates that some days it doesn’t even bother him.
On exam I looked at the neck first:
Posture was anterior head carriage and something was a little weird about his upper T/S area and shoulders. It looked like he was kind of hunched over with his shoulders going anteriorly and inferior and his T/S was rounded a little.
C0-C1 flexion 40 degrees with very mild tightness,
C/S flexion-3 fingers, lots of pain at T4
CT flexion- 35-45 degress lots of pain at T4
Adhesion palpated at SSCAP bilaterally and some at CT erectors T1-T3
SA- 3 fingers limited on right, 2 fingers on left, but when asked if he could go higher, the arms touch the ears with no pain and no scapular compensation seen. Very small adhesion palpated in right infraspinatus, teres minor was clean as well as subscapularis. I did palpated the biceps tendon at the right shoulder and it was very tender.
I diagnosed him with adhesion in the the C/S and upper T/S and possible disc injury in the neck. I believe that his disc injury is causing his neck pain, T4 pain, and his right shoulder pain.
He came back the following day for treatment and all ROM were the same. I treated SSCap bilaterally and there was no change in C/S flexion post tx (3 finger widths), so I treated SSCerv next with no change, then I treated CT erectors with no change. After that I had a brief talk with him and said I was now more concerned that there may be a disc injury in the neck preventing these motions. In the mean time, I spoke with Dr. Lytle over the weekend and he was concerned with C/S disc injury as well and advised a MRI.
He came back in and said he has severe pain in the T4 area last night He said he had numbness and tingling in the T4 area and shoulder area. His arms and hands felt very stiff, but no numbness in them. I asked what he did yesterday and all he did was drive an hour and half. Now here is the part that really has me confused, when I checked his ROM everything was better, much better: C0-C1 flexion was still around 40, C/S flexion was limited by 1 finger width and CT was 60 degrees- His pain with these motion was greatly decreased.
So I hope that some of y’all take the time to read all of this and help me through the process. I Know that if you fix adhesion, then the change is immediate and in real time, so I can confirm that I did not change his ROM from visit 1 to visit 2 and that this change that I saw is due to inflammation or some other factor I’m guessing. Definitely looking for some input here.
So I saw him again this morning and his ROM is C0-C1 40, C/S 1 finger limited, CT 60 degrees with a little pain at the T4 area. I treated T1-T4 erectors and got some improvement in flexion. I also ordered an MRI of the C/S to rule out Disc pathology.
I would also like some feedback on my though process for ordering an MRI after only 3 treatment. This kid is 21yo and throws a 94 MPH fastball. The majors are looking to call him up possibly next year. I ordered the MRI based on the widespread pain and referral pattern suggestive of disc injury, his current profession and future that may be impacted by a C/S disc injury, and because his ROMs are not acting as it normally would if it were only adhesion present.
Ok, so I promise I didn’t set off to make the longest post in history, but I am trying to get better at all of this process and there are a lot of unknowns in this case for me. I appreciate any and all help or criticisms. Thanks and I will keep y’all posted on the MRI findings.September 15, 2016 at 10:17 am #3602
I think you have done everything well up to this point. I am 100% thinking disc and you definitely did not jump the gun on ordering the MRI, especially with a professional athlete. I could be wrong with this but I remember a coaching call with Dr. Brady regarding Cervical spine testing and disc. If I remember correctly, the level 3 tests can loose some validity with disc flare ups. Essentially, you can engage some protective tension because all the tests do load the C-Spine disc. There is no QLF-like test where we can minimize the compressive load.
So with situations like this palpation becomes even more important in locating relevant adhesion. As long as treatment and testing is tolerable, I would continue to work on correcting CF.
If disc is confirmed, I would check nuchal Lig, levator, and Splenius capitus, as adhesion in these structures can place big loads on the disc. Treatment of these can help create that “healing environment”September 16, 2016 at 10:17 am #3604
Sounds right on Caleb and Andy.
As far as the thought process for the MRI, ID practitioners need to be diagnosing patients with integrity and comprehensiveness. This case seems to be pointing at a rather large cervical disc issue. Therefore, it would make sense to get the MRI to determine the exact magnitude of that dysfunction block. As the doctor, you want to know what you’re dealing with.
