Arm pain case histories

Arm pain case histories from the chiropractic coalface.

Neck and arm pain is a frequently reported complaint which can be disabling and costly to society. Certainly they are inter connected and a daily issue at the Chiropractic Coalface.

Two cases from the Chiropractic Coalface:

  1. ´╗┐Tennis elbow, a difficult case.
  2. Frozen shoulder, a difficult case that turned out to be routine.


Tennis elbow

Tennis elbow is the diagnosis of our first arm pain case histories.

INITIAL CONSULTATION

Mrs H is a 64 year old woman, in excellent health, but with a long history of low key left lower neck and upper thoracic pain. There was never radiation to the arm, but it obviously created a weakness in her left arm.
Nine months prior to the first consultation, she had to take her grandchild out of the car, and then carry the child in the Snug and Safe baby car chair for about half an hour. The next day she developed acute left elbow pain which never went away. Physiotherapy brought only very temporary relief.




EXAMINATION @ ARM PAIN Case Histories

Orthopaedic tests (Cozen's and Lateral Epicondylitis test) and resisted isometric wrist extension were severely painful in the left elbow. Shaking her hand hurt, and she reported that lifting the kettle, pots... was very painful. Radial head fixation.

Left neck rotation was restricted and Kemp's test for a facet syndrome was mildly positive in the left lower neck.

Brachial nerve tension test for a frankly pinched nerve in the neck, and Adson's test for a subluxated first rib causing a Thoracic Outlet Syndrome were negative.

DIAGNOSIS

Whilst the case had the appearance of a routine "tennis elbow" or "lateral epidcondylosis" in the jargon (not "itis", there are no inflammatory changes), there were two little warning signs:

  1. CHRONIC LOWER NECK PAIN, and
  2. NINE MONTHS OF PAIN, NOT IMPROVING, NOT RESPONSIVE TO MEDICAL TREATMENT AND PHYSIOTHERAPY.


    THORACIC OUTLET SYNDROME tests were negative.


Consult 2: REPORT OF FINDINGS @ ARM PAIN Case Histories

At the ROF I always like to

  • repeat the case history. Have I missed anything? Did you forget something vital?
  • go over the findings in the examination
  • give the probable diagnosis and differentials
  • tell the patient about Chiropractic philosophy
  • outline the treatment programme.

Oddly, this is the most important consultation, more important than the treatment itself. Chiropractic treatment of musculo-skeletal conditions like Tennis Elbow is superior to anything medicine can do, the research confirms it, but the Chiropractor often fails at this first hurdle, if s/he fails to 'sell' the programme to the patient.

I did it thoroughly, and Mrs H is still with us six weeks later.

I then proceeded with a gentle first consultation. The treatment of tennis elbow can be painful, and it makes no sense to bully the patient in the beginning, though it may well be the case later.

  1. Chiropractic adjustment of C6 (no release, I didn't force it.)
  2. Active Release Technique (ART) of the Extensor Carpi Ulanares Longus muscle
  3. Chiropractic adjustment of the Radial head.
  4. Home treatment: Alternating ice and heat several times a day.

Consult 3: @ ARM PAIN Case Histories

Her neck felt looser, but her elbow rather "burny". No real improvement.

I added an adjustment of Th 5 vertebra in her midback.

Consult 4:

The Lateral Epicondylosis orthopaedic test was slightly less painful.

Consult 5:As before. Perhaps 5-10% improvement. Consult 6:Mrs H confided that she also had chronic right groin pain. She had to dot-and-carry-one up a staircase. Medical treatment hadn't helped.A short examination confirmed mildly reduced range of motion, particularly adduction and internal rotation with sharp pain at the end of the range. Early osteoarthritis was on the list of DDs. I suspect a femoro acetabular impingement syndrome and recommended a trial of 4 treatments before asking for X-rays. FAIS untreated leads inexorably on to arthritis as the replenishment of synovial fluid becomes progressively less, leading to degeneration of the hyaline cartilage one of the few tissues to have no blood supply of its own.
Consult 7: Elbow continuing to improve. Slightly.

Quite a lot of "napijn" after the treatment of the hip.

