HPI
A 56 year old woman presents with a chief complaint of progressive polyarthralgia, or in her own words, “pain which has been on and off for a long time”. Her symptoms seem to have started after a right sided shoulder injury one year ago when travelling with some heavy baggage. She commenced physiotherapy at the time for what was described to her as a “partial tear of her rotator cuff”, but has since felt her left shoulder become progressively worse, and has recently been experiencing radiculopathy into her left arm and side of neck. 3 months ago she began to experience bilateral knee pain which she describes as “achy” and worse on right side, and 1 month ago her hips bilaterally began to experience pain & stiffness as well.
The pain in her shoulders and knees is worse with activity (walking, using stairs or carrying heavy things), overexertion, or pressure on the joint and she does experience any morning stiffness. Her hips become aggravated when sitting for extended periods of time. Muscle guarding and hypertonicity seems to be contributing to her physical complaints. There are no signs of joint enlargement or obvious signs of inflammation.
Her secondary complain is sleep maintenance insomnia which seems to have correlated with menopause which took place for her 2 years ago. She describes being able to fall asleep ok, but quite often will wake up between 3-5 AM with leg cramping, and then struggles to fall back asleep before her alarm goes off at 6 AM. On these mornings she describes her mind as feeling groggy, her energy levels to be low, and her mood to be irritable. In general, she expresses that she has become more sensitive/emotional since menopause (2 years ago).
She is otherwise in good health and is interested in therapeutic and preventative strategies available to stop the progression of her MSK pain as it has begun to interfere with activity levels and overall quality of life.
Past medical history includes a cesarean section 24 years ago, and two spontaneous abortions within the past 30 years.
Family history of heart disease & diabetes on maternal & paternal sides.
Social history: Originally from Iran, lived in Africa & India for 25 years (most of family still overseas). Devoted to her family with strong religious faith & values. No smoking, alcohol or drug use. Enjoys taking long walks (1-2 hours) and playing badminton with her sons.
Digestion: BM 1-2x/day – can be looser, “piecey”. Occasional excess gas, bloating, flatulence & burping. Diet is vegetarian – lots of grains, vegetables, dairy, legumes, fruit, salad, and the occasional treat. Drinks 2-3 cups water/day, herbal tea occasionally, and coffee weekly.
Medications: None. NKDA.
Physical exam
- No palpable or observable joint abnormalities, nodules or signs of inflammation.
- Hypertonicity of trapezius, deltoid, SCM, scalenes, rhomboids & biceps bilaterally.
- Pes planus bilaterally
Shoulder Ax:
- Muscle strength all fields 4/5
- Diminished pulse bilaterally when head turned both to left & right sides
- Right side: pain with numbness & radiation into fingers with resisted flexion & pain in deltoid at 135 degrees with passive abduction
- Left side: pain with passive & resisted abduction
Knee Ax:
- No crepitus, locking, or pain with patellar tracking or valgus/varus gapping
- Muscle strength (knee & hip) 4/5 all fields
- ITB non-contracted
Spinal Ax:
- Right SI restriction
- Right side T3-4 costal subluxation
- Upper thoracic extension restriction
Visual acuity: R 20/50, L 20/70
Oral: mercury amalgams, 2-3 on L & R upper molars.
Abdominal exam: Tympany all 4 quadrants, pain on light & deep palpation in all 4 quadrants – esp epigastric & periumbicular region.
Vitals: BP 106/86, T 36.2 oral, HR 60 bpm
Labs and Imaging
No labs ordered at initial visit.
Working diagnosis and interpretation
- Polyarthralgia (shoulders, knees & hips b/l) with resultant structural imbalance leading to chronic postural stress
- DDx: Polymyalgia Rheumatica, Polymyositis, Fibromyalgia, Osteoarthritis Reflex Sympathetic Dystrophy, Thoracic Outlet Syndrome with radiculopathy due to first rib compression of peripheral nerve or other structural anomaly.
- Sleep Maintenance Insomnia due to Restless leg syndrome
The patient’s multiple joint pain appears to be due to various structural imbalances leading to postural stress on the joints. Her injury 1 year ago has led to various compensatory reactions by the body such as muscle guarding and tension surrounding joint capsules of the upper extremities. There appears to be an underlying inflammatory condition at the root of her case. Possible dysbiosis d/t hypochlorhydria or food sensitivities may be contributing factors, as mineral absorption (Calcium, Magnesium, potassium, Iron) appears to be somewhat compromised (muscle cramping).
Currently it seems that physical therapies will be of greatest therapeutic value. Stress reduction and deep breathing techniques, establishing a daily routine to align and promote healing in the body to avoid undue stressors on the body. Shifting the nervous system away from a sympathetic state will promote healing at a deeper level, while manual techniques will nurture physiological imbalance. Laboratory testing may be warranted in the future if her symptoms continue to worsen (CBC, ferritin, FBG, HgA1C, liver & lipid panels, ANA antibodies, IgG food Sensitivity testing)
Treatment Plan
- Lifestyle: Spinal manipulation, soft tissue massage, stretching & deep breathing exercises.
- Dietary: Avoid dairy completely & limit grains (especially gluten). Add more microbiome supportive foods, rich in pre-biotic fiber. Increase water intake
- Supplemental: Calcium 500mg, Magnesium 500mg Omega 3 Fatty Acids 3 g – daily. Probiotic—Bifidbacterium bifidus, Lactobacillus acidophilus 1:1—60 billion CFU daily to repopulate micobiome.
- Herbal:
- Anti-inflammatories – Turmeric (12 g/day)
- Antispasmodics & Nervine Relaxants – Kava Kava (3 g before bed, if well tolerated increase 6 g before bed).
- Connective Tissue Tonics – Gotu kola (10 g), Grapeseed extract (14 g), Ginkgo (4 g) daily.
Progress:
1 month follow up
Felt instant relief after spinal manipulation which was maintained for ~ 2 weeks. Went for a deep tissue massage 2 days ago which was painful at the time but seems to have brought overall added relief to muscle tension alongside the Kava. Improvements in sleep, irritability & severity of RLS were noticed after 4 days with the introduction of Kava, and she has been able to commit to a stretching & deep breathing practice at least 3 times a week. Patient has made minimal changes to diet (is limiting both gluten & dairy). She has been taking Cal-Mag, probiotic, and Kava Kava consistently, but has been inconsistent with the Omega 3, Turmeric & Gotu kola.
2 month follow up
Patient has been able to commit to monthly massage and spinal manipulations which have improved overall muscle tension, shoulder & neck discomfort. Radiculopathy is still occasionally present, but less frequent and severe. Is currently in the middle of a 30 day meditation challenge and has found it to be useful and enjoyable. Knee pain and hip stiffness seems to have improved after 4 weeks of consistent use of Omega 3, Turmeric & Gotu kola. Advised patient to reduce by half Turmeric, Gotu Kola, Grapeseed extract & Ginkgo dose daily. Bowel movements appear more well-formed. Has continued to limit but not eliminate dairy & gluten, but has committed to eating more veggies & fermented foods and increasing her water intake to 6-8 glasses per day.
3 month follow up
Joint pain, muscle tension & radiculopathy has reduced significantly from first visit, but remains present when overexerted. The patient is able to play badminton once a week now without pain. Suggested hatha yoga at least once a week to continue stretching, strengthening & breath work. Has maintained consistency with Turmeric, Gotu kola, Omega 3 & Cal-Mag daily. Takes probiotic every other day, and Kava now only on nights where “she feels she needs it”. Still struggling with dietary changes but has agreed to a 2 week elimination of dairy to see if she notices any significant changes to the form of her stools which are still sometimes unpredictable.
