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Help on a complex case-differential diagnosis
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Help on a complex case-differential diagnosis - January 7, 2006 11:26:00 AM
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eam
Posts: 292
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From: New York, NY 10028
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Hi everyone-
I was wondering if others had insight on a patient I recently evaluated. Unfortunately, her insurance allows her just 4 visits but she may look into private pay after.
35 yr old PHD student female with insidious onset of left posterior shoulder pain (1 week ago). Paresthesias down left arm into fingers starting a few days after the shoulder pain. Other complaints are: Inability to lift arm and inability to turn head to left.
No notable aggravating or easing factors. Hasn't slept well-pt wakes up from her sx's. PMH includes a recent diagnosis of TB (she was + on a skin test-the MD says she does not have the illness-not in her system yet-does not need to take the medication-but opted to take it anyway.
Pertinent Obj. Findings:
Palapation of ant. scalenes reproduced shoulder pain (post) Very tender to touch central and unilateral sprocess of c4-c6. (no repro of sx's)
Cervical ROM Active FB; Full with shoulder pain at end range. BB-full pain upper c. spine (L) Rotation(B) 30% with ipsi neck pain. SB (R) full with end range left shoulder pain. SB(L) full
Passively (supine on the table) full and pain free. Shoulder AROM (sitting) Unable to lift arm in flexion or abduction beyond 80 degreees without compensation. No pain here just weakness. Passively-full and pain free.
Myotomes: Weakness biceps, shoulder abduction and ER. DTR's hypo on the left brachiorad and biceps. Her other side were actually good (and I know those are tough to elicit).
Other shoulder tests like Hawkins etc were also negative.
I did other things but I did not want to make this too long (it already is)
The weakess in the myotomes and the difficulty in lifting her arm and no pain really had me thinking. The dx I rec'd from the MD read Adhesive Capsulitis. I am thinking maybe C5 palsy or axillary nerve palsy or maybe a myopathy of some sort, RTC tear? Virus or perhaps something more serious. I am leaning towards the C spine dx. I did some soft tissue to the scalenes and upper traps and some mobs to the C5 segment and her biceps strength improved.
PS-x -rays (shoulder and I think she said she a cspine film as well) negative -no mri
Any other insights?
Thanks!
Erica
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Re: Help on a complex case-differential diagnosis - January 7, 2006 11:59:00 AM
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certMDT
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From: Durham, NC
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Well, it's clearly not adhesive capsulitis, and so far sounds like the cervical spine needs to be ruled out. A further cervical screen is warranted here, which for me would involve repeated movements; I'm sure there are other ideas out there. I would be interested to see if it's possible for her to regain her left rotation, and what the effects are.
Has she had neck pain at any point during this episode or previously? Did her shoulder weakness come on at the same time as the pain? Do shoulder movements ever cause her symptoms, or only cervical? What sort of position is she in for most of her day?
That's all I can think of for now. I think you are right on that this is something neurological - the question is whether it is coming from the neck or more peripherally.
Charlie
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Charles Sheets PT OCS Dip MDT
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Re: Help on a complex case-differential diagnosis - January 7, 2006 12:11:00 PM
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jma
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Interesting. Does the patient have a significant past medical history? Smoker, ie. Are any particular dermatomes specifically affected, sensation wise? Since you mentioned the scalenes, were the tests for thoracic outlet syndrome been negative or positive. Just a few questions from me. Others may ask more.
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Re: Help on a complex case-differential diagnosis - January 7, 2006 2:05:00 PM
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Jeffre
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From: Lafayette, LA
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You should try the test item cluster by Wainner et al. These 4 items if present have a 30.3 likelihood ratio for cervical radiculopathy: Spurling A, Supine neck distraction, ULTT A, Ipsilateral Rotation < 60 deg. Here is a link for a Case series by Cleland that used these criteria and also looked at treatment for Cerv radiculopathy.
http://blog.evidenceinmotion.com/evidence/files/Cleland-JOSPT-2005-CxRadicCaseSeries.pdf
Did you look at TOS tests?