Aside: Pain after a chiropractic is not uncommon. Mostly, it's a discomfort, a sense of having been battered about, which you have been. And it passes within a day, or sometimes 2-3. Very occasionally patients have really quite severe "after-pain". Don't be alarmed, afterall you also have after-pain after your wisdoms out... but do phone your chiropractor and let him/her know.

Consult 8-12:

Most encouraging was that the chronic pain in the groin improved greatly after the chiropractic treatment of the sacro-iliac joint, hip capsule and groin muscles, particularly the pectineus and adductor magnus.

Less encouraging was that the progress with the elbow pain was SLOW! IN CAPITALS! But the important "lateral epicondylosis test" was nearly negative.

Consult 13-15: A personal family friend, Mrs H continued to come for treatment of her elbow despite my misgivings. I like the progress to be much faster. But where to refer her after medicine and physiotherapy hasn't helped. She reports that it is now 50 percent better and rarely wakes her at night.

I add acupuncture treatment to all the other therapy.

Rome wasn't built in a day, and sometimes one must accept that some conditions takes time and commitment. We both have that.




Consult 16-20: She reports that the acupuncture is definitely helped. Her grandchildren have been to visit from England, the cause of the original problem, and despite a three week stay, the pain is gradually lessening; she says about 75 percent better. She can lift the kettle with her left hand. Her groin pain is over. We add some rehabilitation exercises for the hip; it's a trying case. Normally patients respond faster than this.

I don't adjust her neck at every consultation. I believe that too much manipulation, like too many drugs, is not good.

But how frequently is "too-much"? We don't know.

She's happy. I should be too.

Here's an update from two months later; she reports that she has no pain whatsoever, but continues to do the stretches.


Frozen shoulder

A frozen shoulder is the second of our arm pain case histories.

Initial consultation

Mrs M is a 51 years old woman, in good health, apart from severe "the top of my head is going to explode off" headaches of many years duration, significantly worse over the last 6-7 years when she relocated, and had a bad experience with a Chiropractor. Previously chiropractic kept her headaches under control, though they never totally abated. She is on heavy medication for migraine.

One year ago insidious left shoulder started with no known cause. Medicine would describe the case as "idiopathic" though subsequent chiropractic examination was interesting... She routinely does her own housework, but no specific injury was recalled.

After a few weeks she consulted her medical doctor who diagnosed a muscle strain, and prescribed anti-inflammatory drugs.

Aside: Interestingly, NSAIDS are the most commonly used medical treatment for frozen shoulders but there are no RCTs (the gold standard of research) confirming that antiinflammatories help. It's unscientific treatment.

Subsequent corticosteroid injections did not help either and after a month there was zero improvement. X-rays showed an acromial spur and calcium deposits in the tendon and subacromial bursa.



Tingling in hands

Tingling in hands often gives the clinician important clues in these arm pain case histories; which fingers are involved?

A burning pain would radiate into her lower arm and hand periodically. She was not sure which fingers but was fairly sure it did not include the thumb. Pain and tingling in arms and hands is a not uncommon feature of frozen shoulder. A cervical stenosis case file in the making needs to be considered too.

She was referred to an orthopaedic surgeon who removed the spur and "cleaned out the calcium deposits" and infiltrated the joint with a combination of NSAIDs and cortisone. For 6 weeks the condition was much improved.

She was then referred for physiotherapy to build up the muscles. Despite faily gentle and conservative exercise regimen the pain returned and the range of motion became progressively worse. She could not sleep on that shoulder, undressing became very difficult and she couldn't lift her arm above 90 degrees, and reaching her bra strap was quite impossible.

A return to the orthopaedic surgeon proved fruitless. "Stop everything and take antiinflammatroy drugs." Despite the medication the arm pain became progressively worse, and stiffer: frozen shoulder.

In desperation she decided to try another chiropractor. Bernard Preston!

X-rays @ ARM PAIN Case Histories

X-rays of her left shoulder reveal an old injury - a subluxated AcromioClavicular joint - and at least three calcium deposits in the shoulder.

Arm pain case histories

Arm pain case histories helps you see how others are progressing.


