Lawyers often think of soft tissue injury cases as hard to prove cases. The client is complaining of severe pain. There is little in the way of visible injury or objective findings and it’s difficult to convince a suspicious adjustor or jury. When you look at jury awards for soft tissue injury cases, a different story begins to unfold. Many settlements in jury awards are substantial in cases that are well documented and explained. To properly document and explain a soft tissue injury, you need to understand the objective and subjective tests, relevant medical history and physical examination results physicians rely on to reach a diagnosis and prognosis and have a basic understanding of the anatomy and physiology of soft tissue.
Soft tissues are muscles in their fascia, tendons, the fibrous bands of tissue that connect muscles to bones, ligaments which connect bones to other bones and stabilize joints, bursa, cartilage and discs which support the bony skeleton, the epithelium or cells that line most of the hollow structures within the body like internal organs and blood vessels and the organs themselves. One of the difficulties in soft tissue injury is that lawyers may rely too heavily on a client’s complaints of pain as proof of injury. The treating physician may only conduct an elementary examination without making a concrete diagnosis, leaving the attorney with little if any objective evidence of serious injury.
While injuries like fractures can be demonstrated by x-ray, the medical proof of soft tissue injuries . Often, requiring a combination of diagnostic techniques and an understanding of how soft tissue responds to and heals after trauma. In cases where there are few objective findings, you may be forced to rely on observations of the client, the client’s description of pain and a description of the trauma, which cause the pain. In a case where pain is the primary reason for disability, the attorney must understand how pain works in the body and what kind of pain is related to a particular soft tissue injury.
Injuries to the disc and the nerve roots that exit the spine are a significant percentage of soft tissue injury cases. The spine is made up of vertebrae, seven cervical, 12 thoracic, five lumbar, five sacral, and four coccygeal. The vertebrae are bones but soft tissues surrounds them. The vertebrae are connected by ligaments on all sides. Nerve roots exit from each side of the spinal column and the vertebrae are separated by intervertebral discs. The discs consist of the external annulus fibrosis and an inner spongy material called the nucleus pulposus.
Common disc injuries include herniation or rupture of the annulus fibrosus, which allows the nucleus pulposus to escape and press on a nerve root. Herniation can be caused by a sudden strenuous action by trauma and by degenerative changes that take place during the aging process. The lumbar and sacral areas have the highest incidence of herniation, most commonly at L4-L5 or L5-S1. This is because it’s the highest motion segment. Pressure on the nerve root can cause pain along the path of the nerve and can interfere with muscle strength. In a bulging disc, the nucleus pushes the annulus beyond its normal boundaries, but the annulus is not ruptured. The bulge may press on the nerve root causing pain and muscle weakness. In a disrupted disc, the annulus fibrosus may appear intact. However, the internal material may have a radial fissure which extends to the innervated outer third of the annulus fibrous.
Dr. Stern: This gentleman was injured carrying a 75-pound water bottle and five months later has pain running down from the back to the ankle. First we’d like to examine your back, if you could just turn around. I’m palpating the paraspinal muscles for spasm. Is that sore?
Male 1: Yeah.
Dr. Stern: Spasm can be indicative of nerve root irritation as well as injury to the muscles themselves, sometimes with bleeding within the muscle. Palpating the spinous processes is usually not painful in a disc problem, but can be painful in a ligamentous injury. Can I ask you to lay down on the pillow face up? We’ll first be examining for nerve root irritation by using the straight leg raising test. Does that hurt you?
Male 1: Yeah.
Dr. Stern: When straight leg raising is positive, pain runs down the leg, sometimes into the foot and usually mimics the pain that the patient is feeling in their daily activities. Pain in the back alone is not a positive sign on straight leg raising. In addition, occasionally you can have cross over pain where lifting the opposite leg… does that cause pain?
Male 1: Yeah.
Dr. Stern: It can cause pain running down the injured leg.
Dr. Pierson: When a patient comes to me complaining of back pain and pain radiating down the leg, I have to suspect that the patient may have a nerve root compression on the lumbar spine. That pain will generally radiate in a dermatomal fashion. That is along an area of skin that’s supplied by a specific nerve root that’s potentially being compressed. Why don’t you tell me where you are experiencing this pain?
Male 2: Well. My lower back hurts. That’s where it starts and it goes down to my buttock and then all the way down my left leg.
Dr. Pierson: And along the outside of the leg or the back of the leg?
Male 2: Right on the outside of the leg and then straight down. All the way down.
Dr. Pierson: Okay. Do you have any weakness that goes along with this?
Male 2: Yeah. The left leg will give up. Give up.
Dr. Pierson: Okay. And is there any area on the left leg that feels numb to you?
Male 2: Just…
Dr. Pierson: Is it numb anywhere where the pain is?
Male 2: Yeah, on the outside basically of the leg.
Dr. Pierson: I see. Okay.
Male 2: And all the way down to the bottom.
