Osteopoikilosis in a patient with frozen shoulder – a case review of a rare incidental radiographic finding.

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Osteopoikilosis, known as ’spotted bone disease’, is a rare and usually asymptomatic bone disorder but can be associated with malignant bone tumours. We present a patient with type I diabetes and Frozen Shoulder that was diagnosed with osteopoikilosis as an incidental finding when assessed radiographically. The radiographic features of this pathology are highlighted and the investigations described to exclude more sinister pathology. One of the usual diagnostic criteria of Osteopoikilosis is normal alkaline phosphatase blood levels however this is the first report of a patient whose alkaline phosphatase levels were persistently raised. This was attributed to diabetes. Raised alkaline phosphatase levels of an unknown cause have been previously reported to be a common finding in this patient group.

Successful physical therapy treatment using high-velocity low-amplitude thrust manipulation of a patient with neck pain scoring sub-optimally on cervical and thoracic clinical prediction rules for manipulative therapy

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This case report describes successful outpatient physical therapy intervention (including High Velocity Low Amplitude Thrust (HVLAT) spinal manipulation) of a 43 year-old female patient with neck pain who did not fit ideal clinical prediction rule criteria for thoracic or cervical manipulation following an initial unsuccessful course of physical therapy. Following patient report of “0% improvement” in a physical therapy clinic that did not include HVLAT, patient care was transferred to a different clinic and the patient received physical therapy care that included HVLAT for 10 sessions. During that time, neck disability index scores decreased from 76% to 18%, meeting previously established criteria for minimally detectable change as well as clinically meaningful change. Cranio-cervical flexion test abilities improved from 18mmHg to 28mmHg, active cervical rotation improved from 45 degrees bilaterally to 85 degrees bilaterally, and neck pain had decreased from 7/10 to 0/10 on a Numeric Pain Rating Scale. Functionally, the patient re-acquired the ability to work an 8 hour shift of manual labor, to turn her head and back out of the driveway with her car, and to sleep through the night without waking in pain. The potential relative importance of non-clinical psychosocial factors in the prediction of outcome in patients who do not ideally fit clinical prediction rules is discussed.

A case of long thoracic nerve palsy

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A 31 year old male developed unilateral neck pain associated with increased kyphotic posture 24 hours after having general anaesthesia for ankle surgery. The pain and postural adaptation resolved, but a painless shoulder dysfunction developed. Following assessment a provisional diagnosis of long thoracic nerve palsy was made, and a ‘wait and see’ approach to management was taken. The dysfunction gradually resolved over a 12 month period without further investigation or intervention. The case study is discussed in light of possible neurophysiological mechanisms involved and of published literature on the management of long thoracic nerve palsy.

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