Question from a new grad physio about neck treatment

Hey Folks,

I am a newly graduated physio who has been practicing for 4 months. I have a puzzling patient. I have seen her for 5 sessions and her pain complaints have improved but neuro signs and symptoms persist.

Here are some of my objective and subjective findings:

Elevated first rib.
Decreased C6 reflex.
C7 myotomal weakness.
Shoulder held in elevation and protraction.
Numbness to index and thumb.
++ Tender to palpation in medial elbow over ulnar nerve.
Burning in posterior shoulder.

Here is my treatment so far:

Heat, soft tissue massage to upper back
Manual cervical traction (no change to subjective complaints)
Strengthening of deep neck flexors, shoulder protractors
Mobilize first rib
Pec - release

What am I missing?

Thanks.

Willeseden

Hi

Quote:

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Shoulder held in elevation and protraction...
Here is my treatment so far:...
Strengthening of deep neck flexors, shoulder protractors

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It seems that your treatment reinforce the problem.
It is better to relax shouders/elevators. Find out if the lattissimus is involved.
Neuromobilizations will work fine, in my view.

Thanks for your reply. That should have read 'retractors.'

By, 'neuromobilizations' do you mean nerve gliding?

Thanks.

I meant gliding/sliding effectively.
A good approach is to teach an active muscular relaxtion to the patient.

Why is the shoulder elevated? Perhaps it's a simple response to the elevated 1st rib and/or neck issue (perhaps aorund C4 region). This is not likely to be the primary cause although you will find cervical problem areas in this situation.

Is there something they are doing that could cause this? e.g. they might be a cellist or tennis player.

In my view you also need to look at the thoracolumbar juction to ensure that there is still enough lordosis to maintain the head over the shoulders and not in front of the shoulders. The later would cause increased upper cervical extension and 1st rib issues etc.

This would then lead on to working on the mid thoracic region to facilitate rib cage and spinal mobility and later, hopefully, posture. Remember that an increase in thoracic kyphosis will by nature elevate the scapula and lead to neck and first rib issues.

It does seem you are on the right track, just keep looking futher afield to ensure they are not back for more treatment 3 months down the track :) Let us know how you get on

Thanks for the replies. The shoulder elevation subsided with 1st rib mobilisation and muscle energy techniques for upper fibres of traps, levator scapulae, etc. I have started T-spine mobs recently.

I will definitely check the T-L junction. Since I am a new grad, I am still operating under "tunnel vision" somtimes by neglecting to check other areas.

Thanks!