Dr. Pierson: All right. When I examine the patient, what I begin to look for are signs of any muscle wasting or atrophy, as well as objective findings on sensory examination and reflex testing. So the first area that I would start with is motor testing. I’m going to have you lift this knee and touch my hand please. Lift up your knee here and touch my hand. Just like that. Great. Hold strong now. Hold strong. Good. All right. Now, that’s the muscle that’s supplied by the higher lumbar roots. We are going to come down here to the quad muscle, which is supplied by the L4 root.
Can you kick that foot out? Kick it out and touch my hand and hold strong. Good. Very good. And now, I want you to bring your foot up. Okay. And keep the big toe up in the air. Hold up there and hold it strong. Don’t even push it down. This muscle is supplied by the L5 root. And now, this time I want you to just step on my hand like you’re pushing on a gas pedal. Real hard. And that is the S1 or first sacral nerve root. The next part of the examination for lumbar radiculopathy will be to check reflexes. These can be checked side to side.
First of all, the L4 or knee jerk on both sides looking for any asymmetry of the knee jerk, which would indicate damage to the nerve root. And then secondly, the sacral, first nerve root, which is represented by the ankle jerk. The final portion of the lumbar radiculopathy examination would be to check pinprick sensation in all the dermatomes of the lower extremities. I start by checking the second lumbar dermatome, which is high in the thigh. Do you feel the same on each side when I test you with a pin? Sorry.
Male 2: No. I feel more on the right part of the…
Dr. Pierson: Sharper on the right?
Male 2: Yeah.
Dr. Pierson: Okay. How about here? Is that as sharp as over here?
Male 2: It’s sharper on the right side.
Dr. Pierson: Okay. Good. And now, we’ll check down here, here and here. Is it the same?
Male 2: I can almost not feel it.
Dr. Pierson: Okay. How does the pin feel on this side, the other side? Okay.
Male 2: Terrible.
Dr. Pierson: Okay. Along the L4, does that feel sharp? Is it sharp on this side too?
Male 2: It is sharp.
Dr. Pierson: Okay. How about here in the back, sharp?
Male 2: Yeah.
Dr. Pierson: Sorry. Sharp on this side? Okay. So the S1 nerve roots are also equal side to side. The last thing that I’m going to check for is a straight leg raise test in order to see if the sciatic nerve is irritated. So I’m going to just have you bring your leg up like this. Okay. And tell me, do you get any pain down your leg when I do this?
Male 2: No.
Dr. Pierson: Okay. How about on this side? Bring your leg up. How does that hurt you?
Male 2: A little.
Dr. Pierson: Good. Okay. Very good. That would be interpreted as a positive straight leg raise on the left side. Objective findings on a lumbar radiculopathy examination include muscle atrophy and loss of reflex in the lumbar level that’s in question. If a patient gives a consistent sensory examination where they report reliably, the pinprick is down in a certain dermatome, this can also be very useful. And finally if the patient seems to be giving a good effort and is demonstrating weakness in the muscle supplied by the nerve root in question, then you can be sure that you may be dealing with radiculopathy.
Objective test that may be helpful in supporting the diagnosis include EMG, which is an electro-physiologic and dynamic test of nerve root compression. Findings on that examination would show denervation or abnormal potentials in the muscles that are supplied by the nerve root. And MRI is also a very useful test and can show compression of the nerve root as it exits through the neural foramina. It may show disc herniation as well.
Facilitator: There are 12 pairs of cranial nerves. They affect our ability to smell, see, move our eyes, tongue, shoulder and head, cry, chew, swallow and balance. Injuries to these nerves can be devastating. Only the peripheral nerves outside the brain and spine can regenerate and are amenable to surgical repair. In crush injuries, individual fibers within a peripheral nerve may be severed while the trunk remains intact. New fibers may regenerate along the channels left by the degenerated fibers if the ends of the fibers are aligned.
Depending on prognosis, crush injuries can lead to permanent loss of muscle strength and sensation. When nerves are completely severed, the fibers try to regenerate, but cannot without directing channels. The fibers may bunch up and form a lump of tissue so that no recovery takes place. Cut nerves require surgical repair and recovery is rarely complete.
Dr. Pierson: Can you tell me what’s troubling you?
Male 2: Well Doctor, I had a… I had an accident at work. And my left leg was in a cast for about six weeks. It’s been off for two months. And when I walk, I drag my left foot. I can’t… I can’t lift it, move it like the other, like the right. And I have numbness too.
Dr. Pierson: Where is the numbness in the leg?
Male 2: In the left foot.
Dr. Pierson: Okay. What this history suggests to me is that this patient may have suffered some type of compression neuropathy to the peroneal nerve, which would be just under where the cast is placed. This may manifest with weakness and atrophy in the foot as well as along the muscles of the calf. And additionally the patient will complain of loss of sensation in the skin that’s supplied by the peroneal nerve.
Test that might support this diagnosis would include EMG, which would show us slowing of nerve conduction as impulses are transmitted down the nerve. And they also show us abnormal innervation potentials in the muscles supplied by the peroneal nerve. MRI is a useful test in some compression injuries of nerves but not in this particular case.
