T8 neural tissue provocation

On a recent outpatient musculo clinic I encountered a 50 yo male who presented to with L shoulder pain, with concurrent elbow and axilla pain and pins and needles down his arm. 16 months before he was on a canoeing holiday where he travelled 90 km in three days. Since then he had developed a twinge in his shoulder which became progressively worse. In the last 3 months the pain in his elbow had developed. He has no previous history of L shoulder pain. Pain in the shoulder would occur first and if it was bad enough it would be followed by pain in the axilla which is a sharp pain occurring with elevation of the arm. Pain in the axilla is followed by pain in the elbow, this was a sharp pain that usually came on with lifting. The pins and needles were intermittent and came on 1% of the timelasting for a few seconds, there were located to follow the ulna distribution of the hand.

Main agg and easing factors in the subjective were elevating the left arm, particularly up and back, this brought an immediate onset of pain which would ease quickly when the arm was put down. Main easing factors were medication and keeping arm by side. There was no noticeable 24hr pattern other than it was slightly better in the morning.

Relevant findings of the physical examination were decreased AROM in shoulder flexion, abduction and external rotaton, limited by pain. Isometric mm tests were clear ( flexion, abduction, IR) except for ER which brought on 2/10 Pain in the shoulder and elbow. Empty can and full can were also mildly provocative bringing on shoulder pain. The Cx spine was also assessed which was clear for AROM. Flexion with L rotation brought on 3/10 L sided neck pain which did not travel down to the shoulder. Central PAIVMs were tender at C2, C7 and T1 again not referring to the shoulder. NTPT of the ulna nerve was positive for reproduction of shoulder pain symptoms were increased with CL cx lat flexion and decreased with neutral or wrist flexion.

The interpretation of these findings was that there was mechanical pain of the shoulder brought on with active movement of the shoulder joint. The pattern of pain presentation involving subsequent axilla then elbow pain pins and needles suggests some neural involvement. As the ulna nerve NTPT was positive and was more provocative than impingment test this indicates that C8 neural tissue sensitivity was the main cause of symptoms, due to the positive response of the impingement the initial diagnosis also included the possibility of a supraspinatus tendinopathy.

Initial intervention by the first therapist was lateral glides of C7 and T1 in an attempt to mobilise the nerve root of C8, which was moderately successful. Subsequent treatment focussed on neural mechanosensitivity including lateral glides and manual traction initially and the patient showed good increases in ROM and reduction in pain however progress appeared to slow a little over the next few sessions. As a result further techniques were attempted to treat the mechanosensitivity more specifically and correct any muscle inbalance that may be contributing to nerve sensitivity hence soft tissue release of rhomboids, pec major, levator scap, postural retraining, PAM of the GHJ and the first rib were used. The most effective treatments being Pec minor release, PA PAM of first rib, GIII with the patients symptoms now being mild pain and near full ROM, however there is still Neural symptoms in the provocating position so to further decrease neural sensitivity slide/glides of the ulna nerve were tried and given as a home exercise. The main difficulty in treating this patient was to think about finding ways to treat the problem specifically- such as mobilising the first rib in an attempt to affect C8 neural tissue, rather than just the Cx spine. I found this was an important lession in thinking of all areas that may be affecting the patient and not just sticking to the most obvious treatment