I recently had a familiar patient whom I had successfully treated years ago for LBP. This time he was referred by a local neurosurgeon for cervical radiculopathy. He certainly had symptoms and a clinical picture that may fit the bill (arm pain below the acromion- in the lateral upper arm and MRI evidence of DDD with multi-level foraminal encroachment). The pain only occurred in the middle of the night or upon awakening in the morning. He was generally painless throughout the day. However, he noted weakness when lifting weights at the gym, especially when lifting overhead.
Examination revealed symmetrical and nearly full cervical spine rotation (>65 degrees, bilaterally), nearly normal sagittal plane motion and no effect on arm symptoms of repeated movements of the head and neck. Additionally, Spurling’s and distraction tests were negative. Evidence suggests that 3 or 4 out of 4 positive special tests for radiculopathy (Spurling’s, distraction, <60 degrees of rotation to painful side and positive upper limb tension test with median nerve bias) have excellent specificity for diagnosis of cervical radiculopathy (3 positives: Sensitivity=.39, specificity=.94, +LR .88 (1.5, 2.5); 4 positives: Sensitivity .24, specificity=.99, +LR 30.3 (1.7, 38.2). It should also be noted that painless external rotation (vs. abduction or elbow flexion weakness) on the L arm was appreciated (rotator cuff vs. C5).
Therefore, radiculopathy can’t be clearly diagnosed with this client. Furthermore, there was no clear effect of neck motion on arm symptoms. Continuing on with the movement exam, overall cervical patterns per the SFMA were DN (dysfunctional and nonpainful) and symmetrical and left upper extremity (UE) patterns were more limited (asymmetric) in both directions (DN) vs. the right upper extremity.
Due to the asymmetry UE was broken out, revealing soft tissue tightness (TED) and motor control deficit (SMCD), due to fact that active unloaded motion was better than loaded, but still significantly less than passive unloaded. However, passive unloaded was still limited/DN, ya dig? Additionally his thoracic extension/rotation to the left was DN, which was a SMCD. Additionally, there was no evident capsular pattern in the left shoulder in supine, meaning glenohumeral capsular mobility is likely clear.
Based on lack of significance with the cervical exam and the movement impairments that are potentially related to the left UE weakness, corrective exercises were issued based on the 4x 4 matrix, beginning in quadruped for the spinal SMCD. UE breakout also revealed limited active vs. passive prone shoulder flexion. Therefore, two lower trapezius facilitation exercises in prone were issued. After 10 repetitions of each, his overhead pattern was FN. Therefore, these were issued for HEP and no arm pain was provoked.
This client has increased ROM and strength at the gym and has noted diminished pain in the morning. Of course we can’t conclude that SFMA guided intervention was the cornerstone, but regardless, he appreciates improved function within 1-2 visits.
Again, spending time looking at multiple avenues (below) lead us to find another Rapid Responder. This time asymmetry(via SFMA), the lack of symptom reproduction, and the negative CPR for cervical radic lead us to the best outcomes.
Symptom Reproduction or Reduction
Tissue Tenderness
Asymmetry (significant) & Aberrant Motion
Resistance Testing
Special Tests and CPRs
I hope this case report leads you towards finding more rapid responders and thinking a little outside the box.