Facilitator: I type a lot at the computer and I fill out a lot of forms. At first, I noticed I was waking up at night and my hand was numb, but I thought it was just because I was sleeping on it. But, then I started to get electric shocks at my wrist that run down my arm and I thought something is really wrong.
Dr. Stern: That sounds like it might be carpal tunnel syndrome, which is the pinching of your nerve here at the wrist. I’d like to do a test called the Phalen’s test, which will help us determine if you have this condition. If you could just bend your wrist down like this for me and hold it for about 60 seconds and just tell me what’s happening in your hand.
Female: My fingers are getting numb.
Dr. Stern: Which fingers are you feeling the numbness in?
Female: The first three.
Dr. Stern: That would be a positive Phalen sign. That’s caused by the median nerve which travels through the wrist here getting pinched as we bend your wrist down. The median nerve can be trapped in other locations in the arm and even in the neck. So we want to confirm that diagnosis with another test called the Tinel’s sign. To do this, I would tap your wrist here and you would tell me if you feel anything different or unusual.
Dr. Stern: That would again be a positive sign of carpal tunnel syndrome as we’re tapping on the irritated nerve. In general, carpal tunnel syndrome is repetitive use injury which can be caused by repetitive motion, vibration or repetitive flexion and extension. In cases where the history or physical examination is a little bit atypical for carpal tunnel syndrome, the diagnosis can often be aided by EMGs or nerve conduction studies. These tests can help localize the area of the median nerve entrapment as well as giving you some indication as to the severity of the injury.
Carpal tunnel syndrome is often caused by repetitive use, vibration particularly due to use of machinery. Can also be caused by fractures, scarring from burns and it’s fairly common in pregnancy. To fully diagnose carpal tunnel syndrome, the physician must be careful to take a detailed medical and occupational history as well as doing a physical examination and occasionally diagnostic testing.
Facilitator: Some lawyers, insurers and jurors think of whiplash injuries as minor and are suspicious when accident victims describe the severity of their condition. This suspicion may be misplaced. Whiplash, the hyperextension, hyperflection of the neck typically occurs when you are struck from the back or side during a car accident. Many of these accidents have legitimate, long lasting effects. A patient may be released from an emergency room, but over the next few days develop increase pain in their neck and shoulders and return to the doctor.
Although many whiplash injuries resolve with physical therapy, one study of 266 cases of whiplash showed 45% of claims were symptomatic two years after settlement. There are a number of serious soft tissue injuries that are associated with whiplash. Cervical disc herniation or disruption, cervical facet syndrome, TMJ trauma and closed head injuries may result from whiplash.
Dr. Stern: The reason that whiplash injuries can be so severe is the complex anatomy of the muscles, tendons, ligaments and bone in the cervical spine, as well as the proximity of the cervical spinal cord and nerve roots. When a patient comes to the office with a history of a whiplash injury, we do a detailed medical examination as well as taking a history as to the time, and place of the injury, the duration and frequency of the symptoms, and what things alleviate or exacerbate the problem.
I’m now going to test the range of motion of your cervical spine. If you could just tip your chin down as far as it would go. Now, we’re looking for spasm in the back of the neck. She has a fairly norma range of emotion there. And tip of the head backwards.
Female: Oh, I feel that down my left arm.
Dr. Stern: Okay. Bring your head forward. That would be a sign of a nerve root irritation sending pain down the arm. If you can rotate your chin this way now and now going the other way. A lack of range of motion again is showing some muscle spasm in the cervical spine. Now, tip your ear down towards your shoulder and again the other way. Excellent. If there were abnormalities in this, we might test passive range emotion, but in someone who’s had an injury to the cervical spine we would do this very carefully to not cause any further damage.
Decrease motion in the cervical spine, particularly rotation, can be a sign of spasm in the paraspinal musculature. This can be caused by disc herniation, muscle or ligamentous injury or even damage to the muscle itself. To complete the examination of the cervical spine, you must do an examination of the appendicular skeleton as well. Looking for weakness, changes in neurological status or changes in the reflexes of the upper extremities and lower extremities. First, I would start by doing examination of the muscular strength of the upper extremity.
Can you hold you arm up this way and don’t let me straighten it out? Excellent. Now, straighten your arm out and don’t let me bend it. Very good. Now, we’ll just rest your arm here. Bring your hand all the way up like this and don’t let me unbend your wrist. Very good. Now, one more time. Don’t let me push your wrist down. Can you hold it up any stronger than that? Try your best. Since this is an abnormal finding, I would compare it to the opposite side. Can you hold this side up? Don’t let me pull it down. The weakness of the left wrist extensors could indicate a C6 nerve root injury. To confirm this, I would now do an examination of the sensibility of the upper extremity. Can you compare the two hands for me? Is there any difference in sensation here?
Dr. Stern: How about in the index fingers?
Female: The left side is numb.
Dr. Stern: And on the thumb?
Female: Numb, on the left side.
Dr. Stern: And coming up the arms?
