Arm Pain!

I am a newly graduated physio and and would appreciate advice with one of my new patients.

33 year old female with intermittent right arm pain lateral upper arm to elbow. Full cervical movement with slight end range stiffness with right side flexion/right rotation. Small amount of tenderness C5/6 with no reproduction of symptoms. Reflexes, dermatomes, muscles strength all normal on testing. However she reports a sensation of weakness occasionally when carrying. Positive median and ulnar nerve test. (median more notably) Symptoms arise when carrying an object in left arm with arm by her side, or stretch arm behind her head, then they resolve within 30 seconds. The onset was 3 months ago, when she lifted a weight at the gym resulting in severe neck pain on the right side, she was seen by an osteopath initially and this improved the neck pain fairly quickly however the arm pain remains unchanged.
Since I have seen her I have been mobilising C5/C6 , and she has been doing a home stretch into left side flexion. Symptoms have improved slightly but no significant difference.

Thanks for your help!!

Just a quick reply, I would think about checking out the trigger points in the cervical/th/gh muscles and review her posture/shoulder balance etc. See whether treating the trigger points changes her comparable signs/objective markers.I have have had great success from looking really closely at the soft tissue. Look at the muscles in the static postural position (cervical and thoracic and its relationship to the shoulder) and then look at the same muscles during dynamic UL movement. Clear Rib 1 and the thoracic outlet.
Good luck.

hi,

I would also check and mobilize the claciculair joint. With ellevation this joint compresses the nerves.

good luke en greetz from Holland

Sanne

Hi,

If you have cleared the joint signs, get full ROM, I guess you can do some nerve mobilisation!

Good luck!

Try assessing her in supine or sitting so that you can reproduce the pain, yes bring it on! Then reassess neck movements, retraction etc to see if they have any effect. I would suggest supine (i.e. Cx unloaded) as a preferred first choice. See what you find and then get back to us.

Can you give a bit more insight into the actual exercise she was doing in the gym when she suffered the injury? 8o

hi
i would suggest you maitlands mobilsn ,incorporated with mckenzies exercises(1-10).Progress gradually as the pain centralises.
as the signs of nerve root reduce go for median n.biased neural mobln.
evaluate the tight muscles & stretch them.
hope this helps,
regards
ark.

Hi
If all the Cx treatments fail, I suggest looking at the deltoid bursa which may cause impingements, plus the supraspinatus tendon area. Does not sound like scans have been undertaken to confirm any pathology. Try a reputable ultrasound scan, plus possible CT or MRI if symptoms remain unresolved.

Prior to scanning, try deep pressure at a 45 degree angle to the acromion, over the supraspinatus tendon, plus deep friction over the teres muscle insertions. Strengthen the shoulder depressors and retractors. Does the patient have a problem laying on the affected side, and is night pain a problem. Any impingement on shoulder abduction?
Regards
MrPhysio

If I would suggest you something, try McKenzie exercises first for cervical spine: protraction and retractaction in connection with manual therapy and mobilisation. Good luck!!!

Hi,

It sounds like this lady has a neural traction injury. Her aggravating activities are at EOR positions which go away after a little while.

Presumably the osteopath has sorted the joint problems in the C/S.

However, some core stability work for the deep cervical stabilisers won't be wasted.

To test for instability, lie the patient supine. Palpate the transverse processes bilaterally. Ask the patient to FF to 90deg - that is her arm to the ceiling. Then ask her to slowly horizontally extend the arm - that is move the arm from the ceiling to parallel to the bed. If she has instability, you will feel the TP rotate towards the bed into your fingers. Try it on people without neck pain to get the feel of what stable is (assuming they have a stable neck!).

Try and let us know...