Solve this Case

[rcheeley]

Pain Location: Just medial to the superior angle of the R scapula
Pain Symptoms: intermittent, fairly intense, 5-7/10
Onset: CS extension > R SB > R Rot
Posture: FHP, slight upper CS extension, slightly rounded shoulders
Unable to return head to neutral position due to pain (get out of FHP)
Unable to lay supine w/ head in neutral position due to pain
Unable to lay on side unless neck is in slight flexion, neutral rotation, neutral SB
Palpation:tenderness negative all areas
CS PROM: limited due to pain (empty end-feel) unable to assess joint mobility w/ end-ROM
CS AROM: In FHP - 5 Ext, 5 R SB, 10 R Rot
ROM: if neck fully flexed, patient is able to perform full rotation bil, and improved SB bil
Upper CS ROM: AA rotation feels to be normal; O/A forward nodding slightly increases symptoms
Reflexes: normal
Strength: again limited secondary to pain (w/ sh testing), however no noticeable strength deficits throughout UE
Imaging: negative x-rays

Any guesses? Ask questions, I may have left something out.

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[jesspt]

Age and sex of the patient?

Cervical compression/distraction test?

Upper limb tension tests?

Any parasthesias into UEs?

Reflexes normal?

Thoracic spine mobility testing?

 

[Akiramay]

Hmmm...pain with ext/SB/rot would lead me to think some sort of cervical foraminal stenosis, though she doesn't complain of any neural sx's. Because she has pain with PROM and there is no tenderness on palpation, I'd rule out any muscle strain or spasm. However, because of her forward head posture, rounded shoulders, and limited cervical AROM, it seems like tight (and possibly weak) muscles would be the issue. She has uneven load on her cervical spine where she is flexed. I'm thinking tight cervical flexors, upper traps, and capital extensors, and weak cervical extensors and rotator cuff? We stopped at thoracic spine in my musculoskeletal class, but this is good for me to think about. Please let me know if I'm on the right tract or completely off. Ha ha.

 

[rcheeley]

Good questions, I got in a hurry and forgot some major stuff...

60 yo male
Compression & Distraction negative
ULTT negative
No UE radiculopathy or parasthesia
Yes, reflexes normal
TS mobility slightly hypomobile

Age and sex of the patient?

Cervical compression/distraction test?

Upper limb tension tests?

Any parasthesias into UEs?

Reflexes normal?

Thoracic spine mobility testing?

 

[Danae00]

I love this new board!

I have a busy few days ahead of me so I'm going to avoid this thread until I have time to properly sit down and think about it. Said e from actually working with real patients case studies are one of my favorite methods of learning

Hope to see many more of these and maybe contribute a few of my own!

 

[rcheeley]

That'd be great! I'm looking forward to hearing some responses to this. As we've exhausted I'll post more regarding treatment and responses to treatment. But you're right, I'd love to see more of this...maybe not more than 2 or 3 active at one time, but 1 or 2 active ones keeping everyone on their toes would be great!

 

[TheOx777]

I usually have a lot to say. At this time, I willl......... HUSH and hopefully learn a thing or two. I definitely agree with Dane about the level of excitement I have for the new format, and look forward to what this thread and many others bring!

 

[DancerFutureDPT]

That'd be great! I'm looking forward to hearing some responses to this. As we've exhausted I'll post more regarding treatment and responses to treatment. But you're right, I'd love to see more of this...maybe not more than 2 or 3 active at one time, but 1 or 2 active ones keeping everyone on their toes would be great!

I LOVE this idea...it makes everything we're learning more relevant.

I just want to make sure, so there's no violation of TOS (since I'm supposed to be on the lookout as a moderator and all that lol)...that these case studies are all hypothetical/you're not seeking suggestions/answers/medical advice for an actual patient, and that this is not some sort of homework assignment for a class (I'm assuming that since you're a DPT the latter is not the case, but for future people who may post practice case studies, I don't want any academic integrity issues).

That said, as long as you're not seeking medical advice/trying to treat an actual patient via the board, and you're not looking for homework answers, then this is an awesome idea and definitely something that is interesting to see on the boards

 

[rcheeley]

Nope, not seeking advice, and I'm not a student. Just a creative thinking exercise for everyone.