Dr. Stern: This decreased sensation in the index and thumb would also confirm a diagnosis of a C6 nerve root injury. One last test that we could perform would be a reflex examination. Just sit nice and relaxed. And again just let your arm hang nice and relaxed. The lack of a brachioradialis reflex is again confirmatory of a C6 nerve root injury. Reviewing the patient’s x-rays in a case of whiplash injury is very important as it can reveal both bony injuries such as fractures, facet jumps, ligamentous injuries and even show you some soft tissue swelling.
If the x-rays are not helpful, it is possible that you would need to get an MRI, which can show cervical disc herniations. And in those cases where none of this is helpful, it’s possible to get a provocative discogram, which can be useful in reproducing the patient’s pain. In a patient whose physical examination is worse than the x-ray appearance, it’s important to note degenerative changes in the cervical spine. These degenerative changes or osteophytes within the cervical spine can cause pinching of the cervical cord with a fairly minor hyperextension injury.
Pain which worsens with extension but is non radicular or does not run down the arm would be considered cervical facet syndrome. To be more specific in the diagnosis, facet blocks can be used to identify which level of the cervical spine is causing this pain. TMJ can be another consequence of whiplash. Patients may complain of ringing in the ears, a click on opening or closing the jaw, sensation of stuffiness in the ear and difficulty with balance as well as headaches in the temple or jaw area.
The temporomandibular joint may be tender. While taking the patient’s history, the physician should find out whether the patient has any typical TMJ symptoms. The physician should palpate the patient’s temporomandibular joint. When you have a headache where does it hurt?
Female: From my temple to my jaw.
Dr. Stern: Is that tender there?
Female: Yes. It’s painful.
Dr. Stern: A cine-MRI of the temporomandibular joint would indicate whether the disc is being displaced while the joint is being opened or closed supporting the diagnosis of TMJ. A dentist or a oral surgeon familiar with TMJ should do an evaluation.
Dr. Pierson: Closed head injuries or post concussion syndrome can be a whiplash related injury. In a rear end collusion, the brain actually moves inside the skull and literally hits the inner walls of the skull. The severity of the injury can be made worse when the brain actually abrades or scrapes along the roughened surfaces of the inner skull. During the mental status examination of a patient complaining of a closed head injury, an in-depth evaluation is needed of higher-level cognitive skills.
These include such things as sustained attention, reasoning, judgment, insight, long term memory, new learning and emotional effect. Like you to do a few things for me right now. At first, I want you to remember three things I’m going to give you. The first is a speedy Cadillac, a white rose in a market street. Try to hang on to those for me. Okay. And now, what I want you to do is just start with December and say the months of the year in reverse order for me. Go ahead and do that.
Male 2: December, November, October, September, August, July, June, May, April, March, February, January.
Dr. Pierson: Very good. And can you tell me what it means when you say something like the grass is always greener on the other side of the fence?
Male 2: Your life looks better than mine.
Dr. Pierson: Okay. And patients who have chronic pain, depression, sleep disorders or fatigue accompanying their closed head injury, you have to give those consideration when you’re looking at deficits in attention, concentration, higher level reasoning skills. These areas may also interfere with the patient’s cognitive performance and have to be weighed into the equation. This is an example of an MRI of the brain in a severely injured patient, which demonstrates several types of injuries that can occur in the brain with trauma.
In this gentleman’s case, he suffered an epidural hematoma, which caused compression of the left side of the brain. In addition, he suffered a cortical contusion which highlights as a very bright spot here in the frontal region of the brain. And finally because of the diffused axonal injury or shear injury to the axons of the brain, you’ll see very small tiny punctate lesions that highlight on this sequence.
In many cases, particularly in milder brain injury the MRI can be negative. If that’s the case it’s not a supporting piece of information and one has to go on and do an objective neurophysiological test battery. If there is evidence of post concussion syndrome, I will refer the patient to a neurophysiologist to do additional testing. Cognitive functioning and behavior are highly dependent on brain integrity and can be affected by a whiplash injury. The neuropsychological examination assesses the patient’s intellectual function, language, memory, sustained detention and concentration, psychomotive function, visual perception, problem solving, mental flexibility, organization and planning skills. As yet, there is no proven role for SPECT scans, BEAM EEG or PET scanning in this condition.
Facilitator: If you are dealing with a client who had a traumatic injury in the past and has persistent muscular pain, yet standard diagnostic test revealed few if any objective signs of continued injury or disease, you should suspect the presence of fibromyalgia or myofascial pain syndrome. These two painful and disabling disorders are not well understood by the medical profession. Correct diagnosis depends upon a physician’s knowledge and experience and a complete medical examination, which includes palpation and interpretation of diagnostic tests.
Although the conditions remain somewhat controversial, in 1990 the American College of Rheumatology developed criteria for the diagnosis of fibromyalgia. Significant work has also been done in the area of diagnosing myofascial pain.
Dr. Colbert: Hello Nancy. How are you?
Dr. Colbert: I’m Dr. Colbert.
Nancy: Pleased to meet you.
Dr. Colbert: I understand you are having some pain problems in your neck and back?
