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. 2003;2(2):66–74. doi: 10.1016/S0899-3467(07)60045-7

Case report: Myofascial pain syndrome: a double crush-like appearance

R Kevin Pringle a,*, Daniel L Richardson b, Robert S Shiel c
PMCID: PMC2646961  PMID: 19674598

Abstract

Objective

To discuss the case of a patient with myofascial pain syndrome that appeared similar to double crush syndrome.

Clinical Features

This is a case report of a 45-year old female who presents to the private practice clinic with the same signs and symptoms of carpal tunnel syndrome, 1 year post-carpaltunnel surgery. The history is consistent with injuries that result in double crush syndrome and thoracic outlet syndrome. The patient history includes a motor vehicle accident (MVA) in 1963 that resulted in a prolonged hospital stay and fracture of a cervical vertebral (C4) body. She fractured the olecranon process of the right elbow during a fall in 1970's. She has smoked approximately 1 pack a day for 20 years. Her job involves long periods of sitting at a keyboard and in a car. All of these portions of the patient history are possible factors in the clinical signs and symptoms of double crush syndrome.

Intervention and Outcome

Treatment involved chiropractic manipulation and physical therapy modalities for the elimination of pain and returning the patient's full range of motion in the wrist, elbow, shoulder and cervical spine. After range of motion was restored, a home exercise program was initiated. The home exercise program included a return to past sporting activity and active, resistive (Theraciser band) activities for the elbow and cervical spine. Also a reduction in smoking was initiated as part of the patient's treatment plan.

Conclusion

It is our contention that patients who have electromyographic (EMG) demonstrable carpal tunnel syndrome need a cervical spine workup and a period of conservative care to include skilled manipulation, physical therapy and home exercises before surgery is recommended.

Key Words: Myofascial Pain Syndrome, Double Crush Syndrome, Manipulation, Botanical Therapies, Somatoform Disorders, Doctor-Patient Relations

