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Initial Evaluation

Thoracic Spine ROM decreased in left sidebending and extension pain reproduced with right rotation Decreased kyphosis from T3 - T7 in upright and full flexion Segmental Mobility P-A glide hypomobility from T3 - T7 Posterior shoulder pain reproduced from T4 - T6. Rib Mobility

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Initial Evaluation

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  1. Thoracic Spine ROM decreased in left sidebending and extension pain reproduced with right rotation Decreased kyphosis from T3 - T7 in upright and full flexion Segmental Mobility P-A glide hypomobility from T3 - T7 Posterior shoulder pain reproduced from T4 - T6 Rib Mobility P-A glide hypomobility in ribs 3 - 7 bilaterally Posterior shoulder pain at left ribs 4 -6 Palpable trigger points Left rhomboid and mid trapezius Initial Evaluation

  2. Shoulder AROM Elevation and external rotation full but painful on the left Shoulder Muscles Unable to assess secondary to pain Scapular Muscles L R Lower Traps 3+/5 3+/5 Mid Traps 4-/5 4/5 Rhomboids 4/5 5/5 Serratus Ant. 4+/5 5/5 Initial Evaluation

  3. Initial Evaluation • + Neer’s and Hawkins Impingement Tests • Scapulo-humeral rhythm • Decreased eccentric control in descent of the left arm • DASH Score • ADL Score 17% • PA Score 25% (McConnell, et. al. 1999)

  4. Hypothesis • Patient had hypomobility and pain in the upper thoracic spine and ribs • Movement of the joints recreated and referred her pain to the shoulder • Lack of scapular muscle control decreased her ability to set the scapula • rotator cuff symptoms

  5. T4 Syndrome • Maitland, 5th ed., 1986 • Describes T4 syndrome as symptoms of an ill-defined nature causing symptoms in the arm or head. • This can apply to any of the segments between T3-T7 • Stralka, April 2000 • Mobilization of T4 decreased pain in patients dx. with Complex Regional Pain Syndrome

  6. Winters, et al., 1997 • Manipulation to surrounding structures in patients with complaints originating from the shoulder girdle are more effective when the shoulder pain is not related to decreased ROM in the glenohumeral joint

  7. Thoracic Position on Shoulder ROM & Strength • McClure & Pratt (1999) • Decreased muscle force and shoulder abduction ROM when the thoracic spine is in a slouched posture • Decreased scapular upward rotation and posterior tilting, and increased superior translation

  8. Intervention • Early Intervention (Treatments 1 & 2) • Manipulation/Mobilizations Thoracic Spine and Ribs • Electric Stimulation • Trigger point stimulation • TENS with ice • Pain range decreased to 0-3/10 • Played in a concert for 2 hours without pain

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