EXAMINATION

Mrs M is a slim woman in apparent good health. Both active and passive flexion and abduction (whether she or I lifted her arm) was severely limited and painful. Internal and especially external rotation were limited, as was extension. Apley's scratch test (reaching for the bra strap) was painfully impossible.

Active resisted isometric contractions of the shoulder (without movement) caused severe pain on internal, external rotation. In particular contractions of the Supraspinatus muscle that lifts the arm were very painful. There was a severe active trigger point in the Subscapularis muscle (under the shoulder blade) that caused pain to radiate deep into the shoulder and chest. The Subclavius muscle that rotates the collar-bone was painful.

Neurological exam was normal. The Upper Limb Tension Test for a pinched nerve root was negative.



Right rotation of the neck caused pain in the Scalene muscles on the left side. The test of Adson was markedly positive with an immediate sessation of the pulse in her left arm when she turned her head and breathed in, a sure sign of the so-called THORACIC OUTLET SYNDROME ...


(more correctly, the inter scalene triangle between the medial and anterior scalene muscles)



CHIROPRACTIC EXAMINATION: ARM PAIN Case Histories

There was a profound fixation of the first rib on the left, the probable underlying cause of the whole syndrome.

In addition the fifth rib head was fixated, and the whole rib was tender on palpation, and the attachment at the breastbone was very painful, but only on palpation. An incipient Tietze's syndrome was in the making. TIETZES SYNDROME ...

I gave Mrs M a very basic set of simple range-of-motion exercises, and asked her to return in a few days for the Report of Findings.



Consult 2: REPORT OF FINDINGS @ ARM PAIN Case Histories

I explained in some detail the nature of her condition, what the treatment would be and what she could expect. In particular that the pain would first increase quite likely for a week or two as we stretched the capsule, then would begin to subside within 3-6 weeks. I expect a big improvement with two months, but the range of motion of the shoulder could take a year or more to return.

Under medical care, research confirms the following:

  1. Phase I: Freezing Phase (~3-9 months): pain and restricted motion of the shoulder joint in all planes.
  2. Phase II: Frozen Phase (~9-15 months): consisting of severe stiffness - very limited passive range of motion.
  3. Phase III: Thawing Phase (~15-24 months): when range of motion returns to normal.

DIAGNOSIS Early Phase II Frozen Shoulder.

In particular, when a new patient is consulting a Chiropractor for the first time, or has obviously had a very different experience of Chiropractic we always give a short outline on the nature of Chiropractic, the importance of the neurological system, and how nerve irritation or impingement can have a profound affect on health.

First treatment: Chiropractic adjustments of the first rib, the fifth rib, mobilisation of the costo-sternal (rib-breastbone) joint, the AcromioClavicular joint, the shoulder joint. Very painful active release therapy of the Subscapularis muscle, and the suprspinatus muscle. Electro stimulation of the shoulder girdle muscles. She tolerated the procedures well, and I warned her the pain would probably increase for a few days. I checked she was doing the exercises correctly.

CONSULT 3:

Mrs M experienced as expected increased pain the next day, but she arrived this morning smiling. The arm pain is 20% less she reported, and the range of motion definitely improved.

We followed the same treatment protocol.

CONSULT 4: ARM PAIN Case Histories

After the last treatment she experienced a disquieting numbness in her whole lower arm and all fingers. No pain. Range of motion continued to improve.



COMMENT: As a doctor one is very aware that one is stomping where angels fear to tread. This is a serious condition, severe irritation of both a nerve and an artery, and continuous weighing of the treatment options is vital.

Happily Adson's test was negative - there was no change in the pulse in her wrist when she turned her head, looked up and breathed in, challenging the structures in the scalene triangle.

On this occasion no manipulation of the first rib was done, but the rest of the treatment was as before.




CONSULT 5: For the first time, BEFORE THE TREATMENT, external rotation exceeded 90 degrees. Flexion was vastly improved and happily the numb feeling in the lower arm was much improved.However, left lower neck pain had increased, pain she had had for years. Chiropractic adjustment of the C7 facet joint on the right proved difficult, and I chose not to use "brute force and ignorance". Instead we adjusted C7 on the left, using a "spinous-push-manoeuvre" with the usual audible release.


