Anterior Chest Pain - ? Local Impingement

[ChrisMorr]

Wondering if there is anybody out there who can help with a patient i having having some trouble with

Brief history, 26yo female, no med hx, fall from a horse approx 10weeks ago, fell head first out over front of horse unable to recall exact landing position, believes onto neck and right shoulder. Mild concussion - no bony injury post fall

Has reponded well to neck and shoulder treatment but continues to have anterior chest pain on the right, corresponding to the apex of the lung in position. I have tried, 1st 2nd and 3rd rib mobilizations, clavicular mobs with limited success. AC joint is normal. No remaining shoulder impingement symptoms. No peripheral symptoms however on my last appointment i was able to reproduce the chest symptoms with a radial nerve stretch.

Just wondering if anyone has come across something similar. My hypothesis is that she has a local neural impingement through the impact and posistion of landing with the original fall, but slightly puzzled about the lack of peripheral symptoms if the neurology is the cause.

I treated her with the radial nerve stretch on her last appointment and there with a reduction in symptoms and a corresponding improvement in neural length

Any feedback, suggestions, comments appreciated

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[physiobob]

I think your observations and treatment seem to be related as the symptoms resolved somewhat following. Maybe though there was a traction injury. For sure she would have a whiplash from the landing but also a traction to the brachial plexus. You mention the apex of the lung. This is rather high in anatomical terms under the upper fibres of trapezius. I suppose some scalene involvement might also be suggested in trying to prevent the impact on the neck. I'd continue working along the lines you've begun. Show a self stretch for the radial nerve. Perhaps give retraction & Ret/rot in supine with a towel supporting the head (ala McKenzie or Mulligan).

If things only get better transiently (always going back to the way they were) and also if there are any discoloration to the upper limb on that side don't rule out a DVD in the subclavian etc. This is an uncommon but real hypothesis that can mimic nerve pain. I have seen it once and I remember a missed diagnosis in the 90's of an uncle toby's iron man by a Sydney physio that got a few people in hot water.

Anyway let us know how you got on.

[quorthon]

u havent reported if the onset of pain was exactly AFTER the accident, or the anterior chest pain was developed during this time interval (10 months) for no apparent reason....I would agree with Physiobob about the supplements u could make on your regime and i will remind you that CERVICAL DISCS has a huge potential of referring pain on anterior chest pain....Check Slipman articles on cervical discography on pubmed...You should use Mckenzie principles (i am not sure that only retraction/extension will do the job) but beware to make proper mechanical diagnosis (dont know if you are familiar with the method) because other forces than retraction can be indicated (for example lateral flexion).
And my advise on "nerve mobilisation" techniques as you have mentioned: its just a waste of time...Many times these maneuvres elicit false-positive results (nerve tissue is MECHANOSENSITIVE so DONT IRRITATE it by any means!!!) and despite some "early" positive results u may gain, u will rarely get positive outcomes counting only on these (as i often observed on practice)

[ChrisMorr]

Update!

The patient came back to me towards the end of last week. She reported that she found good relief from the treatment for approximately 24hours. However, the morning after the treatment she was sitting in the passenger seat of a car and reached backwards to grab something off the back seat, which markedly increased her symptoms and has been present since this, to a greater degree than ever previous.

I rechecked her cervical segments with NAD. She has reduced ROM with all shoulder movements secondary to pain, particularly internal rotation which is a huge aggravater, in the hand behind back test she cannot get past her PSIS secondary to pain. She continues to have NO peripheral neural symptoms. She describes the pain as a strong, burning sensation particularly at night, which appears consistent with neural type pain.

My train of thought is now heading towards a brachial plexus traction type injury, as mentioned by physiobob, and given the limited success of the individual neural mobilizations. I spoke to the GP and he will prescibe a neural type analgaesic and i will re-review her after this course is completed. There appears to be no musculoskeletal or vascular injury remaining, but i am still confused by the lack of peripheral symptoms in the neural complexes are at fault.

[quorthon]

my opinion dear colleague, is that if there was a true NEUROLOGICAL lesion (either on cervical roots or on brachial plexus) there would be true NEUROLOGICAL signs and syptoms....This means that your client should have paresthesia in a more peripheral site (which she doesnt have as u mentioned) and some form of weakness in muscles of upper limb (especially if she has more severe clinical presentation)...And speaking about Brachial Plexus lesions, they more often compromise A8-T1 roots...If there are respective signs and syptoms due to those roots then u should consider that neurological tissue is pathological involved

P.S. the aggravating factor u mentioned (reaching the back seat of the car) is true CERVICAL-induced...She probably rotated her neck for that

[ChrisMorr]

Update!

After a couple more weeks trying the pain did not resolve. I referred her on for an opinion from a consultant anaesthetist wit a speciality in pain management, who preformed an MRI. Turns out she has a small lesion on her C3 and C4 nerve roots, and that this was being referred to the anterior chest by branches of the supra-clavicular nerve.

Seems my original hunch was right in terms of neurology, and in a letter back from the consultant he referred to the difficulty of diagnosing this injury, particularly considering the pain was the only symptom with no peripheral signs. She is being treated with local analgaesic injuection for the superficial cervical plexus

Many thanks for the help!!