5002 Case 5 Cheat Sheet

- 62 y.o.
- Neck & L arm pain
- L pectorals area & down L posterior arm
- L first 3 fingers

Neck & shoulder
- Deep achy pain
- Hand feels numb & bit weak
- 7/10

AF: Working overhead, shaving, & circling head
- RF: Massaging forearm & triceps / raising arm / naproxen relieves pain

Medication
- Naproxen
- Atenolol (β blocker)

ROM Cx
- AROM: pain + restriction
- PROM: L + R rotation pain + restriction
- PROM: pain on extension

TTP (tender to palpation) + hypertonic
- L traps
- Levator scapluae
- Rhomboids
- Scalenes
- Pecs

Working diagnosis
- C7 radicu­lopathy (combi­nation of muscle weakness seen) + potential associated degene­rative change (based on age) & potential pre-ex­isting (asymp­tom­atic) disc herniation
- Traumatic sprain / strain event causing the overall symptoms we see now

Less likely Dx
- TOS: possible from Hx but less likely as no reproduced symptoms in physical examination
- Peripheral nerve entrapment (median / radial): depending on the location of the entrap­ment, less likely to explain the whole presen­tation & the symptoms being aggravated by max. Cx compre­ssion & relieved by Cx distra­ction suggest root involvement
- Sub-acute Cx spine sprain / strain: may be initial onset of symptoms, it doesn't explain the current neurol­ogical picture
- Non-sp­ecific neck pain w/ associated myofascial involv­ement:* could account for part of the presen­tation but doesn't explain the objective neurol­ogical deficit (comment have mechanical & myofascial involv­ement in pts w/ radicu­lop­athy)*

Separate complaint of momentary dizziness: after getting up quickly from a stooped position
- Most likely due to postural hypote­nsion (aka. orthos­tatic hypotension)
- Could be cervic­ogenic & important not to miss (causes would be vascular)

Presen­tations of C6, C7 & C8 radicu­lopathy (nerve root)
⏺ C6:
- Radiating pain down the arm to the thumb & index finger
- Weakness in the biceps & wrist extensors
- Tingling or burning sensations in the fingers
- Difficulty w/ fine motor skills (buttoning a shirt or holding small objects)
⏺ C7:
- Radiating pain down therm to the middle finger
- Weakness in the triceps & wrist flexors
- Tingling or burning sensations in the middle finger
- Difficulty with grip strength & hand dexterity
⏺ C8:
- Radiating pain down the arm to the ring & little finger
- Weakness in the hand intrinsic muscles
- Tingling burning sensations in the ring & little fingers
- Difficulty w/ fine motor skills (typing or writing)

Differ­entiate between radicu­lopathy & peripheral nerve entrapment presen­tations
⏺ Location of symptoms:
- Radicu­lop­athy: usually causes symptoms in specific area of the arm or hand that corres­ponds to the location of affected nerve root (e.g. C6 causes Sx in neck, shoulders, & arms, while C8 causes Sx in the ring & little fingers)
- Peripheral nerve entrap­ment: causes Sx in specific nerve distri­bution in the arm or hand (e.g. carpal tunnel syndrome causes Sx in the thumb, index, middle, & half of the ring finger)
⏺ Pattern of Sx:
- Radicu­lop­athy: usually causes Sx that radiate along a specific nerve pathway (herniated disc causing C6 radicu­lopathy can cause pain that radiates down the arm to the thumb & index finger)
- Peripheral nerve entrap­ment: Usually causes Sx in a more localised area (carpal tunnel syndrome usually causes pain, numbness, & tingling in the thumb, index, middle, & half of ring finger)
⏺ Onset of Sx:
- Radicu­lop­athy: usually develops gradually over time (herniated disc may take weeks or months to cause noticeable Sx)
- Peripheral nerve entrap­ment: can develop suddenly or gradually (carpal tunnel syndrome can develop suddenly due to repetitive hand movements or wrist injury)
⏺ Associ­ation w/ other condit­ions:
- Radicu­lop­athy: often associated w/ other spinal conditions (e.g. herniated discs, spinal stenosis, or degene­rative disc disease)
- Peripheral nerve entrap­ment: can be associated w/ activities or conditions that put pressure on the nerves (e.g. repetitive hand movements, wrist injuries, or certain medical conditions like diabetes)

Different types of TOS, how it's diagnosed & managed
⏺ Neurogenic TOS:
- Compre­ssion of brachial plexus
- Shoulder, arm, & hand
⏺ Venous TOS:
- Compre­ssion of subclavian vein
- Blood vessel that carries blood from arm to heart
⏺ Arterial TOS:
- Compre­ssion of the subclavian artery
- Blood vessel that carries blood from heart to arm
⏺ Diagnosis:
- Combin­ation of medical Hx, physical examin­ation, & diagnostic tests
- Tests: x-rays, MRI or CT scans, EMG, or nerve conduction studies
⏺ Manage­ment:
- Conser­vative manage­ment: manual therapy, medica­tions, lifestyle modifications
- Invasive manage­ment: surgery, vascular procedures (angio­plasty or stenting)

Postural hypote­nsion (aka. orthos­tatic hypotension)
⏺ Defini­tion:
- Drop in BP (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic) that occurs within 3 minutes of standing
⏺ Mechanism:
- Normally, when person stands up, body compen­sates by increasing HR & constr­icting blood vessels to maintain BP → if postural hypote­nsion, compen­satory response is inadeq­uate, leading to drop in BP & reduced blood flow to brain
⏺ Symptoms:
- Dizziness or lightheadedness
- Fainting or near-fainting
- Blurred vision or tunnel vision
- Nausea
- Fatigue
- Headache
⏺ Causes:
- Dehydration
- Medication side effect
- Diabetes
- Nervous system disorder
- Aging
⏺ Treatment* (depends on underlying cause):
- Lifestyle changes: staying hydrated, standing up slowly, wearing compre­ssion socks
- In some cases, medication adjust­ments