_____________________________
"You are as well as your insurance company is willing to allow."
- Dr. Hibbert
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Re: Help on a complex case-differential diagnosis - January 7, 2006 2:37:00 PM
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Alex Brenner PT MPT OCS
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Jeffre-right on, you cited an outstanding study that should be in all of our research drawers (and that doesn't mean in your pants).
A good neuro screen needs to be conducted bilaterally. MMT C5-T1, sensation to pin prick and dull sensitivity over dermatomes, and check your reflexes (biceps, brachioradialis, tricep jerks).
This sounds like a clear cut cervical radiculopathy to me. I don't personally believe in TOS.
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Alex Brenner, PT, MPT, OCS
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Re: Help on a complex case-differential diagnosis - January 7, 2006 3:47:00 PM
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Shill
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If the neck is clear, given the ABD and ER weakness, she could have suprascapular neuropathy. I have seen this before, and it is confusing, but presents as if it is a radiculopathy, but the C spine provocation tests, including repeated movements, are negative. This is quite rare, but you never know.
Its not TOS, given the ER weakness.
Let us know how it turns out.
Steve
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Steve Hill PT
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Re: Help on a complex case-differential diagnosis - January 7, 2006 3:49:00 PM
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eam
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From: New York, NY 10028
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Hi everybody-
Thanks for the timely responses. I did test the ULTT A and it was negative. I would be happy to try again. Did not do distraction (which I should have) and also did not perform Spurling's. I read that case study Jeffre, but I guess at 7 pm on a Friday when she was there, it just was not jumping into my brain yet! :) Her cervical rotation is clearly less than 60 deg. When I see her on Tues I will test that battery of tests and report back.
Did perform the reflexes and they were hypo on the left. I did the whole evaluation bilaterally and that is when the weakness versus her other arm jumped out at me.
Charles-Her shoulder weakness came on at the same time that she had the pain. Did not test for repeated movements.
JMA-She does not smoke or drink. Like Alex I am not a fan of the thoracic outlet diagnosis so I did not go down that route.
Keep the ideas coming! Thanks!
Erica
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Re: Help on a complex case-differential diagnosis - January 7, 2006 3:53:00 PM
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srcase
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From: Michigan
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I agree with above, sounds like a radic. Besides the tests listed by Cleland, you could also try some cervical traction in sitting and see if she can raise her arm higher while tractioning, and note any symptom changes. If positive, traction would be a good place to start. Also, you could try palpation to the nerve roots at the gutters (anteriorly) in supine to try to reproduce her shoulder pain and/or paresthesia. That would help narrow it down to a nerve root problem versus peripheral nerve.
Sarah
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Re: Help on a complex case-differential diagnosis - January 7, 2006 3:54:00 PM
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eam
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Hi Steve-
I think are posts crossed tonight! I thought of the suprascapular neuropathy also. Will check repeated movements (I have a funny feeling they will not help here, but am willing to try!)
Erica
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Re: Help on a complex case-differential diagnosis - January 7, 2006 3:58:00 PM
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eam
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Hi Sarah-
I think our posts crossed also! Boy, it is a busy Saturday night! :) :)
Not to sound totally weird, but how do you palpate nerve roots at the gutters? :)
Erica
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Re: Help on a complex case-differential diagnosis - January 7, 2006 5:24:00 PM
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certMDT
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If I remember right, the ULTT had above 90% sensitivity for radiculopathy as defined in the study mentioned. That knocks the chances of a radiculopathy down pretty fast.
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Charles Sheets PT OCS Dip MDT
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Re: Help on a complex case-differential diagnosis - January 7, 2006 7:26:00 PM
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FLAOrthoPT
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it's 130 and some drinks later, but at quick glance I would not rule out lower cervical upper thoracic instabilities. Try some quadrant testing, and rule out T spine T2-4 can also effect shoulder motions, suprascapular nn. entrapment needs to be looked at, and I agree pure C-spine nerve root problems, got to go to sleep!
