Upper trapezius weakness ? TOS? in complex case

[bikelet]

Hi everyone,

I have a somewhat difficult case which I am dealing with at the moment. This person has been coming for physio for the past 3 months following a MVA where he sustained trauma to the neck (whiplash), shoulder (right) and spinous process #T5-8. He was sent in for physio 8 wks after the initial incident and presented with headaches, subacromial impingement signs (but no rotator cuff damage on scans and good shoulder AROM) and thoracic pain around the #'s.

Picture of this patient: middle aged man, abdominal obesity.
Posture: forward head posture, kyphotic and solid thoracic spine (barrel chest), depressed right scapula++, winging right scapula (especially with eccentric flexion)

Shoulder: positive hawkin's kennedy right, positive arc of pain in keeping with subacromial impingement. Rotator cuff tests-hard to determine as complaints were made of thoracic spine pain during some. Most seem ok -right=left. Very restricted internal/external rotation on the right. In the first month of seeing him, he had a CS injection in the shoulder, and now he has had one this week again (not very good pain relief this time).

Neck: restricted left rotation to 1/4 rom, mainly at the level of C1/2 left. There is also tightness at C6 and C7

Thoracic spine: Tender over #'s T5-8. Also sore T1-3. Muscle bulk/spasm in lower traps.Upper trap is weak, esp right side- fatigues very easily, appears neurologically inhibited.
Right sided rib stiffness which responds best to downslope glides (especially the first and second ribs right and left).

Muscles: infraspinatus is very tight, esp right. Pec minor is tight, as is SCM, scalenes, middle traps, levator scap, suboccipitals.

In the first few weeks of treatment, I focused on soft tissue massage and this was achieving good results. I learned early on that this guy was very sensitive and early aggravated so I don't do too much in treatment sessions (in terms of techniques or intensity etc).

Then I thought I would start treating the neck, and I think this is where things have gone wrong. On one on my sessions, I aggravated him neurally with lateral cervical glides and it has taken probably two months for this to settle. The interesting thing is that the lateral glides helped to clear the right side of the neck pretty much completely but have resulted in ongoing issues (stiffness and headache) for the left. A senior physio reviewed him and tried to manipulate C1/2 as this apparently is out of alignment. However this physio was not sensitive enough and caused much pain and very little gain. Eventually, I realised that I was probably overtreating the neck, resulting in ongoing neural sensitivity. When I gave it a few weeks to settle, with very minimal treatment (such as traction and massage), symptoms have improved very well (but are still there at this stage).

However, at this point in time, the headaches are no the main issue! Because I have spent so much time on the neck, I have lost sight of the big picture. Now that the neck is resolving, my patient is now very aware of the right shoulder pain. He is due for surgical review for the shoulder in the new year and so I want to make as much progress as possible now to prevent surgery. Thinking on it, there is not much mechanically wrong in the shoulder (rotator cuff and labrum) apart from the inflammed bursa, which should be getting better soon from the new injection. So I think the key is to correct his posture and mobilise the cervical and thoracic spine.

BUT as I said before, he is very easily aggravated. Basically any postural correction exercise seems to aggravate his symptoms, no matter how low level (eg scap setting in side lying). I know that it is very important to train the upper traps but on the right this is very weak and appears neurologically inhibited- but by what I am not sure. I have tried taping, as this helped initially. But the last time I taped the upper traps, this gave him severe arm pain (after about 12 hrs with tape on) and the pain lasted for about a week. He does upper traps shrug ex but can only get to 4 before the muscle gives up all together. There has been no change in this over 3 months. He has talked about having hand tremors before, such as when his neck was aggravated. Now he is getting this again combined with TOS signs of loss of circulation with arm abducted (hand goes blue and shakes). I have started treating the thoracic spine and ribs more recently with this in mind. Any thoughts or suggestions about the upper traps?

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[johnwarda]

Hello

Are you trained in dry needling or any other therapist at your practice?
It may be beneficial to trial needling trigger points in upper traps and around the rotator cuff and then retraining scapular stability post needling.
You can also try needling subclavius and trial some rib mobilisations to help with the TOS.

Sounds like a tough case, good luck

[ROBOTONE]

Hello bikelet this Gentleman appears to have had a poor posture pre MVA and is likely to have adopted some postural changes post MVA, which he will need help with, over time. However at this stage does he need further investigations, a Neurology referral, it would concern me that with your, (also a senior physio) and this Gentlemans efforts there has not been any change in the last three months, regarding his upper trap strength.
I understand your responsibility, and part of that is deciding what is amenable to Physio.
Good Luck.