References

  • 1.Travell JG, Simons DS. Myofascial pain and dysfunction: The trigger point manual. Williams & Wilkins; Baltimore, MD: 1992. [Google Scholar]
  • 2.Simons DG, Travell JG. Myofascial pain syndromes. Textbook of Pain. Chapter 25.
  • 3.Simons DG. Myofascial pain syndrome due to trigger points. International Rehabil Med Assoc. 1987 [Google Scholar]
  • 4.Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanism of myofascial pain trigger points. Arch Phys Med Rehabil. 1998;79:863–870. doi: 10.1016/s0003-9993(98)90371-9. [DOI] [PubMed] [Google Scholar]
  • 5.Hong CZ. Myofascial trigger point injection. Crit Rev Phys Rehabil Med. 1993;5:203–217. [Google Scholar]
  • 6.Hong CZ. Consideration and recommendation of myofascial trigger pint injection. J Musculokel Pain. 1994:229–259. [Google Scholar]
  • 7.Rosen NB. The myofascial pain syndrome. Phys Med Rehabil Clin North Am. 1993;4:159–172. [Google Scholar]
  • 8.Osterman AL. The double crush syndrome. Orthop Clin North Am. 1998;19:147–155. [PubMed] [Google Scholar]
  • 9.Richardson JK, Forman GM, Riley B. An electrophysiological exploaration of the double crush hypothesis. Muscle Nerve. 1999;22:71–77. doi: 10.1002/(sici)1097-4598(199901)22:1<71::aid-mus11>3.0.co;2-s. [DOI] [PubMed] [Google Scholar]
  • 10.Johnson EW. Double crush syndrome: a definition in search of a cause. Am J Physical Med Rehab. 1999;76:439. doi: 10.1097/00002060-199711000-00001. [DOI] [PubMed] [Google Scholar]
  • 11.Wilborn AJ, Gilliatt RW. Double-crush syndrome: A critical analysis. Neurology. 1997;49:21–29. doi: 10.1212/wnl.49.1.21. [DOI] [PubMed] [Google Scholar]
  • 12.Mariano KA, McDouble MA, Tanksley GW. Double crush syndrome: chiropractic care of an entrapment neuropathy. J Manipulative Physiol Ther. 1991;14:262–265. [PubMed] [Google Scholar]
  • 13.Upton A, McComas A. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359–362. doi: 10.1016/s0140-6736(73)93196-6. [DOI] [PubMed] [Google Scholar]
  • 14.Naska AO. The role of thoracic outlet syndrome in the double crush sydrome. Ann Hand Surg. 1990;9:331–340. doi: 10.1016/s0753-9053(05)80506-x. [DOI] [PubMed] [Google Scholar]
  • 15.Flatt DW. Resolution of a double crush syndrome. J Manipulative Physiol Ther. 1994;17:395–397. [PubMed] [Google Scholar]
  • 16.Osterman AL. The double crush syndrome. Ortho Clin North Am. 1988;19:147–155. [PubMed] [Google Scholar]
  • 17.Demopulos GA, Urbaniak JR. Carpal tunnel release: comparing the options. J Musculoskeletal Med. 1996;13:51–58. [Google Scholar]
  • 18.Katz RT. Carpal tunnel syndrome: a practical review. Am Family Physician. 1994;49:1371–1379. [PubMed] [Google Scholar]
  • 19.Davis PT, Hulbert JR. Carpal tunnel syndrome; conservative and nonconservative treatment. A chiropractic physician's perspective. J Manipulative Physiol Ther. 1998;21:356–362. [PubMed] [Google Scholar]
  • 20.Hennessey WJ, Kuhlman KA. The anatomy, symptoms, and signs of carpal tunnel syndrome. Physical Med Rehabil Clin North Am. 1997;8:439–457. doi: 10.1097/00002060-199711000-00004. [DOI] [PubMed] [Google Scholar]
  • 21.Vaughn NM, Pease WS. Postoperative complications of carpal tunnel surgery. Physical Med Rehabil Clin North Am. 1997;8:541–553. [Google Scholar]
  • 22.Kraft GH. Carpal tunnel syndrome in patients with peripheral neuropathy: it can be evaluated and treated. Physical Med Rehabil Clin North Am. 1997;8:577–595. [Google Scholar]
  • 23.Franzblau A, Rock CL, Werner RA, Albers JW, Kelly MP, Johnsto EC. The relationship of vitamin B6 status to median nerve function an carpal tunnel syndrome among active industrial workers. J Occupational Environmental Med. 1996;38:485–491. doi: 10.1097/00043764-199605000-00009. [DOI] [PubMed] [Google Scholar]
  • 24.Greenly LW. Carpal tunnel syndrome. Chiropr Technique. 1998;10:190. [Google Scholar]
  • 25.Schelkun, Steyers PH. Practical management of carpal tunnel syndrome. Physician Sportsmed. 1995;23:83–88. doi: 10.1080/00913847.1995.11947737. [DOI] [PubMed] [Google Scholar]
  • 26.Greensspan J. Carpal tunnel syndrome: A common but treatable cause of wrist pain. Postgrad Med. 1988;84:34–43. doi: 10.1080/00325481.1988.11700489. [DOI] [PubMed] [Google Scholar]
  • 27.Spindler BA, DeBon AL. Nerve conduction studies and testing of carpal tunnel syndrome. J Hand Surg. 1982;7:260–263. doi: 10.1016/s0363-5023(82)80176-7. [DOI] [PubMed] [Google Scholar]
  • 28.Morgan G, Wilbourn AJ. Cervical radiculopathy and co-existing distal entrapment neuropathies: Double-crush syndrome? Neurology. 1998;50:78–83. doi: 10.1212/wnl.50.1.78. [DOI] [PubMed] [Google Scholar]
  • 29.Atasoy E. Thoracic outlet compression syndrome. Orthop Clin North Am. 1996;27:265–303. [PubMed] [Google Scholar]
  • 30.Dawson DM. Entrapment neuropathies of the upper extremities. New England J Med. 1993;329:2013–2018. doi: 10.1056/NEJM199312303292707. [DOI] [PubMed] [Google Scholar]