CONSULT 6: Mrs M is ecstatic - for the first time in over a year she was able to sleep on her left shoulder. She says the pain and disability is at least 50% improved. We added an isometric exercise protocol to be done with "every cup of tea or coffee."Progress!


CONSULT 7: A setback...Mrs M bumped her arm on the mirror of the car giving her shoulder a sharp jolt yesterday. It's very sore again, but the range of motion is still improving. Worryingly her lower arm is aching again. There was no spinal fixation, but the scalene muscles in the neck were in spasm, affecting the nerves and artery in the Scalene Triangle.

  • An aside: Do you know about the 50 percent less pain principle. The pain of many conditions abates faster than the tissue heals. 50 percent less pain is the dangerous time.

CONSULT 8: Progress @ ARM PAIN Case Histories

Have you been to read 50 percent less pain? Go on, it's important, I'll wait for you to return...!The ache in Mrs M's shoulder lasted about three days, and then continued to improve. She says the pain and disability is about 80% less. That's fine for a condition that she's had for over a year... flexion and external rotation are almost normal now, but abduction is still limited to about 100 degrees. We added in a new exercise in which she holds a 500 ml water bottle (half full) in her hand and moves it in and out. As the water reaches the end of the bottle, having to stop suddenly, it gives the shoulder a little jolt. Rehab, that's what it's taking now... CONSULT 9-10 Most gratifying progress. Mrs M can raise her arm with pain, though the last bit of abduction is slightly limited. But she has almost no pain. She can sleep through the night without pain, and do most of the chores that every housewife is called upon to do. I give her an exercise device that I make with pulleys and ropes. It's a simple gadget, just a high quality pulley, 2m of rope and couple bits of wood for handle.

Update: Mrs M brought her daughter in today for another complaint. It's now about three to four months since her initial consultation. She has almost no pain in her shoulder. Passive flexion is very slightly limited, but not painful. Apley's scratch is negative, and she can reach her bra-strap with ease. Internal and external rotation are quite normal. Adson's test is negative, and she has no rib pain.

We have a lot of fun in our clinic: she is a firm Baptist by Christian tradition, and waving your arms in the air is definitely Non-U in Baptist circles. Her range of motion is virtually normal: I told her she can shout alleluias, and be very charismatic!

I'm firmly convinced the rapid resolution of this nasty condition, is adjusting the first rib. Untreated, she could have expected another two years of pain, and 5% don't resolve.

Interestingly, her headaches are also very much better.

She will now come for a treatment every 6-8 weeks for maintenance.

UPDATE: It's now six months, and M has little problems with her shoulder. The neurologist has greatly reduced her headache medication, and is considering dropping them altogether. Mrs M continues to come for a six weeks maintenance treatment. Vital in her case.

SLIPPED DISC IN NECK

Without a doubt a slipped disc in the neck is one of the most serious and difficult cases that cause radiating arm pain. The deep ache in the arm is severe, nights are disturbed, the surgeon can't wait to get his knife in, the doctor his pills, the chiropractor his manipulation skills. You be the judge...incidentally self manipulation of the neck is one not uncommon cause of serious injury to the neck.


NUTRITIONAL CORNER @ ARM PAIN Case Histories

What causes those calcium deposits in the shoulder? Probably old injuries, but so often having started in one shoulder, in a few months the pain begins in the other shoulder. Diet almost certainly has a role to play, magnesium being probably the deficient mineral (richest in spinach) and analysis of Mrs M's diet confirms my suspicions. So we are talking about the anti-inflammatory foods like


MUSICIANS

Musicians have to stand or sit for long periods in unusual postures, placing great strain on the arms, shoulders and midback. This often requires innovative Chiropractic treatment... MAESTROS OF THE GUITAR ... ( index )

Need to evaluate how bad your arm pain is? Arm pain Quick DASH questionaire ...



Computers and ergonomics

Suffering from arm pain and tingling in arms and hands, and spend a lot of time at the computer. Think first about your computer station. Read more at this Arm Pain and Mouse Arm page...

Whatever you do, please don't start CHIROPRACTIC HELP Popping your own neck ... that's a serious cause of arm pain.


USEFUL LINKS @ ARM PAIN Case Histories




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