Differential Diagnosis

This is the same patient as I referred to last week. The patient was referred to the clinic with a HPC of slipping on wet grass and falling onto their L elbow, resulting in partial rotator cuff tear and as a result, secondary shoulder impingement. The patient also presented to the clinic with central mid to lower cervical pain 8/10, worse L than R and sharp pain down the lateral-posterior aspect of their L arm 6-7/10 at rest 8-9/10 upon arm movements above 90 degrees. The patient had also been seeing a chiropractor early on in the treatment for her neck pain, with still little to no relief.

Since being treated the pain has remained the same, with minimal improvements in shoulder range and the patient reports that her main concern is that she is not getting much more than 3 hours of sleep per night due to the pain in her neck and arm. Since the patient had been coming for some time now, the initial objective assessment had already been completed and the cervical spine ROM cleared. However I was quite concerned that since coming to the clinic the patient had seen little improvement, still experiencing high levels of pain and irritability during treatment. The pieces of the puzzle didn’t seem to quite fit, so I discussed with my supervisor my concerns and that I wanted to alter the previous treatment given as this had not made the patients condition any better.

I proceeded to do a full neuro Ax and found the patient tested positive to Radial nerve sensitivity, bringing on the exact pain the patient was experiencing. From this everything else started to make more sense. The shoulder wasn’t getting any better as it was limited due to the neck pain caused by the neural sensitivity. So the treatment changed to optimise opening up of the intervertebral foramina with techniques like cervical distraction and physiological lateral flexion. The patient experienced immediate relief of pain and as a reassessment tool had significant increases in shoulder range when the radial nerve provocation was provided and desensitised with its respective manoeuvres. The patient’s mood was significantly higher for my last few treatments as she was experiencing pain relief for days at a time and was even able to get more than 3 hours of sleep at night.

What I learnt from this experience was that it’s really important to stick with your gut instinct. If someone else has seen the patient previously it’s ok to question their findings and discover them for yourself. Also with a case like this she may not have initially had the neural sensitivity to the degree in which she did by the time I had treated her, so it could have been missed, but since Cx ROM was cleared, the previous student felt no need to test neural tissue as there was no indication at the time. Also what I learnt was that you need to be quite thorough in clearing the cervical spine as a source of pathology especially with shoulder injuries because there is a significant correlation between shoulder pathology referred from the cervical spine. So I’m not saying her condition was all cervical spine, there was a component of the cervical spine and also the shoulder pathology itself, but as my supervisor said, you treat the proximal symptoms first, because as they resolve there is often a degree of resolution of the distal pathology.