This topic contains 5 replies, has 4 voices, and was last updated by Adam Holen D.C. January 7, 2020 at 9:23 am.
December 25, 2019 at 1:24 pm #8857
– 26 YO Female
– Right T9-T12 (maybe as far up as T3) – I believe this is sclerotomal or myotomal?
– 3/10 at worst (constant 2/10)
– P+: pull-ups, twisting mid-back, deep breath with TSP flexion and Rotation to left, “weak” when grabbed around ribs (Muay Thai)
– P-: rest, driving with a pillow behind her Low Back
Initial diagnostic hypothesis:
– Thoracic Disc pathology
Second Order Hx:
– Began Jan 2019 (when she started working out more) – worse since starting
– no symptom relief with 3 weeks of rest from workout
– Her bilateral L5-s1 area is chronically stiff
– Had some sustained relief with Graston of “rhomboids”
– x-ray: slight scoliosis in T-spine (I didn’t view myself – she didn’t have it)
Posture: relatively extended T-spine
TF: moderate (my subjective interpretation) limitations throughout T spine from T2-T10 with mild pulling at CCx
TR-R: 49 deg, 89% – moderate pull in Right lat insertion at inf scapula
TR-L: 73 deg, 132% – mild pull at Right CCX
Rule out Lower Cervical disc pathology:
UCF: 28 deg, 112% – no sx
CF: 64 deg, 107%, mild right C5-T1`pulling
CTF: 93 deg, 103%, mild right C5-T1 pulling
CR-R: 73 deg, 80% – no sx
CR-L: 82 deg, 90% – no sx
Standing and twisting to the left (4/10)
Sitting and twisting to the left (2/10) – less LUMBAR involvement
Side lying lumbar adjustment posture produces discomfort
Cobra pose – doesn’t extend T-spine, when prompted to lock and brace L-Spine, she felt moderate tension in right low back
Sitting Serratus Push-Up Plus (as if she is punching) – gets inferior scapula/lat intersection tension
Rule out Lat involvement at scapula:
SA: 0F – mild tension at right inf scapula
– Scap E/D – increased tension a little
SLR-R: 83 deg, 92%, mod pull posterior thigh, increase with DF
SLR-L: 97 deg, 107%, mod pull posterior thigh, calf, and anterior shin, increase with DF
SHF-R: 2f, 85%, no sx
SHF-L: 0f, 100%, mild tension 1″ under ASIS
QLF = 0-6″ flat – mild “awareness” at right T10-L1 area
KHE-R: 11″, 91% – no sx
KHE-L: 12″, 100% – no sx
SLPF: 100%, mod to severe pull in bilateral posterior thigh
Moderate adhesion in L3-S1 multifidus, longissimus
Hypertonicity at R T10-L2
Moderate adhesion throughout TSP – SSL, Thoracic erectors, rotatores
Mild adhesion in intercostals
1. Mild thoracic Disc pathology in TSP and Moderate Disc pathology in LSP (not enough adhesion to justify 50% restriction in QLF)
2. T-Spine Joint abnormalies resulting in “flat” or extended T-spine (NEED HELP HERE?)
3. Moderate adhesion in T-spine and L-Spine
After 12 treatments unloading mostly thoracic and some lumbar adhesion, she has NO symptoms at rest anymore (including driving, sitting, or sleeping).
She reports only 25% improvement because her twisting and deep breath is still 3/10. I got an MRI of T-spine with no observable pathology. She can also now provoke her symptoms with just breathing while sitting (doesn’t have to twist anymore).
Having cleared alot as much T-stuff as I’m able to (including facet capsules), I’ve treated some serratus posterior inferior and levatores costarum (with some apparent relief).
Not sure if I could be missing anything else here?
Her initial wide distribution and provocatives made me think “Sclerotogenous”. Is that thinking correct?
Now, her symptoms appear more local within Right T9-T10 area, although they still move around within 2″ or so. A myotome couldn’t do that, could it?January 3, 2020 at 5:11 pm #8875
Adam Holen D.C.
Did you get eyes on the MRI? Any indication of end plate problem/inflammation? Scoliosis confirmed? Has she reduced her exercise load throughout treatment? Got her doing good mornings?
It def sounds MSK via worse w loading and better w rest, but she certainly doesn’t have much for functional limitations. Lacking any “smoking gun” on imaging, it may be early stages of endplate problem under high load. Especially if her location/pattern fits a sclerotome given her age. I wouldn’t expect a significant pathology for a 2-3/10 and solid function. The coaching call with Brandon was really informative on a somewhat similar case. Couldn’t find any info on specific thoracic myotomes, other than that they control trunk and abdominal muscles.January 6, 2020 at 8:18 am #8877
Hey Adam! I’m Dr. Nina the Upper Extremity Doc at Barefoot, and I also completed the DACBR residency program. I reviewed this patient’s MRI and it was clean except for the mild scoliosis, there was no inflammation of the end-plates or end-plate irregularities. That’s all I can say about the case, but hopefully that helps!January 7, 2020 at 7:08 am #8891
TY Adam and Nina!
Adam – was that a 1 on 1 coaching call you had with Brandon? Or it’s up on ID.com?
Very helpful.January 7, 2020 at 7:15 am #8892
Seth Schultz, DCParticipant
The call Adam is referencing is one from last year that Brandon did with Dr. Brady.January 7, 2020 at 9:23 am #8894
Adam Holen D.C.
It’s under the coaching section, but for whatever reason when you click on the link it’s no longer available. So it’s not going to help much. In light of Dr. Nina reviewing the images and confirming there’s no structural contribution to her symptoms aside from mild scoliosis, along with you having worked through basically every T/S tissue possible, including capsules, I’m at a bit of a loss for help.
What was her FastMap score? Any indicators of a metabolic or psychosocial overlay?
The gist of the case with Brandon was that in the T/S especially in younger patients, it’s most likely an endplate disruption causing sclerotome referral vs true disc problem. The annular fibers rip away from the endplates (fracture). However, these are typically pretty intense with compression loading and extended time horizontal as the well-hydrated discs swell up overnight pushing nuclear material into the endplate creating inflammation. Brandon did some great work on this guy in the case study, but ultimately he needed at least 3-4 weeks of solid rest to allow for healing.
I would suggest working the L/S tests as this is her “base” of support for her T/S. Have her start the Good Morning exercise to further reduce the load on her spine and manage her load throughout.
Again she’s a 2/10 so several “smaller” dysfunctions can add up to her overall picture, even if it’s more downstream.
I very well could be missing something with this case, but this would be my next go-to if you’ve exhausted everything else and there aren’t any yellow flags for non-msk contributing factors.
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