 

[DancerFutureDPT]

Nope, not seeking advice, and I'm not a student. Just a creative thinking exercise for everyone.

Perfect. In that case, great idea, and carry on When I have time to sit down and think it through, I will. Although I'm not even done with year 1 yet so I'm not sure how much I can contribute, but it'll be fun

 

[jesspt]

My assumption is that the onset was insidious. Am I correct?

And, by negative x-rays you mean that they did not reveal a fracture? Someone in their 60s is going to have degenerative changes in their cervical spine.

 

[rcheeley]

Correct! No fractures, no lesions on any kind, just typical DDD/DJD as you'd expect for someone age 60. Sorry I'll make assumptions at times, so if clarification is needed just ask.

My assumption is that the onset was insidious. Am I correct?

And, by negative x-rays you mean that they did not reveal a fracture? Someone in their 60s is going to have degenerative changes in their cervical spine.

 

[WahooDPT]

rcheeley, interesting thread, but you've got to do something with that horrible avatar...laugh:

 

[mtm34]

How bout a grade V seated thoracic distraction mobilization to decrease the hypomobility in the t-spine and see if there is any increase in cervical extension and decrease in pain?

 

[Akiramay]

What do PPIVM's/PAIVM's reveal in the cervical spine? Also, is the man's occupation or extracurricular activities relevant to his present posture?

 

[rcheeley]

Based on previous posts, I think our initial focus here is currently looking for a tissue specific diagnosis/limitation. We'll get more into treatment aspects once we know a little bit more about this patients possible diagnosis.

(Yes I know this goes against the "phylosophy" of many, such as McKenzie, however for education purposes, I think most PT programs expect you to develop some type of PT diagnosis, or tissue specific impairment, prior to developing a treatment plan)

How bout a grade V seated thoracic distraction mobilization to decrease the hypomobility in the t-spine and see if there is any increase in cervical extension and decrease in pain?

 

[Fiveoboy11]

lack of segmental mobility? segment hypomobility beyond expected compared to surroundings, does the patient have excessive kyphosis, are the symptoms the same in standing vs sitting, does the cervical spine have a normal gradual curvature during extension or does it fulcrum at a certain point(s)...

 

[rcheeley]

1st question, what's "PPIVMs/PAIVMs"?

I'm familiar w/ PIVMs - Passive InterVertebral Mobility

But to answer what I think your question is, passive mobility is difficult to assess at this time in typical testing positions due to pain, w/ guarding. However if patient is placed in a flexed CS position, passive mobility appears to be normal.

Retired, no significant extracurricular activties, however patient reports he is not sedentary as he is performing choirs and activities throughout day. Patient reports initial onset developed insidiously 1 day, this has occurred 2-3 times in the past 3-4 years, however not as intense and not for this lengthened period of time (Onset PS is a little less than 1 month ago) Patient during the day at onset noticed he was unable to look up.

What do PPIVM's/PAIVM's reveal in the cervical spine? Also, is the man's occupation or extracurricular activities relevant to his present posture?

 

[rcheeley]

See previous post regarding segmental mobility, or PIVMs. L sided PIVMs do appear to be normal, unable to rest R SB R Rot and Ext, to be specific on regarding previous post.

TS kyphosis is normal, and to clarify more regarding CS, he has FHP as stated previously w/ increased lordosis and therefore excessive upper CS ext.

No difference in sitting vs standing vs laying down, patient always has an increase in symptoms w/ returning CS to neutral position or further into ext, R SB, and/or R rot regardless of position.

No fulcrums observed during ext, as there really isn't any ext to observe.
Not observed during flexion either.

lack of segmental mobility? segment hypomobility beyond expected compared to surroundings, does the patient have excessive kyphosis, are the symptoms the same in standing vs sitting, does the cervical spine have a normal gradual curvature during extension or does it fulcrum at a certain point(s)...

 

[rcheeley]

Go Hokies! Best ACC football team since it joined.

rcheeley, interesting thread, but you've got to do something with that horrible avatar...laugh:

 

[goyo1010]

wow. i can only guess as to what ya'll are talking about. this is definitely an interesting thread.

very pbl-y. for us students anyway.

