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2.  EVALUATION AND TREATMENT OF MUSCULOSKELETAL CHEST WALL PAIN IN A MILITARY ATHLETE 
Background and Purpose:
Athletes reporting chest pain are challenging to diagnose and equally challenging to treat. The majority of chest pain is musculoskeletal in origin, yet differentiating these from other more serious conditions should be the initial primary focus. The ability to reproduce the patient's symptoms aids in the differential diagnostic process. The purpose of this case report is to illustrate the use of dry needling (DN) to aid in the diagnosis and treatment of focal chest wall pain.
Case Descriptions:
A 22 year-old male military athlete with anterior chest pain, refractory to traditional physical therapy, was evaluated and treated with dry needling.
Outcomes:
Favorable results were achieved as demonstrated by clinically meaningful improvements in the Patient Specific Functional Scale, the Global Rating of Change score, and his physical performance which allowed this athlete to return to competition and military training.
Conclusion:
Dry needling in the hands of properly trained providers may aid in diagnosis and treatment of focal chest wall syndromes.
Level of Evidence:
Therapy, Level 4
PMCID: PMC3362990  PMID: 22666647
chest pain; costochondritis; dry needling; military athlete; physical therapy
3.  SHOULDER PAIN AND DYSFUNCTION SECONDARY TO NEURAL INJURY 
Study Design:
Resident's Case Study
Background/Introduction:
The reports of spinal accessory nerve injury in the literature primarily focus on injury following surgical dissection or traumatic stretch injury. There is limited literature describing the presentation and diagnosis of this injury with an unknown cause. The purpose of this case report is to describe the clinical decision-making process that guided the diagnosis and treatment of a complex patient with spinal accessory nerve palsy (SANP) whose clinical presentation and response to therapy were inconsistent with the results of multiple diagnostic tests.
Case Description:
The patient was a 27-year-old female triathlete with a five month history of right-sided neck, anterior shoulder, and chest pain.
Outcome:
Based on the physical exam, magnetic resonance imaging, radiographs, electrodiagnostic and nerve conduction testing, the patient was diagnosed by her physician with right sterno-clavicular joint strain and scapular dyskinesis and was referred to physical therapy. Care was initiated based on this initial diagnosis. Upon further examination and perusal of the literature, the physical therapist proposed a diagnosis of spinal accessory nerve injury. Intervention included manual release of soft tissue tightness, neuromuscular facilitation and sport-specific strengthening, resulting in full return to functional and sport activities. These interventions focused on neurological re-education and muscular facilitation to address SANP as opposed to a joint sprain and dysfunction, as initially diagnosed.
Discussion:
Proper diagnosis is imperative to effective treatment in all patients. This case illustrates the importance of a thorough examination and consideration of multiple diagnostic findings, particularly when EMG/NCV tests were negative, the cause was not apparent, and symptoms were less severe than other cases documented in the literature.
Level of Evidence:
Diagnosis, level 4
PMCID: PMC3164000  PMID: 21904699
Differential diagnosis; shoulder pain; spinal accessory nerve palsy; sterno-clavicular pain; triathlete
4.  PHYSICAL THERAPY INTERVENTION FOR A FORMER POWER LIFTER AFTER ARTHROSCOPIC MICROFRACTURE PROCEDURE FOR GRADE IV GLENOHUMERAL CHONDRAL DEFECTS 
Background:
Power lifting places the shoulder complex at risk for injury. Microfracture is a relatively new procedure for chondral defects of the glenohumeral joint and is not well described in the literature.
Objectives:
The purpose of this case report is to describe the post-operative rehabilitation used with a power lifter who underwent a microfracture procedure to address glenoid and humeral chondral defects, debridement of type I superior labral anterior-posterior lesion, and a subacromial decompression.
Case Description:
The patient was a 46 year-old male who was evaluated nine weeks status-post arthroscopic microfracture procedure for glenoid and humeral chondral defects, debridement of superior labral anterior-posterior (SLAP) lesion, and subacromial decompression. Rehabilitation consisted of postural education, manual therapy, rotator cuff and scapular strengthening, dynamic stabilization, weightbearing exercises, and weight training over nine weeks (24 sessions). Lifting modifications were addressed.
Outcomes:
Results of the QuickDASH indicate that activities of daily living (ADLs), work, and sports modules all improved significantly, and the patient was able to return to recreational power lifting with limited discomfort or restrictions.
Discussion:
A structured post-operative physical therapy treatment program allowed this patient to return to recreational power lifting while restoring independent function for work-related activities and ADLs.
PMCID: PMC3105365  PMID: 21655454
articular cartilage; microfracture; rehabilitation; shoulder

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