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unusual UE pain with weakness
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unusual UE pain with weakness - August 31, 2007 9:29:17 AM
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Tom Reeves DPT ATC
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Joined: March 14, 2006
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I have a 50 yo active male with weakness and atrophy in his L triceps. No real trauma. He was trimming trees overhead with a long handled pruner 2-3 days before symptoms began. He notes numbness and tingling almost always in the dorsum of his 2nd finger only. Nagging/aching symptoms L periscapular area, skips to his shoulder, following the path of the radial nerve to about 6" below his elbow.
wrist flexors 5/5
wrist extensors 4/5
triceps 4-/5
biceps 5/5
grip symmetrical (power and pincer)
shoulder IR 5/5
shoulder flex 5/5
shoulder abd 5/5
supra 5/5
ER 4/5
supination 4/5
pronation 5/5
palpation of triceps (generally, not specific) is painful
lateral epicondyle painful, radial head is not
full wrist shoulder and elbow ROM
What could this be? I think it is a lower brachial plexus stretch, like a reverse stinger (Klumpke-like)
EMG revealed mild CTS but i don't think that has anything to do with his symptoms.
Saw a neurologist and got no answers.
Your thoughts please . . .
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RE: unusual UE pain with weakness - August 31, 2007 10:55:08 AM
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ehanso
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From: Minnesota
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If he was trimming trees with a long handled pruner, he was in a prolonged position of cervical rotation, lateral flexion and extension. There was also a repetitive motion in the shoulders, upper trunk and neck. If you have not done so already, clear the C-spine and 1st rib. This is probably a contributing component. Ginger or nari may have a better thought
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RE: unusual UE pain with weakness - August 31, 2007 11:37:03 AM
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Tom Reeves DPT ATC
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full cervical rom, no pain at end range. I did not do segmental motion assessment, nor did I assess 1st rib mobility. I will do it next time. He has no TOS symptoms. I know that facet compression i.e. close packed position does not provoke. Neural tension tests do not provoke.
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RE: unusual UE pain with weakness - August 31, 2007 1:55:52 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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On the EMG report did the radiologist perform needle electromyography of the paraspinal muscles, specifically C5-T1 regions? This would be critical.
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RE: unusual UE pain with weakness - August 31, 2007 6:20:56 PM
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Tom Reeves DPT ATC
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i just got a copy of the raw numbers. he concludes that the r median distal sensory latency is prolonged (symptoms are on the L anyway) I don't see any references to spinal levels, only peripheral nerves. We are considering getting another neuro opinion.
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RE: unusual UE pain with weakness - September 2, 2007 1:21:28 AM
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ginger
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From: Melbourne Victoria
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spondylitic referred events are difficult to provoke with active movement tests or other forced compressive manoevres. In most cases , use of these tests will offer little to indicate either presence or absence of referred pain from cervical joints/nerves. It will be possible however to give some hints or indicators when doing AP mobs of the cervical facet joints uilateraly. Of interest are your descriptions of hand/wrist position and tightness , all indicative of severe dural tightness. Also indicative of a central locus of irritation as previously pointed out. Use your hands. Mobilise C5 first of all. Do this in prone with a PA movement till protective tone is reduced. This may take five minutes. Be patient and persistant. Check her symptoms immediately after, you will almost certainly have releived enough in this safe and easy way to gain confidence in the approach. If you go off on a tangent and start massaging her wrist , you may as well give up. The signs are there for you to see a central problem with distal symptoms. Common as cow pats in a dairy. Avoid the temptation to get more detailed "neuro" investigations as simply time wasting. You have plenty of info already .
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RE: unusual UE pain with weakness - September 2, 2007 5:40:12 AM
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ginger
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sorry tom I have somehow got this thread confused with another similar one and answered as if for the other. Phew, must've trained harder than I thought this morning. Anyhow , much of what I had to say relates to this in a very similar way.
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RE: unusual UE pain with weakness - September 2, 2007 10:57:39 AM
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rwillcott
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From: Canada
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Sounds like a cervical radiculopathy. Did you check the CPR's for radiculopathy that Wainner et. al. recommened? You've already elimanted two since he has full AROM rotation of his cervical spine and you mentioned his ULTT was negative. How about Spurling's and Head Distraction Tests?
I would check joint play of the cervical spine. Specifically the lower cervical spine. Try PIVM's and both central and unilateral PA's. I would also check both the upper and mid thoracic spine.
Try beginning with some specific traction of the lower cervical spine and manipulations of the thoracic spine. Some DNF's and scapular stability exercises may be a good start as well.
Rob
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RE: unusual UE pain with weakness - September 2, 2007 11:46:47 AM
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Tom Reeves DPT ATC
Posts: 445
Joined: March 14, 2006
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Thanks everyone. I don't do manips Rob but I can simulate with mobs and traction I think. I haven't looked specifically at CPRs but have done traction without apparent effect. It really behaves more like a peripheral radial nerve or lower brachial plexus "palsy", Klumpke-like.
Ginger, thanks for your input as well. I did do some mobs to the Cspine pretty gentle PAs and APs none of which were provocative or easing. Motion is pretty restricted evverywhere. This guy was an athlete and later football coach and psycho softball player, now umpire. bad posture, imbalanced pec muscles vs rhomoboid et al.
I will keep investigating though and keep you posted with findings.
Thanks all
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