In today’s clinic I provided manual therapy for two patients and partnered up with a colleague for a initial assessment. Patient 1 (22-year-old rugby player), came in requesting a sports massage to his upper trapezius and left elbow due to DOMS. Previous injuries included a ruptured ACJ on his left shoulder. Top (tenderness on palpation) on his right supraspinatus and upper traps as well as left triceps brachii insertion. Treatment was STM (soft tissue massage) to upper traps, rhomboids, levator scapula, supraspinatus, deltoids and left triceps brachii. After treatment I went over shoulder anatomy including palpating bony landmarks such as the coracoid process, greater tubercle and acromion process as well as muscle origins and insertions (rotator cuff muscles) as I struggled during palpation and the STM. The supraspinatus originates on the supraspinous fossa of the scapula and inserts on the greater tubercle of the humerus. Triceps brachii inserts on the olecranon process and its three heads originate on the infraglenoid tubercle of scapula (long head), proximal posterior humerus (lateral head) and distal posterior humerus (medial head) (Cael, 2010). Knowing the anatomy better and how to palpate bony landmarks will allow me to more efficiently apply STM in the future.
The second patient (24-year old volleyball player), also came in requesting a STM. He had pain in his lumbar area one day prior to the appointment which was primarily in the left side. Objective assessment found pop (pain on palpation) of L5 spinous process (pain: 5/10) and left transverse process (pain: 6/10), top of ES (erector spinae), QL (quadratus lumborum), lower and middle trapezius & rhomboids. Treatment was PA (posterior-anterior glides) to L5 spinous and right transverse process (3×60 seconds) and STM to the ES, QL, trapezius & rhomboids. Spinal manipulation/mobilisation has been shown to have moderate supporting evidence in treating acute low back pain and high supporting evidence in treating chronic low back pain (Bronfort, Haas, Evans, Leininger & Triano, 2010).
The third patient (24-year-old student) came into the clinic with complaints of a stiff neck and radiating pain down right arm. The pain had started 6 months ago after overdoing it at the gym. Since then he has stopped going to the gym and has had MRI scans of his neck, which showed up negative. Objective found, pop on right upper trapezius (pain 6/10) where a large muscle lump could be felt. An ulnar bias (UMNLT) was found to be +ve on right arm. An examination of the cervical spine was conducted but the radiating symptoms could not be reproduced which rules out C-spine radiculopathy. As such, we came up with a hypothesis that the combination of the large muscle lump and general tightness in the upper right trapezius was causing a compression of the right brachial plexus, which would explain the radiating pain down the patient’s right arm.
On reflection I looked up what causes brachial plexus compression as we were not certain of our diagnosis. Thoracic outlet syndrome (TOS) is thought to originate from an anatomic predisposition with neck trauma, either from an acute incident or from repetitive stress. 2 subcategories of neurogenic TOS exist. Symptoms of lower TOS are compression of C8 and T1 and manifests as pain in pain in ulnar forearm, hand and sometimes axillary & anterior shoulder region. Upper TOS manifests as C6-C7 compression and shows pain in supraclavicular region that can radiate into the ipsilateral head, face, upper chest and pericapsular region or radial nerve distribution to the index finger and thumb. 90% of the time patients have a combination of upper and lower TOS. Treatment of TOS should include stretching, ROM exercises, tendon and nerve gliding techniques as well as core strengthening and posture correction (Kuhn, Lebus & Bible, 2015). In terms of the trapezius being the cause of brachial plexus compression, I found no mention of this in studies, it seems that scalene abnormalities are a more likely soft tissue cause of compression. I will be present for the follow up clinic session of this patient to assess further but I still think that brachial plexus compression could be the correct diagnosis based on subjective and symptom presentation.
Finally, for future reference I will further revise shoulder anatomy including the nervous system to aid my diagnosing skills.
Bronfort, G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: the UK evidence report. Chiropractic & osteopathy, 18, 3. doi:10.1186/1746-1340-18-3
Cael, C. (2010). Functional Anatomy: Musculoskeletal Anatomy, Kinesiology, and Palpation for Manual therapists (1st ed.). Baltimore: Lippincott Williams & Wilkins, Wolter Kluwer.
Kuhn, J., Lebus, G., & Bible, J. (2015). Thoracic Outlet Syndrome. Journal Of The American Academy Of Orthopaedic Surgeons, 23(4), 222-232. doi: 10.5435/jaaos-d-13-00215