The only thing I didn’t see mentioned yet is the communication piece. Sitting provoked his bilateral T-spine pain and arm/hand stiffness. Communicating this to the patient so he gets it. “Dude, I know you’re a minor league pitcher. Sitting makes your pain worse. That’s because your disc is messed up.” Then, manage load as agreed upon from there. His ignorance of that sitting symptom can be a worse loading issue because it’s not obvious.September 17, 2016 at 10:18 am #3606
It sounds like you are right on point with everything so far Caleb. Nice work.
Question: What were his symptoms upon returning for the 3rd treatment yesterday?
Also, with disc cases and the fact that you are seeing an anterior head posture in the absence of an upper C-sp dysfunction, I would start him on the Quadruped Chin Retractions to tolerance. Send him off with maybe 5 reps @ a 5 second hold for the first few days to get him started. Then gradually increase over time.
As you know, you’re certainly not going to completely overcome a huge cervical disc injury, but athletes are used to dealing with pain. Like Step said, you need to communicate that he has a big problem in the cervical spine, and if he wants to keep throwing 95mph for a long career, he needs to do a few things to keep this thing from getting worse. As Dr. Brady would say “the only worse than where you are, is where you’re headed.” So communicate that his disc is not going to heal itself, and that he needs to keep everything else perfect in order to keep that buffer zone as big as possible below his symptom threshold.
I’ve also had success with these patients by unloading the C-sp on some visits when the patient comes in with more a flare-up. C-sp flexion work can be irritating if you are not super careful with your technique. None of us are perfect, so it happens and the patient can experience a flare-up. Not to mention, no matter how good our communication is, patient’s do things they aren’t supposed to do, and consequently have bad days. Like Andrew said, try treating Nuchal Lig, Levator scap to tolerance on these bad days, or if you see irritation very quickly after working C-sp flexion.
Looking forward to seeing what the MRI confirms, and how he progresses with you.September 20, 2016 at 10:19 am #3608
The guy did not show up for his MRI that we took extra time and energy to set up for him before he went out of state with his team. I already knew what happened before my receptionist called him. He ignored all calls the morning of his MRI and he finally answered the following Monday and said that he didn’t go because the trainers with his team didn’t think he needed to go. He said he will be back in town in a month but he will have to talk to his trainers to see if they want him to come back to me for treatment. I’m gonna go ahead and guess that they won’t be sending him back here for treatment.
A big part of this one was on me for lack of communication. I had trouble with trying not to say that his trainers were wrong, but that his neck problem was causing his shoulder pain. I was not convincing that this was a big deal and I did not stress the importance of the MRI like I should have. I was trying to tip-toe around the trainers wrong diagnosis of tendinitis. And I was a little hesitant to pull the trigger for the MRI and I’m guessing that showed. Should I have just blown the trainer’s dx out of the water?
I hate losing a patient, but I really hate losing one to an athletic trainer who doesn’t know whats going on. I really really wanted to see the results of that MRI. I feel like I can’t be sure if I made the right dx now. I also got a little flustered at the end of visit 2 when all he wanted was his upper T/S adjusted and I tried to explain that it wouldn’t help his problem. And this patient is dating my babysitter and they all know my family so that makes it suck more. I am open to any and all advice.
And Brian, his complaints on the third visit were minimal at the time of the appointment, only mild pain at T4 area.September 21, 2016 at 10:20 am #3610
You did good and were headed in the right direction for helping this athlete and looking out for his future. Don’t let this discourage you, but learn from it. Young athletes drop out of care all the time. As soon as their pain diminishes a little, they believe they are all better. this is where the ID tests come in huge in my experience.
Note on trainer’s diagnosis:
When i come across a case like this, and its my word versus someone else’s i may phrase it something like: “I know you’ve been told you have a shoulder problem. In my professional opinion, that is not the primary problem for pain. Tendinitis of the shoulder would not cause pain in/around your upper back. What you have is a neck problem that is referring pain into your upper back. This makes sense all day, and i see this in my office on a daily basis.” I try not to put down any other professional, and try to explain why my diagnosis is different and more accurate.
This is a great time to rely on taking a picture of how well his shoulder moves, vs the lack of motion his neck has, and what normal is for both tests. This way he could see what was wrong.
I too look for better ways to communicate this all the time. It seems to be that more and more often, i’m fighting battles of “well my pcp said this, my massage therapist said this, my cousin said this, and my yard guy thinks its this…..” and somehow all of our opinions hold the same weight????
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