Cervical Spondylosis with left sided breast/chest heaviness?

[jacinta]

Hello all,

I have a 43yo, female pt. with Cervical Spondylosis at C4/C5, C5/C6, C6/C7 and C7/C8.
Symptoms are more Lt. sided orientated. Mild on the Rt. side
Had been on & off for physio elsewhere for since 1 yr ago.

Today she attended her 3rd wkly treatment here.
c/oLt. chest/breast heaviness<--- which had been persisted for long time since having the Cx. spond. but never informed any physio.

Few scanning down last week due to heaviness increase & Lt arm swelling.
mammogram show NO abnormality detected.
Chest X-ray is clear.
Describe of FUNNY feeling on Lt chest/breast and underneath Lt axilla.
Her prob at the left chest is what I am unable to solve...

On Assessment:
- neck mvmnt of poor quality; flx from lower Cx
- pocked-chin posture still not corrected; habitually sitt. slouch/round back
- ROM: 1. mild limitation of Rt. rotation & Rt. lat flx
2. ext -AFROM with ERP
- bilat upp. traps, neck muscle spasm; worse on Lt sd
- mild colour diference n change of skin texture (dry) noted in Lt. arm & chest


Treatment given my Evaluation

neck traction Relieve bilat. neck tightness
MFR high resistance towards my hand mvtment
Manual Upp. Trap Stretch Lt. sd. still tight as previous week; Rt. sd. reduced
& Lev. Sca

* pt. claims to do stretching at home <???>
* I have not ax Tx spine mobility as pt was rushing off for doctor appointment.

Any guidance is very much appreciated.
Thanks!

jacinta

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[jerryhesch]

IT WOULD BE PRUDEENT TO CHECK THE ENTIRE SYSTEM. AS YOU INDICATED, NEED TO CHECK MOBILITY OF THE THORACIC SPINE AND NOT JUST GROSS BUT SEGMENT BY SEMENT. CHECK MOBILITY OF THE FIRST 6 RIBS. THE FIRRST RIB HAS MUCH GREATER FREEDOM THAN IS REPORTED, TEST IT FOR SUPERIOR, INFERIOR, MEDIAL AND LATERAL GLIDE FOLLOWING THE ANGLE OF THE JOINT WITH T1. TEST IT POSTERIORLY AND THEN ANTERIORLY TSTING THROUGH THE MEDIAL CLAVICLE AS THE 1ST RIB LIES BENEATH AND POSTERIOR TO MEDIAL CLAVICLE. TEST CHONDRAL MOBILITY, AS THE COSTOCHONDRAL STRUCTURES ARE IN FACT A CONNECTIVE TISSUE AND FOLLOW RULES OF MOBILITY. DO SAME FOR STERNUM.
THE SYMPATHETIC CHAIN LIES IN FRONT OF THE HEAD OF THE RIBS SO ABNORMAL TENSION CAN CONTRIBUTE TO NUSUAL PRESENTATION.
IT WOULD ALSO BE PPROPRIATE TO TEST SEGMENTAL MOBILITY OF CERVICAL SEGMENTS.
CONSIDER VASCULAR INSUFFICIENCY, HAS SHE HAD A VASCULAR CONSULT?
INTERESTING PRESENTATION, PLEASE KEEP US POSTED.
SINCERELY, JERRY HESCH, MHS, PT
Hesch Seminar
Home

[sharileedahl]

I agree with the above post that it will be very important and revealing to assess the Tsp. Alot of the symptoms sound very sympathetic-y / thoracic-y (sorry...can't think of REAL words!).
If she is habitually sitting with a flexed Tsp as you noted, she is likely extending through her mid-Csp +++ just to be able to look forward therefore closing down the Csp facets and foramen even more than they are just with the spondylosis.
Therefore, check mobility of Tsp (including ribs) and treat appropriately; educate and train re. posture (as much as is possible given anatomical / arthritic constraints); mobilize the Csp as much as possible.