Nancy: Yeah. It’s been… for about the past six months, I’ve had a really deep ache in my shoulders, one of my sides, up and down my spine and tailbone. I’ve got a tingling in my right arm and my right leg. And I’ve never injured my knees or done anything to my knees but my knees are… I’ve got the same kind of pain there.
Dr. Colbert: And what bothers it, what aggravates it?
Nancy: I guess if I go outside, I can’t tolerate cold weather, wet weathers. I just can’t stand it.
Dr. Colbert: And what job do you do?
Nancy: I’m a secretary. I do love typing.
Dr. Colbert: Okay. Let me look at your hands for a minute. You said you had some tingling and numbness here?
Dr. Colbert: Okay.
Nancy: And they feel sort of swollen. I know they don’t look swollen but…
Dr. Colbert: They don’t look swollen but to you they feel swollen?
Nancy: Yeah. They do and they are stiff.
Dr. Colbert: And if I squeeze that? Does that bother you at all?
Dr. Colbert: No. Okay. This history is compatible with diagnosis of fibromyalgia. What I’d like to do is to examine some very specific points on her body to determine whether they are more tender than what would be expected. So, Nancy would you mind turning around a little bit?
Nancy: It’s all right.
Dr. Colbert: Okay. Is there any tenderness through here?
Dr. Colbert: Okay. How about if I touch you up here?
Nancy: Ah! Yes.
Dr. Colbert: I’m exerting about four kilograms of pressure on this particular point and this is in the occipital region, which is a very typical myofascial pain or fibromyalgia point. How about on the other side?
Dr. Colbert: How about through here?
Nancy: Yeah, painful.
Dr. Colbert: When I’m palpating, when I touch her muscles, it’s a ropy band that moves under my fingers. And this particular one is tender. Which would indicate that it’s an active trigger point. Other areas, like perhaps in her mid back, I’m getting the same ropy band. Does that hurt?
Dr. Colbert: No. So that’s probably an inactive trigger point. I’d like you to lie on the table if you can so I can examine your low back. Generally when you are looking at people with fibromyalgia or myofascial pain syndrome, palpating the muscles is really critical to making this diagnosis. Again as I roll my fingers over, I feel this tout band like structure, which is consistent with fibromyalgia. Any tenderness through here?
Dr. Colbert: No. And here?
Dr. Colbert: How about in here?
Dr. Colbert: Yes. Yes?
Dr. Colbert: Okay. And this side?
Dr. Colbert: Okay. How about here?
Dr. Colbert: All right. And over here?
Dr. Colbert: Back of your thighs?
Dr. Colbert: No. So the points that I found that were positive are the occipital region, that’s two points, three, four, five, six, seven, eight. A dolorimeter measures minimum amount of force necessary to produce pain. The person without fibromyalgia can tolerate four kilograms of force at the specific tender points and not perceive it as pain. Patients with fibromyalgia typically have an increased sensitivity to pressure at these tender points and normal readings in control areas. Would you mind turning over for me please?
Dr. Colbert: Okay. Any tenderness right about here?
Dr. Colbert: Yeah. Okay. How about on this side?
Dr. Colbert: Anything right here?
Dr. Colbert: No. Okay. How about down here?
Dr. Colbert: Okay. And here? How about on this part of your leg?
Dr. Colbert: No. Okay. So again those were positive findings. This is on the epicondyle and on the medial aspect of the knee. Which confirms clinically a diagnosis of fibromyalgia. The American College of Rheumatology has defined two very important criteria for making a diagnosis of fibromyalgia. And that is the history of widespread pain lasting longer than three months. She gives a history of almost a year. And also on palpation finding very tender points at specific defined areas of the body. And it defined 18 points and of those, 11 have to be tender in order to make this diagnosis positive. This finding is considered objective because it is consistently reproducible at very specific sites on the body.
Now with Nancy, I’ve demonstrated two in her upper neck, two in her shoulder area, two in her gluteus muscles, also some in gluteal fold. Nothing in her lower extremities and nothing in her mid back area. I’ve also demonstrated some tenderness in the front of her body, on her arms and in her mid chest area. The diagnosis of fibromyalgia is determined by the history in part and by a process of excluding other possible diagnoses. A number of autoimmune diseases and other systemic disorders such as thyroid disease must be ruled out by lab work and other diagnostic test such as EMGs and nerve conduction studies. There are other elements of the history, which if positive help to confirm this clinical diagnosis.
In addition to the history of chronic pain and stiffness, these patients frequently have complains of tension headaches, paresthesias, or numbness in the extremities. Nancy complained of some tingling and numbness in her right arm and leg as well. They also frequently complain of a subjective sensation of swelling of the joints. Nancy also talked about this but objectively speaking, there was no swelling and there’s no tenderness. Some female patients complain of dysmenorrhea or painful periods. Many people have what’s called an irritable bowel syndrome. That is alternating constipation and diarrhea. And probably about 80 to 90% of patients with fibromyalgia have sleep disturbances.
