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Upper Extremity Neurovascular Compromise in a Runner with Asthma:

Upper Extremity Neurovascular Compromise in a Runner with Asthma A case report

History :

History 26 year old female Onset during half marathon January 8 th 2012 Right neck pain, right arm swelling and tingling into entire palmar surface of hand Attempts to run post onset lead to sharp “stabbing” pain at right anterior shoulder, tingling and swelling within 10 minutes of initiating running Swelling lasts ~10 hours post run, tingling subsides in 10-20 minutes post run Notes “aching” in lateral brachium at rest

History:

History Day Pattern Neck and shoulder pain worse as the day progresses Neurovascular symptoms only brought on with running Ibuprofen, heat and rest decrease pain PMH significant for lifetime history of asthma confirmed with pulmonary function tests

History :

History Pain VAS: 7/10 at worst 5/10 at rest located at right lateral neck and upper shoulder McGill pain questionaire Tingling, aching, radiating, piercing, tight and annoying Upper Extremity Functional Scale 93%

History:

History Functional restrictions Unable to run greater than 10 minutes Decreased grip strength-difficulty opening jars Unable to reach fully overhead with the right upper extremity Unable to maintain static sitting posture for greater than 20 minutes without shrugging shoulder to relieve pain

Examination:

Examination Structural Inspection L shoulder elevated Mild left thoracic scoliosis Increased kyphosis /scapular protraction Palpation for condition Edema noted throughout right lateral brachium and forearm Coloration and temperature changes in the right upper extremity

Examination:

Examination Cervical AROM Cervical Motion AROM Symptoms Flexion 35 degrees Extension 45 degrees Sidebending Right 11 degrees Sidebending Left 17 degrees Paresthesia noted up lateral aspect of neck to occiput Rotation Right 78 Degrees Rotation Left 54 Degrees Notes muscle stretching sensation on the right

Examination:

Examination Shoulder AROM AROM PROM Shoulder Flexion (R) 144 180 Abnormal Capsule end feel Shoulder Abduction (R) 146 180 Abnormal capsule end feel

Examination:

Examination PROM Accessory First rib depression hypomobile Right > Left Midcervical upslides hypomobile B Midcervical downslides hypomobile R Generalized midthoracic and rib PA hypomobility

Examination:

Examination Special Tests Negative Roos (False negative (?), short duration) Cervical compression/distraction negative Movement Analysis Unable to recruit diaphragm with inspiration U pper respiratory breathing pattern with significant use of scalenes , SCOM, upper trap Not position dependent

Examination:

Examination Neurovascular Dermatome and myotome testing negative (+) ulnar and radial neural tension

Examination:

Examination Palpation for tenderness First rib bilaterally Supraspinous ligament C7/T1 to T2/3 Right scalene and SCOM Right pec minor, levator scap insertion P ain reproduction down arm with palpation of middle scalene Unable to palpate diaphragm due to significant muscle guarding

Evaluation:

Evaluation Functional neurovascular compromise at the thoracic outlet Likely caused by impairments related to significant accessory muscle respiration

Impairments:

Impairments Impairments contributing to inability to run greater than 10 minutes due to pain, swelling and paresthesia : First rib elevation Postural deficits creating functional compression: generalized thoracic, midcervical and rib hypomobility I nhibition/weakness of diaphragm with inspiration A ccessory muscle breathing with tenderness at scalene triangle

Impairments:

Impairments Impairments causing restriction in end range glenohumeral AROM Limited thoracic mobility ?

Prognosis:

Prognosis Goal: Return to running 3-5 miles every other day with 0/10 pain and no measurable change in edema Good Prognosis Young Age General history of good health Motivated Recent onset of symptoms Concerns about history of asthma

Intervention:

Intervention Phase 1: Postural Treatment First rib depression STM/MFR and manual stretching to upper trap/ levator scap , upper serratus fibers, pec minor NMR for scapular control Mobilization of restricted rib, midthoracic and midcervical segments Neural mobilization

Intervention:

Intervention Phase 1: Treatment of Shoulder ROM Facet lock in prone of right T2/3 facet lead to significant gains in shoulder A/PROM Pre treatment ROM ~140/145 degrees elevation to 160/165 post treatment

Intervention:

Intervention Phase 1: Treatment to improve diaphragmatic breathing Verbal and tactile cues used in facilitated position Progression of Supine 90/90 -> Hooklying ->Supine-> Kneeling hands on hips/Kneeling over a table Light theraband resistance for proprioceptive cues Use of ultrasound for biofeedback

Intervention:

Intervention Phase 1: Response Improvement in symptoms at rest centralization of upper extremity pain to right upper trap, decreased aching, paresthesia and swelling Improvements in all postural impairments thoracic, midcervical and first rib mobility Improved pec major/minor muscle length Improved scalene length and no upper extremity symptom reproduction with palpation Improved ability to recruit diaphragm in progressively more difficult positions

Intervention:

Intervention Phase 1: Response With attempts to run, symptoms became more severe sooner in the run swelling at 7 minutes, numbness at 15 minutes 2 weeks later, symptoms began within 3 minutes and patient was unable to continue running due to right shoulder pain, right upper extremity paresthesia and swelling Shoulder AROM and now PROM worsen with flexion/abduction ~130 degrees passive elevation which improves to 170 degrees with upper thoracic mobilization Gains in ROM lost between sessions despite HEP for thoracic mobilization with shoulder ROM

Reassessment:

Reassessment More impairments Limited posterior mobility of ribs 1-4 Weak deep cervical flexors Subcranial examination: limited FB, B AA rotation SCOM fascial mobility restricted Fascial restrictions at lateral border of latissimus dorsi at the ribs

