“Neck or Biceps ? Who`s gonna be the pain driver ?”
Short Case Description over two days of a Lithuanian professional Tuba player
Last week we (Sandra and Jürg) had an interesting patient in the student patient session group during the Level1 Maitland course in Kaunas/ Lithuania.
I give you a short description and some clinical reasoning thoughts about these two treatment sessions during the course.
Pain in the right elbow during 3 months limits his body building sport and working situation
Pain reduction during working and participation at a planned body building competition in June
Profession: professional Tuba player in a symphonic orchestra
Hobbies: Body building 5x week
no dizziness ,numbness ②
coughing √, no WAD in history
activities of daily living/ work: several difficulties
social contacts/ hobbies/ sports: severely restricted
24 h behaviour/aggravating activities: Biceps training in the morning with twenty kilos suddenly ①, stays sometimes the whole day
Night: no pain except during baby bed pulling ① during 30”
Grabbing security belt before car driving ①
Taking the instrument during work ① (shown wit Flex+Sup elbow), change position of the instrument ①, playing is okay
②③ unclear when aggravating
Low back pain problem: on the left side and no connection with the elbow problem
Symptom reduction: with rest
History: ③ since 5 y comes and goes without special onset
① since 3 months started with a Triceps Training and get worse with child lifting
② numbness started 3 months ago, then better and since 1 week again increased
No PT treatment,
Special Questions: No medication, No imaging, No diagnosis, health status √
Observation: ++ muscle (body building); Neck: prominent skin line over C6
Elbow flexion + supination 140° ① 2/10
Elbow flexion + pronation 130° ① 5/10
Elbow extension -10° √
Sensibility /light touch: whole arm right – 10%
Mot: Biceps muscle right -30% C6 ?
Mot: Triceps muscle right -30% C7 ?
Reflexes: BSR : both √, TSR both sides no reflexes
ULNT 1 left: -5° local pain lower arm
right: -30 ° ① + Cx LF right ①–
Rx 1: In 90 ° Elb Flex Do a-p Radius IV- 3` // Elb flex+ Pro ①++
Conclusion Rx 1: There are some differentiation tests missing as well as further assessment of passive movements of the elbow. Never the less: What is the clinical pattern ?
Plan Day2 :
screening the Cx spine
Active cervical movements : no symptom reproduction and mobility not restricted
Cx Ext 70 °√ with ++fold at level C6
Palpation and Rx day 2
C5-C7 unilateral left ant.- post IV- 4`// Elb Flex + Pro ①1/10 and ULNT right – 10°
His spontaneously reaction: “Ah, you guys are painkillers“
Conclusion Rx2 : The cervical spine seems to be an important contributing factor for the main symptom and especially for changing the neurodynamic system.
What is still missing ?
At the end please see the following/attached video and make your own picture
“So what could be more exciting than having real patient on imta courses?” ……….Plan Day 3 ?
I am looking forward with great expectation to your proposals and hypothesis