They describe a non-restorative type sleep. They never really feel rested after… even though they’ve been in bed all night. They may have some early morning wakening. They may have some difficulty getting to sleep but it’s never a restful type of sleep. I’ve also demonstrated when I was palpating Nancy’s neck, the jump sign, which we can find on physical examination. And that essentially is just a grimace or a reaction to an exquisite type of pain at a particular tender point.
Dr. Colbert: Hello Steve. I’m Dr. Colbert, how are you?
Steve: Hi. Good.
Dr. Colbert: I understand you have a problem with your back?
Dr. Colbert: You want to tell me about it?
Steve: Well, it started about a year and a half ago. I worked for a bottling company and I was taking these huge bottles of soda on a dolly and I slipped and I fell. And that’s when it started.
Dr. Colbert: Okay. And what… you had a workup at that time. I understand you had some x-rays and an MRI?
Steve: Yeah. The x-rays and the MRI were negative. But I’ve had very bad… very bad stiffness. I can’t get up in the morning. I can’t physically get out of bed and it hurts a lot.
Dr. Colbert: Is it present all the time or the…?
Steve: It’s present all the time.
Dr. Colbert: Okay. I’d like to take a look at it and demonstrate some things in your back?
Dr. Colbert: Do you mind standing up? Turn this way if you would? And essentially, I’m looking for some asymmetries. So I run my finger down the middle of the spine and that looks fairly well aligned, although he has a slight prominence to the right. I put my hands on his iliac crest and it’s a bit lower to the left.
Dr. Colbert: When I touch there, does that bother you?
Steve: Yes. Right there.
Dr. Colbert: Anything over here?
Steve: No. Not on the right side. Nothing.
Dr. Colbert: Okay. How about up in here?
Steve: Yeah. Yeah. Yeah. Right there.
Dr. Colbert: Okay. And I’m touching right about the L5- S1 level. How about here?
Steve: Yeah. That hurts.
Dr. Colbert: Is that as bad?
Steve: Yeah. Just as bad as it was a minute ago on that side.
Dr. Colbert: Okay. Good. Now I want to check the range of motion on his back. He complained of stiffness which is part of a myofascial pain syndrome. Can I have you bend forward as though you are going to touch your toes and how far can you go?
Steve: That’s it. And it hurts when I do that.
Dr. Colbert: Okay. That’s about 12 inches. What I usually do… you can come back up. What I usually do is to measure that to quantify it for several reasons. To get an objective measurement of his impaired range of motion but also if he’s undergoing treatment, to see if that changes and improves. Now can you bend towards the right? Okay. That’s a nice gracious curve. Okay. Come on back. And bend to the left. And there’s asymmetry again. This is rather straight. So he doesn’t bend quite as well to the left as he does to the right. And your symptoms have always been on the left? Is that right?
Steve: Yes. Always. Right there.
Dr. Colbert: All right. Very good. Myofascial pain syndrome is a very common disorder. It may be caused by a direct injury or a sudden strain to a muscle such as in a whiplash injury. Or it may occur more gradually as a result of repetitive stress or accumulative trauma to a particular muscle or group of muscles. I see this very frequently in assembly line workers who are preforming the same repetitive task during an eight-hour day and stressing the same muscle groups without adequate breaks or change of activities. Both static and dynamic surface EMGs may be helpful in demonstrating excessive activity or lack of activity in the muscles.
Surface EMGs are used to quantitatively assess electrical activity in certain muscles. What we are looking at with Steve is whether he has increased activity in one group of paraspinals compared to another. And you can see I’ve hooked him up with a green electrode on his right paraspinals and a blue electrode on his left. And I’m going to ask him to perform a number of exercises and determine whether… which muscles are active with each exercise. They should in the normal person be symmetrical. Now could I have the screen please?
Steve, would you bend to the right please? Okay. Now go to the midline again. And bend to the left. And what we see is that the green, the right paraspinals are active in both activities, much more so than left paraspinals. Whereas the blue line, representing the left paraspinals was relatively inactive. This is consistent with my clinical findings where we saw an asymmetric curve to the left. He has a more difficult time bending to the left because those muscles are relatively less active.
Facilitator: Sometimes trauma or injury causes strains or sprains to soft tissues. Medical professionals may define these terms differently. So it’s important to clarify these terms with the treating physician or expert. A client may have injured his or her back unloading a truck. There’s no evidence of a herniated or bulging disc but the client is in a lot of pain and may not be able to go back to a job that involves heavy lifting.
Female: I don’t understand why my back still hurts.
Dr. Stern: Muscle injuries could be quite painful due to do bleeding into the tissue. Tearing can cause scarring within the muscles and cause pain or decreased range of motion. Although the prognosis is good for early return to functioning in most muscle injuries, some muscle injuries can take quite a bit longer to heal and a few patients may even have to change their work or leisure time activities permanently.
Facilitator: Our current understanding of why soft tissue injuries hurt so much and take so long to heal is that damaged tissue causes the release of various chemicals, which perpetuate the problem. The chemicals activate two types of nerve fibers. The A delta and unmyelinated C fibers causing first a short, sharp pain and then a dull aching pain. This sets up a circuit of pain carrying messages, which tighten the muscles around the painful site. The local blood supply decreases resulting in a further build up of chemicals and a consequent increase in pain. Because of this cycle, the subjective pain complaints far out last what would expected from the initial injury.