 

[Akiramay]

PPIVMs- Passive Physiological InterVertebral Motion (assess flex/ext/SB/rot mobility by palpating the spinous processes)

PAIVMs- Passive Accessory InterVertebral Motion (assess ext mobility if a central posterior to anterior force to the spinous process, or rotation with a unilateral P-->A force to the transverse process)

 

[mtm34]

The MSK pathology sounds like a mid cervical closing pattern on the right due to the lack of Extension along with limited RSB and RROT. Dysfunction in the mid cervical area can refer pain to the scapular region.

 

[rcheeley]

If it is what you say it is, could you be more specific? You reference mid-CS, however how about a specific level? If gave a pretty specific location of the patients complaints of their symptoms, would there be a specific level that might be associated with this? Also, if you have any research or literature that might back up this answer that would be great as well.

Also, why do you believe this could be the tissue specific diagnosis/impairment? What biomechanically might lead you to believe this?

Please keep the comments coming. Do you agree with this, why or why not?

The MSK pathology sounds like a mid cervical closing pattern on the right due to the lack of Extension along with limited RSB and RROT. Dysfunction in the mid cervical area can refer pain to the scapular region.

 

[jesspt]

Based on previous posts, I think our initial focus here is currently looking for a tissue specific diagnosis/limitation. We'll get more into treatment aspects once we know a little bit more about this patients possible diagnosis.

(Yes I know this goes against the "phylosophy" of many, such as McKenzie, however for education purposes, I think most PT programs expect you to develop some type of PT diagnosis, or tissue specific impairment, prior to developing a treatment plan)

Given that finding a specific tissue/pathology that is responsible for spinal pain is a bit like finding a needle in a hay stack, are you sure this is the road that you want to go down? I'd recommend against it, but to each their own.

At this point, we can most likely rule out HNP/nerve root encroachment as he has normal strength and reflexes. Likewise, lateral stenosis is not likely as patient has no UE symptoms to speak of. His symptom characteristics don't represent any red flags, and it seems unlikely that we're dealing with anything systemic.

So, my preliminary diagnosis would be mechanical neck pain/segmental dysfunction, possibly of the upper cervical spine, as small ROM flexion/extension of the upper c-spine reproduced his symptoms.

 

[Fiveoboy11]

excessive upper cervical mobility secondary to hypomobility distally, poor cervical posture, forward head posture during day causing hyperextension strain to upper cervical, dowager's hump, scapular retractor weakness, deep neck flexor weakness, shoulder horiz abd inflexibility, reduced scapular mobility especially into retraction and rotation?

 

[FrutoJC]

wow i just learned a lot from reading this... thank you. I need to learn more! keep them coming.

 

[rcheeley]

Thanks for asking, and yes I agree that it is like finding a needle in a haystack, however this is required in most PT programs now, so this is the route we will take. It also requires us to think about all aspects, not just the treatment. So yes, I would like to go down this road.

I understand where you are coming from, probably in terms of we don't necessarily "need" a specific tissue impairment or pathology in order to treat our patients, and I completely agree with that as in most cases I don't even bother with it. However we're doing this for educational purposes, so we shouldn't leave out this area.

Great answer! The way you broke it down is perfect and what I'd expect in terms of why you don't feel it is "this," and why you think it might be "that."

Now, I'd like to re-emphasize that one of the more painful, if not the most painful motion, involves CS ext, as well as returning his head to a neutral spinal position (out of the FHP posture). I'm not saying I doing agree with your answer, but just want to make sure you didn't over look this.

Then I'll push the questions I posed to a previous poster, regarding a bit more detail as to why this dysfunction might be causing pain at this particular area, if there is a specific segment (based off literature) that might be the cause, etc.

Given that finding a specific tissue/pathology that is responsible for spinal pain is a bit like finding a needle in a hay stack, are you sure this is the road that you want to go down? I'd recommend against it, but to each their own.

At this point, we can most likely rule out HNP/nerve root encroachment as he has normal strength and reflexes. Likewise, lateral stenosis is not likely as patient has no UE symptoms to speak of. His symptom characteristics don't represent any red flags, and it seems unlikely that we're dealing with anything systemic.

So, my preliminary diagnosis would be mechanical neck pain/segmental dysfunction, possibly of the upper cervical spine, as small ROM flexion/extension of the upper c-spine reproduced his symptoms.

