Chiropractic physicians evaluate and manage patients with acute and chronic pain conditions on a daily basis. Sometimes, a patient presents with both acute and chronic chief concerns on their initial encounter. Let's discuss such a patient, whose case demonstrates the need for chiropractic physicians with advanced evaluation skills to be accessible for patients suffering with severe, acute, disabling neuropathic pain episodes and chronic spinal conditions. A case report is presented for your consideration, followed by a few questions and then some clinical pearls.
History of Present Illness
A 50-year-old male presents with the two chief concerns: "I can't lift my shoulder" and "My neck is killing me." The patient points to the area of the left deltoid muscle as the site of pain. He describes the pain as sharp, stabbing pain when he tries to lift his arm. It is obvious that severe pain in the left shoulder prevents him from abducting or externally rotating the left shoulder.
The pain began this morning upon waking. He denies any previous shoulder problems or trauma to the shoulder. Yesterday, he did some overhead work and felt a painless, snapping sensation in the left armpit. He has no pain in the shoulder if he does not attempt to move it. Patient rates the severe pain at 10/10 when attempting to lift the shoulder and 0/10 at rest. He has not attempted any self-treatment.
His neck pain also started this morning. The pain becomes a sharp, shooting pain from the lower cervical spine on the right to the index finger and thumb. There is a constant stiffness and ache in the lower neck at rest, which becomes severe when he bends his head to the right and looks backward.
He points to the lower cervical spine on the right as the area of the pain in the neck, and rates the pain severity at 8/10. The patient believes a chiropractic adjustment will relieve his pains. He also mentions the recent purchase of a memory foam, contoured cervical pillow.
The patient reports a motor vehicle incident at age 35 that caused a "whiplash." Chiropractic care for a period of two years was necessary to reduce the severe neck pain and headaches. The treating chiropractor referred him to a neurologist because the patient was experiencing neck pain and weakness in the right hand that caused him to discontinue playing racquetball. Apparently, he was an accomplished tournament player. An MRI examination was ordered by a medical neurologist. It demonstrated two herniated discs at the C5-6 and C6-7 levels. The neurologist advised him to discontinue playing racquetball.
Physical Examination
This 50-year-old male appears his stated age and is mildly obese. He is a mesomorph, a good historian, alert and cooperative.
Posture: Sitting posture demonstrates a head tilt to the left.
Palpation: Extreme pain is produced when palpating the lower cervical spine at the levels of C5-6-7 midline and on the right. Myofascial trigger points are present in the lower posterior cervical paravertebral muscles and the upper trapezius muscles bilaterally. There is no pain with palpation of the left AC and GH joints or the left rotator-cuff muscles.
Range of motion: Active cervical ROM is full and without pain except with significant limitation upon right rotation, lateral flexion and extension. Pain radiates from the lower cervical spine on the right to the right index finger. Active left shoulder ROM is extremely limited, with an inability to abduct or internally rotate the shoulder because of severe pain in the shoulder.
Orthopedic testing: Cervical compression produces pain in the lower cervical spine with radiation into the right index finger. Cervical distraction is positive with relief of the pain in the cervical spine.
Joint dysfunction: Posterior cervical joint dysfunction is present at C-5-6-7 with reduced ROM, pain and hypertonicity of the paravertebral muscles.
Three-part PNS examination: Sensory function intact for the C5-7-8-T1 dermatomes bilaterally except for hypoesthesia at C6 right dermatome. Motor strength is 5/5 bilaterally for the upper extremities; except C5 left myotome is not testable because of the shoulder pain and limited shoulder ROM. Deep tendon reflexes are 2+ bilaterally for the upper extremities. Hoffmann's pathological reflex is absent bilaterally.
Imaging Studies
Radiographic examination included a five-view cervical study dated six months prior to this visit, which revealed disc space narrowing at the levels of C5-6 and C6-7 with osteophytes in the same neuroforamina.
Assessment
Acute exacerbation of cervical radiculopathy due to a whiplash-type injury, with degenerative disc and joint disease.
Treatment Plan
- Cryotherapy to include ice massage in order to reduce pain and spasms prior to cervical distraction
- Manipulation to reduce pain and improve function
- Daily treatment for three days and then re-evaluate to determine the need for future care
Follow-Up: What's Happening?
The patient responds well to the initial treatments, with improved cervical range of motion and pain reduction. He rates his improvement at 90 percent. He returns the next day claiming that the neck pain and the pain down the right arm are completely resolved. Unfortunately, he is still unable to abduct or internally rotate the left shoulder, with no reduction in the pain level. These are the questions racing through my cerebrum:
- Why did the shoulder pain not reduce? Either I have the wrong diagnosis or the wrong prognosis, or maybe both!
- What did I miss? Well, did I reproduce the patient's shoulder pain with palpation? No, I did not. Did I attempt passive range of motion? No, I did not.
- What should I do next for the shoulder pain? Well, why not perform additional examination and find a working diagnosis prior to suggesting a treatment plan!
Additional Evaluation and Findings
- Patient did mention that the day before, he heard a pop in his left armpit while reaching up to change a light bulb. He denied any pain at that time.
- Palpation of the quadrangular or quadrilateral space reproduces the left shoulder pain.
- Passive range of motion of the left shoulder is painless, full and without limitation. Following passive movement of the left shoulder through all ranges of motion, the patient experiences 90 percent relief of the pain over the deltoid muscle.
- Sensory evaluation reveals anesthesia in the regimental badge area (lower half of the deltoid muscle) only.
Can You Solve the Dilemma?
I now have a better working diagnosis. Which would you select as the cause of the patient's ongoing problems?
- C5 nerve root compression
- C6 nerve root compression
- Radial nerve compression
- Axillary nerve compression
Clinical Pearls
If you selected axillary nerve compression, you are correct. Now you may create your new treatment plan for axillary nerve compression syndrome. I suggest you advise the patient to be careful while sleeping. The patient should not sleep on the affected side with the shoulder abducted and externally rotated. This patient will be prone to dislocate the shoulder if sleeping in this position because of weakness of the musculature. You will notice atrophy of the deltoid muscle as time passes.
Recommended Reading
- Neal SL, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician, 2010 Jan 15;81(2):147-155.
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