A ligament sprain or strain may occur during a car or industrial accident. Often involving the ligaments which support the spinal column. Another joint which is vulnerable to ligament injury is the knee joint. Typically, the passenger in the car which is rear-ended sustains knee injury. Minor sprains may be treated with ice, bandaging, and physical therapy. If a ligament is torn, the joint may be immobilized by a plastic cast or repaired surgically.
Dr. Stern: The posterior cruciate ligament can be injured in automobile accidents. An MRI can be used to confirm the tearing of the ligament and be helpful in making this diagnosis. Ligaments have a notoriously poor blood supply and therefore may heal slowly or not at all, leaving a residual instability and perhaps disability.
Facilitator: In soft tissue injury cases, the medical history and exam frequently need to be supplemented by diagnostic tests. X-rays should be taken at the area where damage is suspected in the position which produces the patient’s pain. This will enable the physician to confirm if one vertebrae is slipping on to another. Spondylolisthesis. This would impact the soft tissues surrounding that area. Myelography involves taking a sample of spinal fluid and injecting a radiopaque dye into the fluid-filled space that surrounds the spinal cord. Myelograms are being replaced by less risky diagnostic procedures, MRIs and CAT scans.
MRIs are best for diagnosing soft tissue problems such as herniated discs, disc displacement or muscle tumor. Because it’s a well accepted radiographic modality for soft tissue. It’s particularly good at showing edema, which may indicate an acute process. CAT scans are very good at diagnosing bony disorders and are more likely to pick up bone lesions because they show bony detail more clearly. However, even CAT scans miss a number of bony lesions. Not all damaged discs show up in these tests. And soft tissue injuries involving the back are complicated by the fact that many people with damaged discs do not complain of back pain or impairment.
It’s possible that abnormalities exist inside a disc while the outside of the disc appears normal. A CAT scan may appear normal and an MRI would show disc morphology in terms of water content but will not reveal changes from internal disc disruption. A doctor may recommend a provocative discogram, which is an invasive procedure that involves injecting the disc with a radiodense material so that the internal integrity of the disc can be evaluated. Due to a lack of objective findings in soft tissue cases, the question of a non-physiologic basis for pain or disability is frequently an issue. There are a number of clinical tests that can be performed to evaluate whether there may be a non-physiologic basis for patients complaint.
Dr. Stern: There are five none physiologic or organic signs of low back pain as described by Dr. Waddell, a Scottish orthopedic surgeon. Having any three of these five signs be positive is strongly indicative of non-physiologic or non-organic low back pain. And… if I ask you to lay your head down on the pillow there, can you lay back for me?
Male 1: Yeah.
Dr. Stern: When the patient comes into the room, I first observe him for pain behavior, such as grimacing or moaning particularly dis-robing or getting on and off the table. In addition, I would look for pain with very light palpation, which would not normally cause discomfort. The third would be a lumbar flexion test or distraction. I first would ask the patient to bend forward. The patient would indicate difficulty with this maneuver but then when I’m pretending to examine the patient’s knee, with the patient sitting, I can fully extend the leg. Or with the patient lying down, I’m pretending to be examining the hip or foot… How is your hip? Does your hip hurt you much?
Male 1: No. My hip is okay.
Dr. Stern: I can do a straight leg raise without causing the patient any discomfort. Again, if the nerve roots were irritated, all three of these would be positive for pain running down the leg, rather than just bending forward while standing. If I just press down on top of your head, does that bother much?
Male 1: Oh, yeah. That hurts my back.
Dr. Stern: Axial compression of his cervical spine should never cause an increase in lower back pain because this small amount of pressure at the head would never increase the disc pressure at the bottom of the lumbar spine. In addition, if the patient is rotating through the trunk and hips, it should not cause irritation to the nerve roots as rotating the trunk would.
Male 1: Ah! That hurts! Right there. Yes.
Dr. Stern: Okay. Regional disturbances are those which are non-anatomic in their nature. Such as weakness in areas, which are widely varying from the normal neurologic anatomy. Just tell me if there’s any difference in the sensation between the two feet where I’m touching.
Male 1: No. They are both numb.
Dr. Stern: And how about over here?
Male 1: I can’t feel it. It’s completely numb.
Dr. Stern: How about coming up the leg?
Male 1: I can barely feel it.
Dr. Stern: And how about on the thighs?
Male 1: I can feel that up there. That’s numb.
Dr. Stern: Okay. That’s numb?
Male 1: Yeah.
Dr. Stern: Okay. You can also see patients who have cogwheeling, giving away of their muscle strength, where you are pushing against the patient’s resistance. And instead of having a gradual lessening of the patient’s ability to resist you, there’s a sudden sharp giving way. This again is non-physiologic. I’m going to ask you to hold your feet in like this and I’m going to push them out. You hold them both in real strong.
