Left Upper Trapezius Strain Case Study

02/09/16 Progress Report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The pain is on the left side. It is rated as 3-4/10. It is stabbing, burning, and pins and needles. Medications and rest alleviate the pain. Work, standing, walking, and activity aggravate it. The patient has tried muscle relaxants, strong pain meds, PT, hot packs, and ice, all of which have helped, but he continues to experience substantial pain. The exam revealed that the DTRs were mildly diminished in the left upper extremity.

12/16/15 Progress Report indicated that the patient wakes up with headaches. She mentioned headache in the frontal vertex or temporal occipital areas. She also feels imbalance. She denies bruxism and has no significant neck symptoms. She reported having some minor neck tightness. She was being treated with acupuncture 2 X per week and craniosacral therapy 2 X per week. She noted that she was able to read better in the past two weeks. She had difficulty scanning a written page in the past. She also mentioned that her insomnia has slightly improved since initiating these 2 therapies. Physical exam showed no palpable spasms in her cervical region over her muscles of mastication. Cervical range of motion: backward flexion 70 degrees and forward flexion 60 degrees. She was able to turn 60 degrees to each side. She is able to tilt 40 degrees to other side. Comments: Based on the absence of objective findings, she has reached a medical end result with no need for any further treatment. No additional treatment or diagnostic testing is

DOI: 2/24/2016. Patient is a 46-year-old male production technician who sustained injury while he was lifting a heavy door when he felt immediate pain in his right shoulder. Per OMNI, he was initially diagnosed with right shoulder strain.

DIAGNOSIS: Strain of muscle, fascia, and tendon at neck level; Carpal tunnel syndrome, unspecified right limb,;Carpal tunnel syndrome, unspecified left limb; Status post left carpal tunnel release; and Adhesive capsulitis of right shoulder (M75.01).

Physical examination revealed that the patient’s back is less tender. There is facet tenderness over the bilateral L3-S1. There is also slight pain with limited rotation, flexion, and hyperextension. The right lower extremity is noted to be weaker. The lumbar spine examination is positive for seated straight-leg raise on the left and facet loading. As per treatment plan, the patient will be continuously evaluated for medication regimen and make alterations as necessary. It was noted that the patient states that there is continued need for his Zanaflex as necessary for flare-up of muscle spasms until he is able to start up chiropractor therapy again. He will try to discontinue the medication next month with chiropractor therapy. As per office notes dated 5/23/16, the patient’s pain level is 5-6/10. He states continued need for his Zanaflex as necessary for fare-up until he is able to start up chiropractic therapy. He continues to have neck pain with intermittent periods of sharp-stabbing pain over the right side with radiation to the bilateral upper extremities with numbness as well as associated cramping into upper extremity and into fingers. Current medications include Zanaflex, Nexium, Celebrex, and

IW was diagnosed with cervical strain with right arm dysesthesia with what appears lo he chronic regional pain syndrome of her right arm, right shoulder biceps tendonitis and subacromial bursitis with associated impingement, status post subacromial injection x 1, mild medial and lateral epicondylitis of her right elbow, carpal tunnel syndrome by EMG/nerve conduction velocity and reactive depression.

On March 25, 2016 a 45 year old male patient came in to Mount St. Mary’s Hospital to have x-rays done of his cervical and lumbar spine, hip, shoulder, sacrum and coccyx. The patient indicated that 16 years ago he woke up with a stiff neck that never went away. Along with his stiff neck, the patient stated that he was experiencing lower back pain as well for the past 16 years. The patient also specified that recently he had started suffering from pain in his right hip and right shoulder. When asked, the patient stated that he had not had any injuries to cause the pain. The patient also indicated that he had never had any surgeries to his lower back or neck. For this case study we will only be looking at the images of his cervical and lumbar

Namely the upper portion of the trapezius muscle laterally flexes the head and the neck towards the same side, and assists in extreme rotation of the head so that the face turns to the opposite side. It can draw the clavicle backwards and raise it by rotating the clavicle. It usually helps to carry the weight of the upper limb during standing, or support a weight in the hand with the arm hanging. Acting bilaterally, the upper fibers extend the head and the neck .The upper trapezius can reflect headaches on the temples, dizziness, severe neck pain, intolerance to

There was decreased range of motion and positive Spurling’s. Trigger points were noted over the bilateral trapezius, suprascapularis, and dullness to pinprick to both hands. There was weakness to grip 1st and 2nd digit opposition, and 1st and 5th digit opposition bilaterally. Deep tendon decreased 1/4 bilateral triceps/biceps.

The patient, Miss Tedo, is a 69-year-old female with a diagnosis of cervical degenerative joint disease, also known as cervical osteoarthritis or neck arthritis. Miss Tedo complains that she has neck stiffness and pain rated as 6/10. Miss Tedo also reported that she has tingling and pain rated as 5/10 that radiates down the right arm to the little finger. Upon her visit to the clinic, Miss Tedo presented with limited cervical range of motion, 30o of rotation bilaterally and 10o of lateral flexion bilaterally. She exhibits moderate cervical paravertebral muscle hypertonus with a forward flexed posture and poor postural awareness.

On examination the cervical ROM was restricted in all planes. Spurling’s test was positive on both sides, worse on the left. Sensations to light touch were decreased in the left hand 1-2 digits, which indicates sensory losses at C6-C7 levels. This level is most remarkable on the imaging as well. The MRI revealed 3mm protrusions at C6-7, with mild canal stenosis at this level; and mild to moderate foraminal stenosis greater on the left at C6-7. The patient has tried and failed conservative treatment including, PT, TPI, and medications. In addition, the patient reported functional improvement and pain relief from the first ESI, which was performed at a different, level i.e. C7-T1. CO Guidelines state indications for ESI :injections are allowed for only a small subset of patients with radicular findings. They may be used for patients who are having significant pain that is interfering with daily functions and the active therapy necessary for recovery despite medical pain management and active therapy. Injections should be preceded by an MRI. Interlaminar injections should not be done above level C6-C7. Guidelines have been met. Medical necessity of cervical ESI has been established. Recommend

On examination of the neck, there is tenderness over the facet joints and paraspinal muscles. Spasms are noted over the paraspinal muscles. There is tenderness and trigger points in the trapezius muscles bilaterally. Range of motion is limited. Extension is 40 degrees. Flexion is 25 degrees. Rotation is 40 degrees bilaterally. Lateral flexion is 25 degrees bilaterally.

Based on the progress report dated 06/02/16, the patient presents for evaluation of her left wrist. She is still having a lot of symptoms. She did have a repeat nerve study which showed normal.

My Research topic is a comparative study to evaluate the effectiveness of Bowen Technique and Positional Release Therapy on Trapezitis.

On examination, there is tenderness in the right trapezius musculature extending down into the right shoulder girdle. Right shoulder range of motion (ROM) is full with pain at end range. Impingement testing was mildly positive. There is a los tenderness in the right knee with range of motion