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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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



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