Trigger Point Injections: A Case Study

Inspection of the right shoulder joint reveals atrophy. Movements are restricted with flexion to 90 degrees limited by pain and abduction to 75 degrees limited by pain. Hawkin’s test, Neer’s test, Shoulder crossover test, Empty Cans test, Lift-off test, and Apprehension test is positive. On palpation, tenderness is noted in the acromioclavicular joint and subdeltoid

Per the QME report dated 06/11/16, patient has reached maximum medical improvement and is P & S. Future medical care includes physical therapy for neck pain flares four to six visits twice a year, follow-up with a physiatrist or occupational health physician intermittently, every one to three months and nonsteroidal anti-inflammatory drugs for flare-ups. He declines injections.

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

~Chief Complaint: The patient c/o bulging to the right shoulder possible dislocation with 7/10 localized pain x2 day. The patient states that when she woke up Tuesday she had right shoulder pain with mild swelling and bulging that appear to be her bone. The pain states that she is able to move he arm but it is extremely pain. The patient states that she has been taking Advil and icing her shoulder with very little improvement. She denies possible injury or numbness and tingling in the right arm or hands

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

Assessments include bilateral shoulder pain, bilateral subacromial bursitis, bilateral shoulder tendinosis, left elbow pain, numbness and status post left shoulder surgery on 03/23/16.

On 12/19/2017, the claimant presented with lumbar pain. She had continued constant nagging pain with radicular pain in the left lower extremity. She had weakness and numbness. In 2012, she underwent L4-S1 fusion. She had lumbar medial branch block in 04/2017, which helped with the axial low back pain by more than 50%, but the radicular pain becomes severe. She stated that the previous bilateral L5 and left S1 selective nerve root block on 06/21/2017 provided 100% pain relief for 3 days before the pain gradually returned. She also had epidural steroid injection and trigger point injection, which did not help with the pain. The alleviating factors include medication, rest, heat, and TENS unit. The previous physical therapy and chiropractic care had helped significantly. Objective findings showed positive straight leg raise test on the left with tenderness in the left lower lumbar area and bilateral

01/26/16 Progress Report noted that the patient presented with left shoulder pain. The pain was gradual in onset and is constant. The pain is characterized as burning, sharp, shooting, and throbbing. It radiates to the neck. She described her pain as moderate to severe. Her condition is associated with numbness in her left fingertips and weakness in her upper extremities. Any activity, movement and reaching aggravate the pain. Stretching and hot showers relieve the pain. The level of sleep has been decreased due to difficulty falling asleep. The quality of sleep is poor. She has difficulty performing her ADLs. Current medications: Meloxicam, Naproxen, and Spironolactone. Review of Systems was positive for weakness and nausea. The patient also has anxiety and depression. She has had psychiatric, psychological, or social work evaluations or treatments for problems. The physical exam of the cervical spine revealed that the ROM is restricted. There were spasms and tenderness of the paravertebral muscles bilaterally. There was also spinous process tenderness noted on C6 and C7. Tenderness is noted at the paracervical muscles and trapezius. Spurling’s maneuver produces no pain in the neck muscles or radicular symptoms in the arm. Adson’s test is negative. No signs of meningism. Cervical facet loading is negative on both sides. The exam of the right shoulder was

Based on the progress report dated 02/16/16, the patient presents with persistent right arm and shoulder pain. She also complains of pain at the base of thumb and tingling in the

This is a 44-year-old male with a 2/7/2013 date of injury, when she tripped over a doctor's rolling computer backpack and fell.

He is status post 3rd cervical ESI with catheter up to C4-5 towards the left. Pain prior is 9/10 and lowest at 4/10. There is improvement with radiating pain. Patient is demonstrating and detailing improvement along the C4 and C5 dermatomal region. He states that he has continued radiating pain through the medial aspect of the left upper extremity, through the elbow, left medial forearm and 4th-5th digits. Relief from the last ESI has begun to subside. He has increased pain through the neck radiating to the left hand and fingers. Pain is rated as 7-10/10. He also reports weakness, numbness and tingling into the upper extremities, left greater than the right. Pain is also extending through to the upper thoracic spine and left greater than right paravertebral regions. Pain is worsened with prolonged standing, sitting, walking, bending, holding head and neck in one position for too long, driving, bending head and neck back and forward and abrupt cervical movements. Ice, rest, heat, therapy and medications provide modest short term relief. He contionues to have difficulty with activities of daily living as well as work/professional activities of daily living, personal and

Regarding follow-up in 4 weeks; ODG states that evaluation and management (E&M) outpatient visits to the offices of medical doctor(s) play a critical role in the proper diagnosis and return to function of an injured worker, to monitor the patient’s progress, and make any necessary modifications to the treatment plan. 01/13/16 Progress Report noted that the patient has persistent neck, bilateral shoulder, mid back, bilateral upper extremity, lower back, and bilateral knee pain. The exam revealed that there were tenderness and muscle spasms about the thoracic spine. ROM of the cervical spine, thoracic spine and lumbar spine was decreased in all planes. There was tenderness over the bilateral upper cervical facet regions. Considering pain and functional limitations in multiple body parts, it seems medically necessary to monitor the patient and make any necessary adjustments to his treatment plan. Recommend certification.

Patient is in obvious discomfort. He outwardly appears to be in pain. He does have outward signs of pain after some motor testing of the left upper extremity. He walks with a reciprocal gait. Strength show 4/5 of the left shoulder deltoids with pain, left wrist extensors and left finger flexors. “Decreased index middle and ring fingers.”

The pain is better with rest. The upper neck pain is radiating around the skull and triggering frequent headaches, low back pain is radiating to the right posterolateral thigh and calf wrapping around and including dorsum of the right foot and middle toes. The patient also has left wrist pain. Current medications include Menthoderm, Flexeril, Naproxen, hydrocodone-acetaminophen, Bactrim, bupropion “Sr”, and Ventolin “Hfa”. Physical examination revealed that the patient’s gait has a left-sided antalgic gait. He does not use assistive devices. Cervical spine examination revealed asymmetry or abnormal curvature noted on inspection. There is also tenderness and trigger point (a twitch response was obtained along with radiating pain on palpation) is noted on both sides. Lumbar spine examination revealed loss of normal lordosis with straightening of the lumbar spine. Lumbar range of motion is has limited flexion of 60 degrees and limited extension of 10 degrees. The range of motion is limited by pain.

Based on the latest medical report dated 02/10/16, the patient complains of posterior neck pain rated as 4/10, described as throbbing. She also has 6/10 back pain. Sacroiliac belt increase her left hip pain. She also reports 0/10 elbow pain.