PCP and Physical Therapist disagree about severe upper back, shoulder and arm pain

by Jessica
(Gray, ME)

PCP and Physical Therapist disagree about severe upper back, shoulder and arm pain; keep an open mind particularly if there is a fever.

Hello,

I've had deep upper back pain for 6 weeks now with severe pain in my left shoulder, tricep and forearm ending in hand numbness from my thumb to the middle finger on the left hand. I have 2nd and 3rd toe numbness on the left side and occasional tingling in my chest.

I am unable to look upward without pain in the middle of my back (T1). I have terrible squeezing muscle spasms at the left scapula and in my pectoral muscle. There was no injury initially.

The pain started as low back pain (unable to rise from sitting and straighten) then became severe muscular pain in my left back and shoulder before settling into the base of the neck. The only relief is to bring my arm over my head with my hand resting on my head. The relief is brief as my shoulder joint begins to complain quickly now. I am unable to sleep well as I awaken in pain when I move.

My PCP, a DO, saw me at the end of week one and felt it was lower back pain from poor posture at the computer. I was seen a week later at quick care (PCP unavailable) as the pain became severe in my neck and mid-back. X-ray showed nothing obvious. I was given pain meds for a "herniated disc" in my neck and referred to PT the very next day. The physical therapist, after assessment, felt that the pain was likely a bulging disc in the mid-back with nerve irritation. He has done stretching, stim and cervical traction with only short lived relief.

My PCP disagrees with PT, saying that a mid-back bulging disc is uncommon. She continued ice, muscle relaxants and pain meds. After reaching week six, she has ordered a cervical spine MRI upon my request. I am waiting for insurance to authorize. I'm asking for referral to a spine center.

I have now developed a persistent low grade fever without other symptoms for the last two days. I do not know if this is just coincidental.

Please advise your thoughts on the treatment I should be pursuing.

Thanks.

Hello Jessica,
Because of the unusual history - starting in your lower back, and then progressing into the midback, neck, shoulder and arm - that fever must be considered as being significant. Do you have a cough or signs of upper respiratory infection? Blood tests are called for, and a complete reassessment. You obviously have pain, but do you feel sick? Are there any lymph nodes swollen in the groin, in the neck or armpit?

Your PCP is correct; disc herniations in the midback are rare. There are two other considerations here.

1. Do you have deep inspiration pain? A rib head subluxation can cause very severe midback pain, sometimes radiating to the pectoral and sternal area. Run your fingers down the joints on either side of the breastbone; are any of them particularly painful or swollen? Is there a nodule? If so then Tietze's syndrome should be considered.

2. The muscles in the midback are supplied by a nerve from the lower neck; it also supplies the shoulder and arm. That extension of the neck provoking pain fits with this; so does relief of pain by raising your arm; the so called shoulder abduction relief sign.

If you turn your head to the left, and then look up, does it cause pain in the neck and down the arm? That's called Spurling's sign. Disturbed sleep is a common feature; it's worse at night.

Of course, it's theoretically possible to have four different conditions; lower back, midback, cervical spine and a fever of unknown origin, but it's most unlikely.

My best thought is this is a lower cervical lesion and an MRI is the right way to go.

Obviously, I'm guessing and throwing out ideas. Give me some answers and what's good is that you are thinking and asking the right questions.

If any of my questions click, make sure you point them out to those handling your case?

Let me know what happens, Jessica; you've piqued my curiosity!

Dr B



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