Male 1: Okay. Oh, God.
Dr. Stern: All right. Try that one more time for me. Just hold them in. Don’t let me push them out. Hold them in. If a patient complains of weakness in a leg, the hoover test can be used to see if a maximal effort is being given to lift the leg. This is done by placing one hand under the good leg while asking the patient to lift the weak leg. Could you lift your leg please? If there’s no pressure under the good leg, a submaximal effort is being performed. On the other hand, if you place your hand under the weak leg… Could you lift your opposite leg? And there’s substantial downward pressure under the weak leg. You can at least say that the hip extensors on the weak side are intact. Which side of your neck is weak?
Female: My right side.
Dr. Stern: Can you turn your head towards me?
Female: I don’t think so.
Dr. Stern: Can you turn your head to the other side? And a patient who’s complaining of weakness on one side of the neck, the sternomastoid test can be used to confirm whether it’s a physiologic or non-physiologic weakness. In the sternomastoid test, the left sternomastoid turns the head to the right. So a patient who cannot turn their head towards the weak side would be demonstrating a non-physiologic cause for this weakness.
Dr. Pierson: Bizarre sensory findings that do not correlate with any anatomic substrate such as a hemianesthesia that involves only the front of the trunk as opposed to the front and back, maybe the indication of a non-physiologic basis to a patient’s complaint. In special instances such as multiple sclerosis, a patient can present what this as long as there are other supporting items in the history or on clinical exam. Just hold the table first, okay? Put one foot in front of the other. Now let go the table, hold your balance. Okay. Can you walk that way for me? One foot right in front of the other. Give it your best shot.
Inconsistent performance on muscle testing as in give away weakness, [inaudible 00:48:32] and mild performances on gate evaluation are all indications of exam embellishment or somatization disorder. I’m going to have you test your strength here in you arms. Hold this arm nice and strong for me. Don’t let me push it down. Hold hard. Okay? No. The side. Hold hard. Okay. Very good. Just put your arms out straight now. Keep these arms strong, don’t let me bend it. Keep it strong. Is this your good arm? It’s a good arm. Excellent. Now try on this side too. Hold strong, hold strong. Good. Very good. I’m going to test vibration here on your face, can you feel this?
Male 2: Yeah.
Dr. Pierson: Do you feel a buzzing on this side?
Male 2: I don’t feel anything there.
Dr. Pierson: How about on this side of your chest? Do you feel it here?
Male 2: Yeah.
Dr. Pierson: How about on this side?
Male 2: No.
Dr. Pierson: Okay. Very good. These appear to be non-physiologic findings for these patient’s complaint of numbness on the right side of this body. One would expect that vibration would be felt the same on either side of a single bone such as the forehead bone or the sternum. The same is also true in the pelvis. I’m just going to touch you lightly in several places and tell me how it feels. Feels normal?
Male 2: Right.
Dr. Pierson: Normal. How about on this side?
Male 2: No. I don’t have any feeling on the right side. It’s like I’m numb. I don’t have feeling in the right side of my body.
Dr. Pierson: How about here?
Male 2: Yeah.
Dr. Pierson: Okay. How about when I touch you like that, where do you feel it?
Male 2: Right here on my left arm.
Dr. Pierson: Very good. All right. In the next part of the exam, what I would like to have you do is close your eyes. And when I touch you, I want you to just point to where I touched you. Okay?
Male 2: Okay.
Dr. Pierson: Close your eyes please. Okay. Good. Very good. This patient presents an interesting finding on examination. On the sensory examination where I just asked him to tell me whether he could feel the light touch on either side of his body, he claimed anesthesia on the right side, even in the face. When I asked him to do touch localization that is to point to the places I had touched for him with his eyes closed, he was able to indicate to me that he felt light touch on the side that he had claimed was anesthetic.
Facilitator: Soft tissue injuries can be caused by pre-existing conditions. Osteoarthritis, degeneration of the joint cartilage affects virtually everyone over the age of 60 but can be more pronounced in people who do heavy manual labor and in those who have already been affected by injury or disease. Infections can cause muscle spasm and weakness. Diabetes can cause damage to nerve fibers and complicate diagnosing other soft tissue injury. Many people are born with congenital abnormalities such as cervical spondylolisthesis which do not cause pain or disability until there’s been trauma to the area. Metabolic disorders can cause a number of symptoms such as fatigue, anxiety, sensitivity to temperature or weakness.
Exposure to toxic substances can cause muscle and nerve damage and many medications have side effects. Physicians need to have this kind of information to make a correct diagnosis and prognosis. Pre-existing conditions do not necessarily foreclose an individual’s claim for damages. Sometimes injuries exacerbate or aggravate conditions causing further soft tissue damage, pain and disability. Attorneys need to be fully aware of pre-existing conditions because they may ultimately play an important part in the outcome of a soft tissue injury case.
To prove or defend a soft tissue injury case, counsel must be familiar with anatomy, physiology and the diagnostic tests and techniques used by physicians to evaluate these clients. This program has introduced you to the medical evidence of soft tissue injury.