[jerryhesch]

i agree with las tpost. another thought re the comment aboutt diffficulty reducing "poke chin/forward head". You cannot effectively reduce this in this type of client without increasin extension below. If head and a few cervical segments needs to glide posteriorly, something has to glide anteriorly. Extension and anterior glide is often lost at T1-2-3-4, so using a fulcrum such as a firm rubber ball for 5 minutes per segement and doing same to the ribs, then working on inferior glide to ribs will help this immensely.
Jerry hesch

[jacinta]

Extension and anterior glide is often lost at T1-2-3-4, so using a fulcrum such as a firm rubber ball for 5 minutes per segement and doing same to the ribs, then working on inferior glide to ribs will help this immensely.

hi jerry & sharileedahl,

thanks for ur replies guys!
but jerry, smthg that i don understd.
The highlighted part in above quote, how do i do it? mind u guide me?
I was doing some reading on her condition,
was thinking of can Tx Outlet Syndrome(TOS) be the cause??
will do detail ax on her next visit next wk.
keep u guys posted soon.

jacinta

[jerryhesch]

supine too painful , in standing against wall with rubber ball of 2-3" diameter against spinous process of T1, repeat t2-3-4 while tucking chin. repeat at rib joints just lateral to trnsverse processes. 2-5 minutes each
Jerry hesch

[sharileedahl]

TOS is definitely another thought and worth ruling in/out. Based on your client's posture and tightness in upper traps etc. it is a reasonable thought that the thoracic outlet could be affected.However, based on the symptoms that you have noted I wouldn't expect it to be the main problem. Definitely continue with your assessment though!
Another thing I wanted to add to my last post is that it is unlikely that trigger points are causing the poroblem but releasing them may at least give your client some relief and buy you more time while you try to sort out the real issue. (i.e. some clients will give up on you too soon if they don't get some relief right away) You mentioned upper traps and lev. scap........also check pecs (major and minor), subclavius....

[alpana]

Hi Sharileedah,
I appreciate the suggestions given by Jerry regarding the T1-T4 mobility with the mobility of ribs. I will be more interested to check the status of your patient's latissimus dorsi on her left side. as you must be knowing that latissimus dorsi helps in maintaining the supero-lateral tension of the thoraco-lumbar fascia (TLF). Any slackness in the TLF also slackens the lumbar and cervical core muscles and this leads to slouched posture and expended neck.

Weakness in latissimus dorsi may be accompanied with tightness of pectoralis major and internal intercostals thereby limiting the mobility of ribs. So instead of mobilizing the ribs and vertebrae, first try to stretch the pectoralis major and minor, emphasize on lateral costal breathing, strengthening of latissimus dorsi, and work on core stabilization of lumbar and cervical muscles. This will help your patient with total relief. You may require total of 10 sittings.

But again prognosis depends on presence/absence of radiological evidence of thoracic facet joint arthritis.

Please keep informed.

[linbin]

hi
i did n't understand the relation between lattisimus dorsi slackness and cervical core muscle.i agree with the relation between TDF and lattisimus dorsi and lumbar area

[jerryhesch]

I respectfully disagree re stretching versus mobilization of T spine and ribs. Most adults develop a loss of accessory motions of the spine and ribs due to thise things call chairs, couches/sofas, and automobiles. stretching is important indeed but you must still test accessory motions of the upper 4 ribs. Specifically, test P-A glide just lateral to the spinous processes. Merely applying a P-A force after taking up the slack will lift the rib slightly off of the transverse process and off the relevant vertebral bodies and disc. People tend to develop some kyphosis and restoring this and P-A at upper 4 thoracic segments restores normal accessory motions (or at very least improves them). Another important accessory motion is anteromedial glide (costal).
Before and after you do the stretching you can test the accessory motions. It is unusual for stretching alone to restore normal motion. Spring is an emergent property of connective tissue such as costovertebral and costochondral joints.
A thorough review of capsular and ligamentous (and golgi tendon organ) mechanoreceptors adds to the relevancy.
lastly, re first rib, go beyond what normal mechanics describe and evaluate pathomechanics, recognizing the it can be evaluated anteriorly and posteriorly. It can compress medially, laterally, superiorly and inferiorly.
Yes, this is only a part of the evaluation and treatment, but relevant and effort is very generously rewarded by the body's response.
jerry hesch, mhs, pt
Hesch Seminar
Home

[jacinta]

hello all,

thanks again for all the replies.
tomorrow the pt will turn up for her treatment
I shall look into her Tx region and re-ax
keep u guys posted again.
hope to produce some good outcome

Sincerely,
Jacinta

[msk101]

something else to try...I'd like to suggest if it seems like the left shoulder is "dropped" relative to the thorax and in comparison to the right side (secondary to poor neck function) as opposed to needing to stretch traps and lev scap, perhaps manually elevating the shoulder girdle (you can tape effectively under the scapula to try this) will unload the brachial plexus and can relieve symptoms in the arm inc swelling, neuro-vasc. if the taping works then strengthening deep neck flexors, rhomboids, central deltoid, and shoulder shrugs can do this actively.

