A bizarre issue. Pictures attached. Any help would be appreciated.

[Jasonm]

I ordinarily would not ask for medical help on an internet forum, however, I'd appreciate some ideas or suggestions if anyone has the time or interest in assisting me. Anyway, I've been struggling with severe upper left back pain for about 3 years. I had paresthesia in my left fingers and profound weakness of the left arm if it was raised above my head. Doing a corner pec stretch would exacerbate the numbness. After about 2 years on and off of PT, the numbness has resolved completely and the weakness has improved but is still present. I now get muscle twitches in my neck and in the upper left back and my scapula wings on that side with pushing movements. I've had a barrage of tests done including an MRI of the C-spine, CTA of the thorax, EMG (after the numbness had resolved), and the reports were normal.

The eventuality diagnosis was thoracic outlet syndrome by a vascular surgeon. He advised a first rib resection. I got a second opinion and that doctor disagreed and he referred me to a neck surgeon, who determined it was not my neck. At this point, had been waiting for 5 months to get into "the best manual therapist in my area", who practiced osteopathic manipulation. I went for a few months, saw no improvement and after he said he believed he could do skull adjustments, I gave up. I asked for a copy of my CTA and used some open source 3D medical imaging software that renders the 2D CT slides into a 3D image. Almost immediately I noticed something looked asymmetrical and strange. Directly in the spot the majority of my pain is to boot. I have a fairly good understanding of anatomy but I'm out of my depth on this one. The rib elevation on the symptomatic side appears to begin relatively low and gets to the point where the ribs appear to be virtually touching. I uploaded the non-symptomatic side up as well for comparison.

If someone has some ideas it would be greatly appreciated.

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[physiobob]

Hi Jason and thanks for your interesting post. It's a bit late where I am right now but let's make a start. You mention weakness. Can you be a little more specific to what seems weak and which actions e.g. arm, hand, shoulder movements. My initial though was also TOS. You cannot really comment on the scan in terms of boney alignment as no one is symmetrical but a rib that is closer to another one (without any birth deformity or injury) could mean that the joint where it attached to the spine could be out of place slightly. Paresthesia and numbness and weakness would point to more nerve involvement but then your EMG studies are normal (shame they were not done when you had more symptoms).

Was there something that you did at the time the symptoms began? Also is there ever any discoloration of the affected arm in comparison to the unaffected arm? I await some of your initial responses and come back to you tomorrow. It could be as simple as a thoracic disc which would not have been found on the MRI of the C-Spine.

Chat again soon

[Jasonm]

Hi Bob. Thanks for the reply. The weakness is more of a general heaviness with overhead movement. If I had to pinpoint it I'd say the shoulder. I did not do anything in particular. I just began having some upper back pain one day and it progressed rapidly. I don't really notice any discoloration of the affected arm. Though the veins are darker on the symptomatic arm and my hand turned colors and became weak during a roo's test.

If I sit upright for a few minutes, my shoulder and neck will tighten and twitch which then causes the TOS like symptoms. The left sided upper back pain is the only constant. If I stretch my neck it feels restricted in the same area.

Would any additional diagnostic tests be helpful? What is the treatmebt for a misaligned thoracic disk?

Please feel free to ask me anything else.

[physiobob]

Thanks Jason for the reply. I ask about discoloration to see if there might be any vascular issues such as a DVT in the veins of the arm (very uncommon but I have seen it before with people on a lot of pain meds and steriod users in the gym). I think if we forget all the recent treatment it sounds like is could be as simple as costovertebral joint perhaps in combination with a C4/C5 lateral disc bulge. I see this in combination a lot, especially as the local treatment of the painful rib area (usually close to the scapula on the rib cage as if it is a painful area) doesn't resolve until you treat the neck component. It can be in such cases that some manual therapy with guided neck retraction and extension +/- rotation can be really useful (although painful in the beginning as you try to reduce any lateral disc bulge). In terms of a +ve Roo's test (elevated arm stress test) this might also be positive when you are able to extend your thoacic cage fully so not sure it helps much in that case.