Ben
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Re: Help on a complex case-differential diagnosis - January 8, 2006 6:59:00 AM
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srcase
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From: Michigan
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Hmmm, don't know if you should do this on a patient without practicing on a colleague first, but you can palpate each nerve root as it exits the foramen just lateral to the trachea and anterior to transverse processes. Have to move SCM anterior/medial at about C4 level to palpate. Put fairly firm pressue and wait for symptoms to provoke. It's called a "doorbell" test because, if positive, the patient will be like "DING-DONG! That's the spot!" :) The test also tells you about the irritability of the nerves in general.
Sarah
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Re: Help on a complex case-differential diagnosis - January 8, 2006 7:20:00 AM
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drbuddy
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Does she have pain when she is just sitting there? Is the pain constant? If so, have her put her hand on her head (Bakody's) and/or shrug the shoulder on the side of complaint. If the pain decreases, think disc. I have had two patients with negative findings throughout the exam, but those movements releived the pain. MRI confirmed a fairly substantial disc protrusion in both cases.
If things arent adding up, maybe a call to the physician is in order to let him know it is not adhesive capsulitis and the patients needs further workup (MRI). For one of those patients I discussed above, she came in diagnosed with rotator cuff tear (despite no shoulder weakness whatsoever).
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Re: Help on a complex case-differential diagnosis - January 8, 2006 8:05:00 AM
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Jeffre
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Which fingers have the paresthesia? If dermatones and DTR hypotonicity match up it could help to focus your exam.
_____________________________
"You are as well as your insurance company is willing to allow."
- Dr. Hibbert
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Re: Help on a complex case-differential diagnosis - January 8, 2006 10:39:00 AM
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steve
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The Wainner study, I believe, was only used on C6 and 7 radiculitis. This could potentially be a C5 radiculopathy and explain the negative ULTT 1. Dr. Buddy's test is correlated with C7 nerve root problems and not C5 level issues. The specificity of altered reflexes is quite high and would suggest that the neck should still be cleared.
Steve
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Re: Help on a complex case-differential diagnosis - January 8, 2006 11:30:00 AM
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BTDC
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I would think that Bakody's would be more sensitive for C5 vs C7. Allowing the arm to hang in the normal position would tend to traction the C5 nerve root more than C7, would it not? Kinda like how lateral flexion injuries tend to damage the upper brachial plexus, whereas hyperabduction injuries tend to damage the lower plexus. I could be wrong.
Buddy
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Re: Help on a complex case-differential diagnosis - January 8, 2006 4:12:00 PM
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eam
Posts: 292
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From: New York, NY 10028
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Thanks for all the posts-much appreciated.
The pain is not constant and when she was sitting in the chair with her arm resting she did not have any shoulder pain at all.
I believe all the fingers had the paresthesias but I will clarify that. The Wainner study -I don't have access to unfortunately. The Cleland study, I believe, does not specify the levels studied.
With regards to the Bakody's test-never heard of it-but given her weakness she would have a tough time getting her hand on her head. And she has no pain with those movements anyway-just weakness. Could try it though.
Tks! Keep them coming!
Erica
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Re: Help on a complex case-differential diagnosis - January 8, 2006 4:54:00 PM
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BTDC
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If she is having weakness with loss of reflexes and sensory changes, it might be a good idea for a neuro consult (or referal back to the PCP) in order to come up with some sort of working diagnosis, since this is obviously not adhesive capsulitis.
Just my two cents...
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Re: Help on a complex case-differential diagnosis - January 9, 2006 5:01:00 AM
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eam
Posts: 292
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From: New York, NY 10028
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I agree with the neuro diagnosis, I am going to talk to the MD today.
Keep the ideas coming.
Tks!
Erica
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