Phase 2 treatment:

Phase 2 treatment Treatment for restricted AA mobility Seated AA manipulation NMR for newly gained cervical rotation ROM Response: Immediate full GH AROM flexion/abduction post manipulation Significant headaches post manipulation and subcranial mobility restrictions return between sessions Shoulder A/PROM lost between sessions

Phase 2 Treatment:

Phase 2 Treatment Latissimus transverse lift from ribs Intercostalis manual stretch End range sustained hold PA rib 2 and 4 in prone with GH ER and cervical rotation Inhibition to upper fibers of serratus anterior SCOM fascial lift NMR for serratus and diaphragm in newly gained ROM

Phase 2 :

Phase 2 Immediate Treatment response Immediate full glenohumeral elevation and combined ER/Cervical rotation Full diaphragmatic excursion observed and palpated with no accessory muscle compensation Significant and rapid onset of upper extremity edema after the first treatment session treated immediately with posterior rotation of the clavicle with passive GH flexion

Phase 2:

Phase 2 Long Term Treatment Response Diaphragmatic breathing continued to improve with treatments to SCOM and Lat Some degradation in diaphragm recruitment persists between sessions Shoulder A/PROM remained full after 2-3 sessions

Outcomes:

Outcomes UEFS: 96% Return to running progression Week 1: 3 x 5 min jog, 2 min walk 1/10 mild sensation of throbbing reported Ceases immediately upon walking Week 2: 3 x 7.5 min jog, 2.5 min walk Symptoms onset on second repetition rated 3/10 both aching and swelling Persist 10 minutes post run and subside

Outcomes:

Outcomes

Outcomes:

Outcomes

Discussion:

Discussion “One of the most controversial topics in musculoskeletal medicine and rehabilitation” (Hooper et al.,2010) TOS outlines location of problem, not the cause Diagnosis of exclusion

Discussion:

Discussion Special tests show high rates of false positive findings General “best” tests: Elevated arm stress test (loading) Cyriax release test (unloading) Upper limb neural tension (provocation to neural tissue under tension load) *high sensitivity

Discussion:

Discussion Cluster of 2 provocative tests increases sensitivity to 90% Cluster of 5 provocative tests increased specificity to 84% (Hooper et al, 2010)

Discussion:

Discussion Three Compartments Interscalene Triangle Brachial plexus, subclavian artery Costoclavicular Space Brachial plexus and subclavian artery and vein Thoraco - coraco -pectoral space ( retropectoralis minor space) Axillary Arterty and vein

Discussion:

Discussion Best special tests by location Thoraco - coraco -pectoral Wright’s test (neural tissue compromise) Costoclavicular Space Costoclavicular maneuver Scalene compression Supraclavicular pressure test Adson’s

Discussion:

Discussion Costoclavicular Space Accessory muscle breathing with use of SCOM, overuse of scalenes (not an accessory muscle to breathing) Anatomical anomoly ?

PowerPoint Presentation:

— Costoclavicular space with arms positioned alongside body. 1 = clavicle, 2 = subclavian artery, 3 = subclavian vein, 4L = lateral nerve cord of brachial plexus, 4M = medial nerve cord of brachial plexus, 4P = posterior nerve cord of brachial plexus, 5 = first rib, 6 = subclavius muscle, 7 = pectoralis major muscle, 8 = pectoralis minor muscle, 9 = serratus anterior muscle, 10 = lung. Demondion X et al. AJR 2000;175:417-422 ©2000 by American Roentgen Ray Society

PowerPoint Presentation:

— Costoclavicular space with arms hyperaducted . 1 = clavicle, 2 = subclavian artery, 3 = subclavian vein, 4 = cords of brachial plexus, 5 = first rib, 6 = subclavius muscle, 7 = lung. Demondion X et al. AJR 2000;175:417-422 ©2000 by American Roentgen Ray Society

Discussion:

Discussion Incidence and Differential Diagnosis 1% arterial Pain and numbness in non- radicular distribution Pain is in hand, seldom in neck or shoulder Cool to touch with pale discoloration Worse with cold ambient temperatures 3-5% venous Deep pain in shoulder, chest, entire UE Feeling of heaviness in the UE worse after activity Cyanotic discoloration with distended collateral veins Edematous increases in volume of extremity

Discussion:

Discussion Incidence and Differential Diagnosis 90% neurogenic True Neurogenic Objective neurological signs are present (C8, T1) True axonal compression Disputed Neurogenic No objective neurological signs are present Mild perineural dysfunction

Discussion:

Discussion Outcomes for conservative management Good or very good results acheieved in 76-100% of disputed neurogenic cases in one month 59 to 88% after at least one year Poor outcomes associated with work comp, obesity and double crush pathology Venous or arterial outcomes?

References:

References Demondion , X, Boutry , N, Drizenko , A, Paul, C, Francke , JP, Cotton, A. Thoracic Outlet: Anatomic Correlation with MR Imaging. Am Journ Rad August 2000 175:417-422 Friedman, HH, Argyros , TG, Steinbrocker , O. Neurovascular Syndromes of the Shoulder Girdle and Upper Extremity: The Compression Disorders and the Shoulder-Hand Syndrome . Postgrad Med J. 1959 July; 35(405): 397-404, 412, 425. Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis . J Man Manip Ther . 2010 Jun;18(2):74-83. Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management . J Man Manip Ther . 2010 Sep;18(3):132-8. Pratt, NE. Neurovascular Entrapment in the Regions of the Shoulder and Posterior Triangle of the Neck. J Phys Ther . 1986 Dec; 66(12): 1894-1899

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