Case report Clinical conundrums in a case of upper quadrant dysfunction Lisa Roberts a, b, * a Therapy Services Department, Southampton University Hospitals (NHS) Trust, Tremona Road, Southampton, Hampshire SO16 6YD, United Kingdom b Faculty of Health Sciences, University of Southampton, Highfield, Southampton, Hampshire SO17 1BJ, United Kingdom article info Article history: Received 6 March 2011 Received in revised form 16 May 2011 Accepted 17 May 2011 Keywords: Neurodynamic Double crush Scapho-trapezio-trapezoidal fusion abstract This case study charts the progress of a 60-year-old angling coach presenting with a complex upper quadrant dysfunction. Following a brief summary of the history and physical examination, the main focus of the paper explores the mechanical and physiological rationale for adopting a neurodynamic approach for a proposed double crush condition. This case further highlights mismatches that arose between the clinical findings and traditional healing timescales, and the importance of considering pathomechanics of the whole quadrant in complex clinical circumstances. Ó 2011 Elsevier Ltd. All rights reserved. 1. Introduction In December 2009, the patient was referred to physiotherapy one year following a scapho-trapezio-trapezoidal (STT) joint fusion for his longstanding wrist pain, secondary to degenerative arthritis. Post-operatively, he acquired an infection, which was treated with six weeks of intravenous antibiotics, multiple immobilizing plasters and opioid analgesia (morphine). At six months, he was further diagnosed with a ‘nasty carpal tunnel syndrome’ which was surgi- cally decompressed, resulting in worse pain and anaesthesia throughout the hand and wrist. Five months later, the patient reported numbness and loss of dexterity in all fingers, which significantly impacted upon his work as an angling coach. 2. Referral and investigations A referral was made to physiotherapy for desensitisation and sensory re-education, noting a superficial radial nerve neuropraxia. Nerve conduction study findings revealed “Only very mild slowing across the carpal tunnel.; although there is an un-recordable superficial radial nerve response.” In clinic letters, the orthopaedic surgeon stated: “I am afraid that I cannot explain the profound numbness here in light of the nerve studies. The numbness does go across all the fingers and not just that of the median nerve.” 3. Examination findings At his initial assessment, the patient reported being unable to tie hooks, cast lines and assist the children (and adults) he was coach- ing. He expressed frustration with his clumsiness, disappointment and anger at his lack of progress, and described his arm as ‘useless. as if it didn’t belong’. He reported virtually constant numbness, with only occasional paraesthesiae, unaffected by activity (Fig. 1). The key findings from the physical examination were: flattening of the mid-thoracic kyphosis; increased tension in the upper fibres of trapezius; restriction in all active thoracic and cervical movements (except cervical flexion) (Fig. 2); only 90  of right active shoulder abduction and flexion; discomfort on all shoulder girdle active move- ments; hypomobility of the first rib, cervicothoracic junction and on posteroanterior palpation of the thoracic spine down to the level of T6. There was minimal limitation in active elbow flexion and extension and 25% loss of active radio-ulnar pronation on the right side, limited by pain in the posterior upper arm. In addition, neurological testing revealed weakness at all levels from C5 to T1 and neurodynamic testing reproduced symptoms for the median, ulnar and radial nerves on the right, and the median and radial nerves on the left. Palpation (in neutral) revealed local tenderness and apparent tethering of the carpal tunnel scar. In summary, this routine STT fusion had progressed to involve the whole upper quadrant over the intervening twelve months. 4. Clinical conundrums The patient considered he was far worse following surgery than with his original arthritis, and twelve months on, presented with * Faculty of Health Sciences, Building 45, University of Southampton, Highfield, Southampton, Hampshire SO17 1BJ, United Kingdom. Tel.: þ44 (0) 23 8059 5311; fax: þ44 (0) 23 8059 5301. E-mail address: L.C.Roberts@soton.ac.uk. Contents lists available at ScienceDirect Manual Therapy journal homepage: www.elsevier.com/math 1356-689X/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2011.05.009 Manual Therapy 17 (2012) 192e195