  • 31.Brown MJ, Asbury AK. Diabetic neuropathy. Am Neurol. 1984;15:2. doi: 10.1002/ana.410150103. [DOI] [PubMed] [Google Scholar]
  • 32.Kumar A, Lennard TA, Margherita A. Extremity trauma in motor vehicle accidents. Physical Med Rehabil: State of Art Reviews. 1998;12:99–109. [Google Scholar]
  • 33.Vender MI, Truppa KL, Ruder JR, Pomerance J. Upper extremity compressive neuropathies. Physical Med Rehabil: State of Art Review. 1998;12:243–262. [Google Scholar]
  • 34.Huffman JD. Electrodiagnostic techniques and conservative treatment of thoracic outlet syndrome. Clin Orthop. 1986;207:21–23. [PubMed] [Google Scholar]
  • 35.Karas SI. Thoracic outlet syndrome. Clin Sports Med. 1990;9:297–310. [PubMed] [Google Scholar]
  • 36.Twogood DA. Carpal tunnel syndrome: A new way of thinking. Am Chiropr. 1998;20:42–43. 47. [Google Scholar]
  • 37.Golovchinsky V. Double crush syndrome in lower extremities. Electromyogr Neurophysiol. 1998;38:115–120. [PubMed] [Google Scholar]
  • 38.Simpson Rl, Fern SA. Multiple compression neuropathies and the double crush syndrome. Orthop Clin North Am. 1996;27:381–388. [PubMed] [Google Scholar]
  • 39.Karas SE. Thoracic outlet syndrome. Clin Sports Med. 1990;9:297–310. [PubMed] [Google Scholar]
  • 40.The medical advisor. The complete guide to alternative and conventional treatments. Time-Life Books. 1996:234–237. [Google Scholar]
  • 41.Nichols HM. Anatomic structures of the thoracic outlet. Clin Orthop. 1986;207:13–20. [PubMed] [Google Scholar]
  • 42.Kapetanos G. The effect of the local corticosteroids on the healing and biomechanical properties of the partial injured tendon. Clin Orthop. 1982;163:170–179. [PubMed] [Google Scholar]
  • 43.Sucher BM. Thoracic outlet syndrome-a myofascial variant: Part 2. Treatment. J Am Osteopath Assoc. 1990;90:810–845. [PubMed] [Google Scholar]
  • 44.Sucher BM, Heath DM. Thoracic outlet syndrome-a myofascial variant. Part 3. Structural and postural considerations. J Am Osteop Assoc. 1993;93:334. 340–5. [PubMed] [Google Scholar]
  • 45.Rydevik BL. The effects of compression of the physiology of nerve roots. J Manipulative Physiol Ther. 1992;15:62–66. [PubMed] [Google Scholar]
  • 46.Sunderland S. Brachial plexus injuries. Clin Neurol Neurosurg. 1993;95(Suppl):S1–S2. doi: 10.1016/0303-8467(93)90026-d. [DOI] [PubMed] [Google Scholar]
  • 47.DeFranca GG, Levine LJ. The T4 syndrome. J Manipulative Physiol Ther. 1995;18:34–37. [PubMed] [Google Scholar]
  • 48.Maitland GD. Vertebral manipulation. 5th Ed. Butterworth; Boston, MA: 1986. p. 344. [Google Scholar]
  • 49.McGuckin N. Modern manual therpay of the vertebral column. In: Grieve GP, editor. The T4 Syndrome. Churchill Livingstone; New York, NY: 1986. p. 238. [Google Scholar]
  • 50.Grieve CP. Common vertebral joint problems. Churchill Livingstone; New York, NY: 1983. p. 238. [Google Scholar]
  • 51.Chamberlain GJ. Cyriax's friction massage: a review. J Orthop Sports Physical Ther. 1982;4:16–22. doi: 10.2519/jospt.1982.4.1.16. [DOI] [PubMed] [Google Scholar]
  • 52.Idler RS. Persistence of symptoms after surgical release of compressive neuropathies and subsequent management. Orthop Clin North Am. 1996;27:409–416. [PubMed] [Google Scholar]
  • 53.Kleinman A. The illness narratives: Suffering, healing and the human condition. Basic Books; New York, NY: 1988. [Google Scholar]
  • 54.Ware NC. Suffering and the social construction of illness: The delegitimation of illness experience in chronic fatigue syndrome. Med Anthropology Quat. 1992;6:347–361. [Google Scholar]
  • 55.Riley TL, Roy A. Pseudoseizures. Williams & Wilkins; Baltimore, MD: 1982. [Google Scholar]
  • 56.DSM-IV. American Psychiatric Association; Washington, DC: 1994. [Google Scholar]
  • 57.Gunn CC. Prespondylosis and some pain syndromes following denervation supersensitivity. Spine. 1980;5:185–191. doi: 10.1097/00007632-198003000-00014. [DOI] [PubMed] [Google Scholar]
  • 58.Chang MH, Chiang HT, Lee SSJ, Ger LP, Lo YK. Oral drug choice in carpal tunnel syndrome. Neurol. 1998;51:153–156. doi: 10.1212/wnl.51.2.390. [DOI] [PubMed] [Google Scholar]
  • 59.Katzung B. Basic and clinical pharmacology. 7th Ed. Appleton; Connecticut: 1998. [Google Scholar]
  • 60.Seaman DR. Clinical nutrition for pain, inflammation and tissue healing. NutrAnalysis; Hendersonville, NC: 1998. [Google Scholar]
  • 61.Werbach MR. Healing through nutrition. Harper-Collins; New York, NY: 1993. [Google Scholar]
  • 62.Werbach MR. Nutritional influence on illness: A sourcebook of clnical research. 2nd Ed. Third Line Press; Tarzana, CA: 1987. [Google Scholar]
  • 63.Ray O. Drugs, society and human behavior. Mosby Company; St. Louis, MO: 1983. [Google Scholar]

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