Background – Upper arm pain + neurological symptoms
This case has a mix of symptoms and potential pathologies to test your ability to triage and prioritise each aspect of the presentation.
You’ll need to determine if any symptoms or aspects of the case are concerning and devise a management plan that takes any diagnostic uncertainty into account.
Minimum level
Physiotherapist with 1+ years experience
History
Abby is a 23 year old female with a desk job in corporate finance. She has had a recent increase in time spent working from home (longer weekdays, also working weekends). Abby is Right hand dominant.
Abby has been experiencing Right upper arm pain as well as pain and pins & needles into both hands.
She recalls neck and medial scapular pain on her Right side recently but states that it’s quite common to experience that pain during periods of intense study or work.
Abby’s upper arm pain has been worsening for 3 weeks, extending from the upper triceps region into her forearm.
The upper arm pain interferes with sleeping but there seems to be no obvious AM/PM pattern.
Abby is unsure of any specific aggravating factors.
The pins & needles have been around for 6 weeks but not worsening, mostly occurring at night.
No relieving activities have been identified for the pain or pins & needles.
Abby took paracetemol and ibuprofen for one week – it may have helped with the pins & needles but there was no change to Abby’s arm pain.
After attending her doctor, Abby’s GP ordered an X-ray which was reported as normal without adverse findings.
List your primary and differential diagnoses after the history
Physical examination
Your examination found generally restricted cervical spine range in all directions. There was also pain in the cervical spine with flexion, Right rotation and Right and Left lateral flexion. During your ROM assessment, there was no change to arm pain or pins & needles.
Neuro assessment found reduced triceps reflex on Right, sensation was normal, and there was reduced power in Right biceps, Right triceps and bilateral grip strength.
Shoulder range was normal, symmetrical and pain-free.
Nominate any specific tests that you would perform and your expected results
What considerations would impact your clinical testing on day 1? (Hint: think about time taken for each test vs the test’s usefulness).
Are there any history or physical examination findings that you’re concerned about?
Name potential pathologies that may cause each of the concerning features and how they would generate that presentation.
Treatment
Abby begins to describe worsening upper arm pain from your assessment.
Nominate your treatment approach, making reference to specific features of the case to justify your choices.
Any further advice regarding activity modifications, need for imaging and/or medication?
What’s your prognosis for this case and why?