[jacinta]

Hi all,

these are my latest finding which I somehow thk the pt is'amazing'.
I must apologize that it'll sound kind of bored as it's bit long.


Hx
off physio for 6/12 & back again now.
previous history taking was imcomplete d/t manage by other PT.
back pain since 12 yrs ago

Observation
trunk flx/ext severely limited; flx from hip
Low. Tx - Lx spine mobility: poor, mvt : poor quality
trunk rotation: bilat. limited at outer range with TRP
bilat wide area of muscle bulging -
2 noticeable lumps inf. to Lt. Scap; 1 smaller lump inf. to Rt. Scap

Kyphotic posture with rounded shd, no imbalance in both shd height; poked-chin

Palpation:
trigger points at Lt. T5-T8 & Rt. T6 tender on palpation, VAS : 7/10
, crepitus produced on palpation.
broad area of muscles spasm all the way down from bilat. upp traps
to bilat. Iliac crests. width about 4in' on each side.
deep palpation revealed spasm +++

PPIVMs: (P-A glide)
Level & Pain at
C2-C5 G II
C6-C7 G I
T1-T3 G II
T4-T9 G I
T10 - L2 G II
L2 - SIJ G III

A-P on clavicle & costocondral joints
-pain at G II

Inf. glide of 2nd - 4th ribs
- pain at G II

it seems her Lt. chest problem is of Tx origin.

As Jerry suggested, mobilising with rubber ball slightly reduced her Lt chest heaviness, but done in supine.
I was unable to progress further than G II glide, be it P-A, A-P, or inf. glide d/t pt claims to feel highly 'sensitive' if i increase the pressure.

By the way, sharileedahl, trigger points release is done in every rx.
her feedback: ' it helps me a day or two; last longer IF i stretch sometimes'
(pt. doesnt keep up exercise; dont involve in any sport at all)
anyhow, I continue it to ease her pain a little bit to give her some good sleep.

stretching was taught as home prog.
focusing on trunk rotation & flx stretch and ext. of upp. back. in std.

hopefully next week,she comes with some improvement.
thanks for all the replies guys, i appreciate that.
Hope to hear more opinion from everyone, problem yet to be solved


sincerely,
jacinta

[jacinta]

Hi msk101,

thanks for bringing up the idea of relieving brachial plexus.
I shall look into that in her next rx.
appreciate that.

sincerely,
jacinta

[jacinta]

hi all,

some update here.
the pt returned 2/7 ago and claimed pain reduced.
She went for swimming and kept up strecthing ex at home 2x/day
said that generally symptoms eased off a lot as compared to previous.
able to sleep well.

on examination,
- bilat. upp traps less spasm.
- generalized spasm on the whole upp. to low. back had reduce
- lumps med. to both scapulae still present. only less sensitive to touch and MFR.- SIJ mobility increased
- AROM mildly improve

tests:
adson's : -ve
neural tension: +ve
----------------------------------------------------------
Previous Ax:
PPIVMs: (P-A glide)
Level & Pain at
C2-C5 G II
C6-C7 G I
T1-T3 G II
T4-T9 G I
T10 - L2 G II
L2 - SIJ G III

A-P on clavicle & costocondral joints
-pain at G II

Inf. glide of 2nd - 4th ribs
- pain at G II
-------------------------------------------------------------
Latest Ax

PPIVMs: (P-A glide)
Level & Pain at
C2-C5 G III
C6-C7 G II
T1-T3 G III
T4-T8 G II
T9 - L2 G III
L2 - SIJ G IV

A-P on clavicle & costocondral joints
-tolerate G III

Inf. glide of 2nd - 4th ribs
- not done due to breast tenderness as pt having menses

I continue
-joint mob (PPIVMs)
-MFR
-Manual neck traction & stretch
- nerve glide was introduce. initially with only Lt. UL. in shd. 90 dg abd. elb. ext; then progress both ULs; then progress with head loading by Rt. lat flx
- On posture part, I re-enforce correction and education.
encourage a lot of head retraction ex. in upright sitting ( so that pelvic in neutral to avoid Cx spine malalign)

feedback:

-initially c/o pain increase ++ on nerve glide, slowly reduce after 20 glides.
-c/o 'tightness' when 2 ULs gliding together,
- on loading, pain eased off by half after 50glides. (of course, she c/o ULs tired but feel much relief)

pt been advised to keep up swimming & stretching. As long as her Tx spine mobility gradually improve, i thk her prob with Lt. chest shd be solve soon.



jacinta