 

[rcheeley]

I'm a little lost by this post. Are you saying this is how he is presenting? Because some of this information is not information I presented, and therefore should not be assumed. Also, what are you referring to when you mention "distally"? There is no dowager's hump. What is normal H. Abd? Scapular mobility is normal.

excessive upper cervical mobility secondary to hypomobility distally, poor cervical posture, forward head posture during day causing hyperextension strain to upper cervical, dowager's hump, scapular retractor weakness, deep neck flexor weakness, shoulder horiz abd inflexibility, reduced scapular mobility especially into retraction and rotation?

 

[mtm34]

Childs et al. http://www.jospt.org/issues/articleID.395,type.4/article_detail.asp

-good article to start with, as far as localizing a segment I would have no way to do that without being able to perform cervical glides to asses intersegmental mobility. If the patient can't tolerate this I would try to focus on calming down the pain and inflammation process to allow for a full assessment.

 

[jesspt]

Now, I'd like to re-emphasize that one of the more painful, if not the most painful motion, involves CS ext, as well as returning his head to a neutral spinal position (out of the FHP posture). I'm not saying I doing agree with your answer, but just want to make sure you didn't over look this.

Then I'll push the questions I posed to a previous poster, regarding a bit more detail as to why this dysfunction might be causing pain at this particular area, if there is a specific segment (based off literature) that might be the cause, etc.

Ryan,

It seems from your previous posts you have a piece of literature which lets you specifically implicate a segment that typically refers pain into this area. If so, please share it so we can debate its merits. As of right now, I would tend to agree that I have no way of making a segmental, biomechanical diagnosis based on the information you have provided, and I would say that the literature you provide would need to be pretty solid in order for me to make that leap.

 

[jesspt]

Childs et al. http://www.jospt.org/issues/articleID.395,type.4/article_detail.asp

-good article to start with, as far as localizing a segment I would have no way to do that without being able to perform cervical glides to asses intersegmental mobility. If the patient can't tolerate this I would try to focus on calming down the pain and inflammation process to allow for a full assessment.

You're right - good article! It is essentially how I approach patients with neck pain.

 

[DPTgrad]

Just looking at this quick-- did anyone say cervical facet syndrome? Although I guess there would be significant point tenderness? I need to come back and look at this when I get some extra time!

 

[Fiveoboy11]

I'm a little lost by this post. Are you saying this is how he is presenting? Because some of this information is not information I presented, and therefore should not be assumed. Also, what are you referring to when you mention "distally"? There is no dowager's hump. What is normal H. Abd? Scapular mobility is normal.

I didn't assume anything, I was giving ideas, thought that's what you wanted.

Distally (oops, you're right probably not the right term, probably should have said caudal or inferior) - and I meant caudal to upper cervical spine, normal should h. abd - to neutral? not exactly sure

 

[jesspt]

I didn't assume anything, I was giving ideas, thought that's what you wanted.

Distally (oops, you're right probably not the right term, probably should have said caudal or inferior) - and I meant caudal to upper cervical spine, normal should h. abd - to neutral? not exactly sure

I think that the OP was looking for clinic reasoning, rather than a scatter-shot smattering of possibilities.

 

[Fiveoboy11]

Thanks for that. I prefer to have as much relevant information as possible before I babble some first thought that comes to mind "clinical reasoning." Scatter-shot? All the things I mentioned have a strong impact on cervical spine function. By the way, it is likely more than one thing that is causing the problem, so these aren't "possibilities." Even if they were, it's better to base treatment on objective findings with clinical reasoning, than some lame quickie evaluation with a POC based on a process of elimination theoretical diagnosis. Such as your brilliant post.

 

[rcheeley]

What are you referring to as "some lame quickie evaluation w/ a POC based on a process of elimination theoretical diagnosis" ?

This is a critical thinking post...

It's easy to just "throw up" a bunch of non-sense about EVERYTHING that could possibly affect the CS, but we're trying to make this a learning experience. You could throw a lot of what you said out there w/ MOST CS patients, however I don't want that. I want information relevant to this particular case.

Thanks for that. I prefer to have as much relevant information as possible before I babble some first thought that comes to mind "clinical reasoning." Scatter-shot? All the things I mentioned have a strong impact on cervical spine function. By the way, it is likely more than one thing that is causing the problem, so these aren't "possibilities." Even if they were, it's better to base treatment on objective findings with clinical reasoning, than some lame quickie evaluation with a POC based on a process of elimination theoretical diagnosis. Such as your brilliant post.

