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Upper Extremity Pain
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Upper Extremity Pain - January 18, 2007 8:53:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
Status: offline
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Tough case with which I could use some help:
76 yo male with > 1 year progressive left (non-dominant)UE pain, mainly in the ventral foream, deltoid, and wrist. Driving can cause numbness in the hand. He decreases (or tries to) his pain by opening and closing his fist and rubbing his forearm. He can occasionally get a little decrease with his elbow flexed and shoulder adducted / internally rotated. Medical Dx or cervical stenosis (not specified central vs. foraminal)and possible carpal tunnel syndrome. MRI positive for degenerative changes in C-spine (I don't have more specifics) and recent EMG/NCV showed "possible carpal tunnel", but I don't have specific resluts. Any use of the left UE increases pain. PMH unremarkable except for bladder tumor removal 2003 and right hip OA.
Exam:
normal, painless cervical ROM - repeated motions don't increase arm pain
5/5 strength in UE myotomes
Pain in forearm elicited with resisted supination and overpressure into supination / pronation
Spurling's negative
Positive ULTT median / radial nerve - mild/mod
Intact reflexes and sensation
Positive Hawkins-Kennedy for impingement in shoulder
Tender along long head of biceps, antecubital region
Significant resting pain as well.
Over last 2 visits, he indicates pain in the anterior / posterior aspect of the elbow most often when asked about pain. I have done some premodulated e-stim and heat to the bicpes and ventral forearm, neural gliding, and gentle soft tissue work in the pronator / supinator group. No significant changes at this time.
Any further suggestions for eval or treatment would be appreciated. If any further info is needed I'll provide what I can.
Thanks in advance.
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Upper Extremity Pain - January 19, 2007 1:03:00 PM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
Status: offline
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3 days after his epidural injection and 2 treatments of heat/e-stim and neural mobs - slept well for first time in months. Today there was a palpable click int he antecubital area with passive pro / supination in 90 deg of elbow flesion while he ws supine - it went away and was not painful. Squeezing the bicpes induced numbness in the ventral forearm.
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Upper Extremity Pain - January 19, 2007 3:08:00 PM
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PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
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Wow..poor guy. It sounds like you are on the right track, with the relief coming from either the epidural, your treatment, or both. Odds are the neural problems are beginning in the neck, and you're just seeing the cascade of double/triple "crush" syndromes into the limb. I'd treat the neck, and the limb itself. And, at his age, I'd be surprised if he DIDN"T have impingement and tenderness to the biceps
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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