Neurologist Dr. Sluss sent me to this physician as Dr. Sluss concluded I had myofascial pain! No MRI of my Thoracic spine other than an XRAY!
Here is Dr. Lester Owens treatment notes. Another runaround instead of finding the Thoracic Arachnoid wen/cyst. what happened to the positive hyperextension signs and the babski's signs from the neurologist Dr. Sluss tests??? I guess we just forget that info?
It is nice to have this 20 - 20 vision now but you have got to wonder why you would not pickup where the last guy found positive signs of a neuro issue?
4/1/92
Rehabilitation Resource Group, Ltd.
Lester A. Owens, D.O.
CONCLUSIONS:
1. Acute exacerbation of levator scapulae, middle trapezius, and rhomboid myofascial strain, with reflex myalgia.
RECOMMENDATIONS: A trigger-point injection in the levator scapulae, middle trapezius and rhomboid triggers was performed today, followed by spray and stretch techniques. He would benefit from a brief course of neuroprobe, spray and stretch techniques, and myofascial—release techniques.
This appears to be a temporary aggravation of a chronic, recurring condition. He will be given specific exercises and techniques that he can perform at home for the current problem and to prevent or minimize recurrences.
CHIEF COMPLAINT: Mr. xxxx is a 37-year-old white male who with chief complaints of pain over the posterior neck and medial scapular border, with referred pain into the left posterior arm. He has constant burning, aching discomfort over the medial periscapular region, which is sharp, when he uses his left upper extremity out in front of him or overhead. He denies any numbness, tingling, or paresthesias. He denies any upper—extremity weakness. Coughing and sneezing do not cause radicular pain.
ONSET: He states he has a history of similar complaints occurring approximately 8 years ago. He was seen by Dr. Rotkis, a physician in Tucson. He was diagnosed as having an acute myalgia. He was given a trigger-point injection, which provided dramatic relief. He underwent additional workups, including a lumbar spinal tap. Results of those studies are unknown.
He comes in today with complaints of acute pain in the left intrascapular region, which he states presented this morning. He states last night, he was working overhead in the basement of his home. He states he woke up this morning, took a shower, and upon reaching with his left an, he developed acute pain. He indicates he had some intermittent discomfort in the neck and left shoulder girdle area for the past 8 years, but it hasn’t been as severe as its initial onset 8 years, while he was living in Tucson. He did not seek any medical attention for this intermittent discomfort.
He states he has been quite active, he golfs, runs, skis, etc. In the past 8 years, he has experienced increased discomfort and neck pain while doing these activities, but generally the pain subsided with bed rest and careful use of the left arm for a few days to a week.
He states he subsequently relocated to Green Bay, Wisconsin, from Tucson, Arizona, in 9/90. He has been under Dr. John Brusky’s care, his family physician, who referred him to Dr. Pat McKenzie. Dr. McKenzie referred Mr. xxxx to Dr. Sluss.
Dr. Sluss contacted me today regarding Mr. xxxx. His MRI scan was normal. No other neurological findings were noted and it was his opinion, that his pain was primarily myofascial and soft-tissue in nature. He referred Mr. xxxx to me for further evaluation, treatment, and possible trigger-point injections.
Mr. xxxx comes in today for this evaluation.
PAIN ANALYSIS: The patient states he has constant sharp pain in the left posterior neck and left posterior shoulder. He states he has intermittent left—upper—an soreness. He denies any upper— extremity paresthesias. On a scale of 0 to 10, with 10 being the worse pain the patient can possibly imagine, the current pain is 8/10, worst 8/10, best 0/10. Activities that increase pain are driving, jarring his neck, and flexing his head forward. Nothing decreases his pain.
PAST MEDICAL HISTORY:
Medical problems: He denies any previous work—related injuries to the back, neck, or shoulder. He states his general health is good.
Family history: Denies.
Previous surgeries: He states he had his right eardrum repaired and has a 20 percent loss of hearing in the right ear.
Fractures and dislocations: fractured nose.
Accidents and injuries: Denies.
Psychiatric history: Denies.
REVIEW OF SYSTEMS:
HEENT: neck pains, hearing difficulties
Respiratory: Negative
Cardiovascular: Heart murmur.
Skin: Negative
Neuro: Negative
CI: Negative
CU: Negative
Musculoskeletal: fractures, neck or shoulder pains
CURRENT MEDICATIONS: Lodine-300 mg BID.
ALLERGIES: No known allergies.
PERSONAL HISTORY: He is married and his wife works part-time. She is in good health. Children: 0. Education: 4 years of college. Military Service—1975 to 1979 served in the U. S. Air Force and received an honorable discharge.
HABITS: Ethanol—2 to 6 drinks per week, tobacco-denies, coffee—2 cups daily, soda—minimal
HOBBIES: Downhill skiing and golfing
JOB ANALYSIS: He works as a mechanical engineer for xxxx Engineering, Green Bay, Wisconsin. He works full—time, 40 hours per week, 7 a.m. to 4 p.m., Monday through Friday. No lifting is required. He works with blue prints and plans for machines.
PHYSICAL EXAXINATION: This is a well—developed, well-nourished, white male who appears pleasant and cooperative in nature. He has some mild discomfort and pain behaviors are noted. The patient has a mesomorphic body build. Height is 5’B” and weight is 176 lbs. Head is norinocephalic. Eyes are PERRLA-EOMI. Neck is supple. Trachea is midline. No thyromegaly, carotid bruits, or lymphadenopathy is noted. Active neck ROM for flexion is 0—45 degrees (pain reported in the left posterior shoulder and neck) extension 0—40 degrees, right lateral side bending is 0-35 degrees with pain reported in the left side of the neck and left lateral side bending 0—50 degrees, right and left rotation 0—75 degrees. T—spine right and left rotation is 0—30 degrees. Thoracolumbar spine shows no significant kyphosis or scoliosis. L— S spine flexion is 0—80 degrees, extension is 0—60 degrees, right and left lateral side bending is 0-40 degrees. ROM of the shoulders, elbows, wrists, MCP, PIP, DIP joints, hips, knees, and ankles is within normal limits. No redness, swelling or joint deformity is noted. When standing, his left shoulder is retracted. The peripheral pulse (femoral, popliteal, DP, TP, and radial) are present and within normal limits.
PALPATION: Posterior cervical neck-tenderness on the left side (C4); Trapezius—tenderness on the left side; Levator scapula— tenderness and increased tone on the left side.
NEUROLOGICAL EXAMINATION: Cranial nerves II—XII are grossly intact. Motor examination of the upper and lower extremities is grossly intact. No gross muscle atrophy or asymmetry is noted. Muscle strength of the deltoids, biceps, triceps, extensor carpi radialis, abductor pollices brevis, first dorsal interosseus, quadriceps, anterior tibialis, vastus medialis, extensor hallucis longus, and gastrocnemius/soleus muscles are 5/5 and within normal limits. Pain reported with resisted left-upper-extremity movements. Gait is unremarkable. Thoracic outlet syndrome maneuvers are all negative. There were no upper or lower motor neuron signs noted. There were no upper or lower motor neuron signs noted. Negative Tinel’s and Phalan’s signs.
Lester A. Owens, D.o./smb
cc: Dr. Sluss
Dr. John Brusky