 

[rcheeley]

Agreed.

I think that the OP was looking for clinic reasoning, rather than a scatter-shot smattering of possibilities.

 

[rcheeley]

Excellent article, and great to keep on hand to use as a basis for diagnosis and treatment. All clinics should have this one in their folders or on their computers to reference quickly. Thanks for posting this.

Childs et al. http://www.jospt.org/issues/articleID.395,type.4/article_detail.asp

-good article to start with, as far as localizing a segment I would have no way to do that without being able to perform cervical glides to asses intersegmental mobility. If the patient can't tolerate this I would try to focus on calming down the pain and inflammation process to allow for a full assessment.

 

[rcheeley]

No, I don't have a specific peice of literature that I want someone to post. ANY peice of literature that someone can find in regards to "referral patterns" to this area would be great. As the person who has posted this case, I already have some literature on this, yes, but it's a critical thinking exercise. So if you, or anyone else doesn't have it, I'd like there to be some effort to search and find more information on it. If it can't be found, then yes I'll post something eventually, but I'm not going to just post it immediately.

As of right now, it seems 3 or 4 people have mentioned a cervical facet issue, and I would agree with that. So what I want to know, is what are the cervical facet referral patterns? Based on the location of symptoms (medial to the superior scapula, what cervical level(s) could be the culprit?

Thanks,

Ryan,

It seems from your previous posts you have a piece of literature which lets you specifically implicate a segment that typically refers pain into this area. If so, please share it so we can debate its merits. As of right now, I would tend to agree that I have no way of making a segmental, biomechanical diagnosis based on the information you have provided, and I would say that the literature you provide would need to be pretty solid in order for me to make that leap.

 

[Fiveoboy11]

Duly noted,

I wasn't throwing up anything. I was stating other things you could look at that you probably didn't, because I thought it was relevant. But you go ahead trying to clinch a specific facet joint. As if that is actually the source of the problem.

 

[Akiramay]

As of right now, it seems 3 or 4 people have mentioned a cervical facet issue, and I would agree with that. So what I want to know, is what are the cervical facet referral patterns? Based on the location of symptoms (medial to the superior scapula, what cervical level(s) could be the culprit?

Thanks,

C5? That would be dorsal scapular nerve to the levator scapulae which is to that area. It could be C3/4 too but I would think maybe with the person's FHP C5 would be affected since it has more mobility than C3/4.

 

[jesspt]

Of course the cervical facets can refer to this area. There is a some overlap as to the dermatomal representation in the intra-scapular region, but generally C3 through C7 could theoreticaly refer pain to this area.

However, if we are going to go down this biomechanical road, we have yet to stress the facets during the examination. If we want to stress the facet joint capsule (which would have nocioceptive capacity) we would place the neck into a coupled movement (ipsilateral rotation and sidebending), and if we wanted to stress the facet joint surfaces we would place the neck in a combined movement/position (in this instance (L) rotation with (R) sidebending to approximate the bone partners of the (R) facet joints).

So, the fact joint could be playing a role, but until we can move the patient into these positions, assess joint-play, etc. making a biomechanical diagnosis is difficult.

 

[jesspt]

Thanks for that. I prefer to have as much relevant information as possible before I babble some first thought that comes to mind "clinical reasoning." Scatter-shot? All the things I mentioned have a strong impact on cervical spine function. By the way, it is likely more than one thing that is causing the problem, so these aren't "possibilities." Even if they were, it's better to base treatment on objective findings with clinical reasoning, than some lame quickie evaluation with a POC based on a process of elimination theoretical diagnosis. Such as your brilliant post.

There's the Five I know and love.

Why the venom? I know that comunication on a forum such as this can be difficult as we're not able to see non-verbal cues, but I didn't think my post was that inflammatory. It certainly wasn't my intention.

In regards to the impact of your list on cervical spine function, well, I'd like to see some support for that.

And I'm not sure that my post was babbling the first thought that came into my mind. I was going through what I consider a logical thought process, ie. rule out red flags, determine if symptoms are musculoskeletal or systemic/visceral, determine if symptoms are local or referred, etc. Perhaps you feel providing a laudnry list of things which could contribute to a patient's symptoms is helpful as a first step, but I think Jensen and others who have studied expert clinical practice would disagree with you.

