HISTORY: 33-year-old professional rock climber presents with one month of right arm weakness and pain impairing climbing performance. He initially experienced sharp, right shoulder pain with a maneuver requiring arm abduction. He then developed weakness limiting the ability to pull with his right arm. A pull test was performed with a 94 lb pull force on the right compared to 140 lb on the left. Associated symptoms included painful radiation extending from the right lateral neck into posterior upper arm, dorsal forearm, and hand with tingling in digits 1-3 of the right hand.
PHYSICAL EXAMINATION: Full strength in all muscle groups of the right upper extremity except for 4/5 shoulder external rotation. Sensation intact to light touch in all dermatomes. Upper extremity deep tendon reflexes were 2+ and symmetric bilaterally. Negative Hoffman’s bilaterally. Cervical evaluation revealed full active range of motion with pain in flexion and extension. Spurling’s test was positive for radiation into the right upper extremity. Shoulder impingement signs were negative.
DIFFERENTIAL DIAGNOSIS: 1. C6 Radiculopathy 2. Brachial Neuritis 3. Brachial Plexopathy 4. Suprascapular Neuropathy
TEST AND RESULTS: Cervical spine radiographs: -No acute fracture -Normal alignment of cervical vertebrae -Mild loss of disc height at C5-C6 -No dynamic instability with flexion and extension Cervical Spine MRI: -Mild disc degeneration notable at C5-6 -Disc osteophyte complex at C5-6 extending to the right foramen with moderate right foraminal stenosis Right Upper Extremity EMG: -Right C6 radiculopathy primarily affecting the forearm musculature (pronator teres) and cervical paraspinal musculature with active and chronic denervation changes.
FINAL/WORKING DIAGNOSIS: C6 Radiculopathy
TREATMENT AND OUTCOMES: 1. 8 weeks of physical therapy including nerve gliding, mobility, and strength exercises with resolution of pain but persistent weakness. 2. Continued tracking of objective data measuring pulldown force without improvement. 3. Discussed surgical referral versus C6 Transforminal Epidural Steroid injection. Patient elected to undergo C5-6 foraminotomy and disc replacement. 4. Full return to activity is to be determined. Patient and care team remain optimistic regarding a return rock climbing in the near future.