Don’t Let Diagnosis Dissuade Deeper Communication

Luckily, she didn’t see my eyes when I read her text. In the text, the physical therapist asked if I would be willing to see one of her clients who had been diagnosed with Parsonage-Turner syndrome. I must have re-read the text three times. This was a syndrome I had never heard of, so agreeing would be a tacit acknowledgment that I might be able to help. Since she was referring him, at least she thought so!

I arranged to see him in our team environment, where two of my staff would be with me in the session. They, like myself, had done some prior research on the condition and were curious to know more about my experience with Parsonage-Turner syndrome. I think they were a bit concerned when I revealed I had never heard of the condition before this referral.

“Here’s what I know,” I assured them, “before we go down a path of creating an exact approach to this specific syndrome, let’s step back and listen to the client’s description of symptoms. Let’s keep a beginner’s mind and be open to all possible explanations. Instead of a client with Parsonage-Turner syndrome, let’s focus on the person in pain, hear his description of symptoms, and understand more about his journey to our table.” 

A Winding Road

And what a journey it was. As he described, he had not been much of a fitness enthusiast before he was somehow introduced to boxing, which he absolutely loved. He pursued it intensely but began having shoulder symptoms two years ago. Trying to push through it was a mistake, and symptoms intensified. He developed intense pain in the left shoulder and tingling and numbness down the arm, which often made changing sleeping positions very painful. 

Even when someone presents with a diagnosis, be open to listening to symptoms and constructing an approach in response.

He sought the help of multiple doctors and received more than 100 physical therapy sessions and four cortisone injections. Three months before our appointment, a surgeon performed a subacromial decompression; sadly, the client was much worse after the surgery. Going back to the surgeon for follow-up, that’s when the diagnosis of Parsonage-Turner syndrome arose, which the physician said is rare but possible after surgery.

This client’s sense of hopelessness was not indirectly connected to the physician stating that very little could be done and that it would likely get worse over time. The physician’s parting statement was, “Good luck.” I’d be devastated hearing that too. 

The client had mentioned some cervical discomfort on the left, and we began there, focusing on the C4–6 segments because those nerve roots most directly affect the brachial plexus. We then followed that anteriorly to the scalene muscles, hoping to affect the brachial plexus at that level. Approaching the upper arm, he described his most distressing symptom, a somewhat random but very intense pain in the deltoid area that happened when he raised his arm, especially if there was internal or external rotation involved. He estimated this happened at least 30 times a day and randomly at night. Each arm movement was preceded by the fear of another sharp pain. Exploring the deltoid muscles, it was difficult to isolate a specific problem area. 

The second session followed a similar protocol to the first, but during the third session, he demonstrated one motion that was consistently problematic. Lying prone, he could not externally rotate his humerus, which points directly to the infraspinatus. As one of my staff was treating the infraspinatus, I realized that a potential explanation for his symptoms was compression of the axillary nerve and/or posterior humeral circumflex artery in the shoulder’s quadrilateral space, which can result in poorly localized pain, neural symptoms down the arm, and weakness in external rotation. Boxing biomechanics can also stress this area, so that was a match. While we still treated structures affecting the brachial plexus, 80 percent of our time was focused on relieving any entrapment in the quadrangular area. 

The result? By session number five, his random shooting pains in the shoulder decreased from 30 times a day to multiple days without a single occurrence. His symptoms were so much better that we decided to wait three weeks to meet again. I fully expect him to continue to improve and make progress with strength and his ability to resume activity. As you might expect, he’s a happy guy. 

Keep Asking Questions

There are several lessons here, but perhaps the primary insight is that even when someone presents with a diagnosis, be open to listening to symptoms and constructing an approach in response (as long as nothing is contraindicated relative to the original diagnosis). For example, calling a pain down the lower extremity “sciatica” implies that the ultimate cause is in the lumbar spine. There are a multitude of reasons to have pain down the leg, and lumbar issues are only one of them. To fixate on lumbar sources because of the name blinds us to other possibilities. 

Secondly, to be effective requires a deep knowledge of the potential role of soft tissue in the client’s presenting symptoms. This is why we study: to prepare to meet the moment when someone like this client is on our table. With deep knowledge and excellent palpation, we can offer hope and healing to people who have fallen through the cracks of our health-care system.