 

[jesspt]

Here's a reference...

 

[rcheeley]

There's no need to be difficult with this! Your original post, did not make a whole lot of sense. If you would have made it a little more gramatical, and better written, then maybe your original statement could have been better understood. That's why I asked questions instead of assuming.

Now, if you want to think that this "evaluation" was very lame and done quickly, then I would doubt the quality of your examination skills if you're getting through them that quickly.

Duly noted,

I wasn't throwing up anything. I was stating other things you could look at that you probably didn't, because I thought it was relevant. But you go ahead trying to clinch a specific facet joint. As if that is actually the source of the problem.

 

[rcheeley]

Since you can't actually see or place your hands on the patient, just think more in terms of what some of the literature has said regarding the referral pattern of specific facet joints. So you wouldn't say "C5" you'd refer more to a joint, such as C5/C6, like you stated w/ C3/4. This isn't a guessing game, so if you have a peice of literature, look at it, use what it says, and post it if you can. If not just reference it. See a previous post and refer to it if you don't have one.

C5? That would be dorsal scapular nerve to the levator scapulae which is to that area. It could be C3/4 too but I would think maybe with the person's FHP C5 would be affected since it has more mobility than C3/4.

 

[rcheeley]

Do you not believe that the motion from approximately 10-20 degrees of neck flexion, into to the neutral position, would cause extension motion of the CS facets?

Ideally, when you are extending the CS from the neutral positon, just as if you rotate or SB, then I would have to state you are, for the most part, essetially moving from the "top down" in terms of causing motion through the spine/facets. Then, I would agree that you aren't getting any motion into the lower mid to lower CS and therefore could be really causing an extension, or closing, issue of any of the R sided facets.

However, this patients presentation is that they can't even get to the neutral position, and when he moves from a flexed position into a neutral position, he is developing a painful sensation of the superior and medial scapular region, that is not painful to palpation. He also reports these symptoms, of less intensity, w/ R SB and R rotation.

So I wouldn't believe that he is having a facet issue at end-ROM extension, however maybe more of a facet capsular entrapment issue (instability) when moving from a flexed facet position into the neutral position.

Thoughts?

Of course the cervical facets can refer to this area. There is a some overlap as to the dermatomal representation in the intra-scapular region, but generally C3 through C7 could theoreticaly refer pain to this area.

However, if we are going to go down this biomechanical road, we have yet to stress the facets during the examination. If we want to stress the facet joint capsule (which would have nocioceptive capacity) we would place the neck into a coupled movement (ipsilateral rotation and sidebending), and if we wanted to stress the facet joint surfaces we would place the neck in a combined movement/position (in this instance (L) rotation with (R) sidebending to approximate the bone partners of the (R) facet joints).

So, the fact joint could be playing a role, but until we can move the patient into these positions, assess joint-play, etc. making a biomechanical diagnosis is difficult.

 

[rcheeley]

Thanks for the reference/article post Jess. I've read this one before and I like it.

This is just a preference based off experience from these types of issues, when I'm trying to just brainstorm and be more specific, especially with a case like this, I typically use a referral pattern that is more central. So based of this article I'd be more inclined to say this patient's problem were more of a R C5/6 issue.

Again thanks for the post.

Here's a reference...

 

[rcheeley]

I hate to post this, because I don't have the reference. But I remember reading something by Stanley Paris, or maybe he just said it, but basically the point is that most CS facet capsules do not become compressed during end ROM, but likely through mid-ROM, and many times c/o pain will be associated w/ mid ROM.

Thoughts here?

Of course the cervical facets can refer to this area. There is a some overlap as to the dermatomal representation in the intra-scapular region, but generally C3 through C7 could theoreticaly refer pain to this area.

However, if we are going to go down this biomechanical road, we have yet to stress the facets during the examination. If we want to stress the facet joint capsule (which would have nocioceptive capacity) we would place the neck into a coupled movement (ipsilateral rotation and sidebending), and if we wanted to stress the facet joint surfaces we would place the neck in a combined movement/position (in this instance (L) rotation with (R) sidebending to approximate the bone partners of the (R) facet joints).

So, the fact joint could be playing a role, but until we can move the patient into these positions, assess joint-play, etc. making a biomechanical diagnosis is difficult.