I think in relation to a possible scenario as I have mentioned above it is important to know that this is a very VERY common presentation and VERY normal. There is no real need to investigations other than manual movements of your spine and assessment of your symptom behaviour during and after mobilization of those areas. I would look maybe for a physiotherapist in your area who has skills in McKenzie 'Therapy' or his approach to the assessment of the neck and thoracic spine. This method has some very good self help exercises to administer at home once the physio has assessed what they believe to be the root cause of the problem.

If you were to have a further investigation at some stage and wanted to rule out any sinister pathology (as we call can get worries about such things from time to time) then a bone scan of the thoracic area would perhaps suffice as it would show any abnormal activity in the boney structures in that area.

Another very possible approach to this would be to get involved in some private (one-to-one) studio or 'Equipment' based pilates classes (not matwork classes) OR a private Gyrotonic class. I teach both and used them as a more natural way to restoring normal spinal movement and importantly 'breath' as well. Sometimes all it takes is 6-8 session to make a full recovery when the issues are more a mechanically restricted skeleton.

[Jasonm]

Hi Bob:

Thanks for the reply. I'm not worried about anything of sinister pathology. However, this has pretty dramatically affected my quality of life for over 2 years and I want to do everything and anything to tackle it. I've had about 40 sessions of PT and chiropractic with modest results. I probably should have included this in the original post since it was a large part of why I thought something atypical may be going on. When I was going to PT, they were unable to recreate the symptoms by bending my head in various positions and pushing down. He still tried manual and mechanical traction for about 5 sessions since he felt like a disc bulge was the most likely culprit. Unfortunately, it didn't do much. But hopefully I'm a little taller now . Another PT said I had the best feeling neck they'd dealt with in a long time. No one was ever able to "pop" me on the left side doing a thoracic thrust maneuver, although I'm not sure that's clinically relevant. On a side note, I seem to have very spasm prone muscles. For instance, I strained my piriformis wrestling with a girlfriend about 10 years ago and had nerve pain down my thigh and severe weakness of my leg to the point it had noticeably atrophied after 3 months. I rested for months hoping it would go away with no luck. It resolved with with just a few sessions of PT and some simple stretches. I'm hopeful this is a similar deal.

I took the the pictures to my physician yesterday and he speculated it could be a serratus posterior superior ("SPS") spasm because of the location of the elevated ribs. Although he noted he had limited training in musculoskeletal disorders. He referred me to a interventional radiologist for injections. I tend to believe physiotherapists have a lot better understanding of this stuff than most MDs, so I have a couple questions and will quit bugging you.

Is the SPS capable of causing that sort of rib elevation?

Could the rib compression impinge on the long thoracic nerve and cause the scapular winging?

Is there anyway to stretch the SPS or that general area? I can just look up the stretch if it has a common name.

I hope you're right about the pathology. I'm definitely going to look into your suggestions. I want to sincerely thank you for taking the time to answer my questions regarding these issues. It's unbelievably refreshing to see someone who has some genuine interest in helping people rather than profiteering. I'm sure it's not really worth your time at your current price but it's greatly appreciated. I'm glad I stumble across your forum and you've been an enormous help. If I end up having more questions down the line, I'd be happy to compensate you more adequately for your time. Thanks again!

[physiobob]

You only 'Stretch' is something is considered 'tight' or 'restricted. So I would think this is not something you need to consider. In general normalising overall spinal/shouder movement is going to be the best approach, of course with some relevant functional strengthening too. Let's see how you get on with some injections and if that has an effect in pain reduction then get moving and strengthening asap there after.

[toddchaney]

I agree with Physiobob. You should go for therapies which would strengthen your spine & shoulder. You can browse through the internet and learn some manual exercises which could help you.

[KiwiPike]

I agree with PhysioBob. Go see an MDT(Mechanical Diagnosis and therapy) and have them assess it. Make sure they are certified and dont just do "McKenize exercises". The should be able to sort it out

[Jasonm]

Update:

I'm doing substantially better than I was at the time of my original post. I couldn't find a certified McKenzie therapist less than an hour away which I couldn't do with my schedule. I did, however, buy McKenzie's book on self treatment and found it very helpful. It helped me realize that despite my pain being on the left side of my neck/thorax, my right side was much tighter. I took a photo of myself and it was very apparent that my head was significantly leaning toward the right. It's still a tad annoying but I'm no longer waking up from pain and wanted to express my thanks for the help.

Jason