Intercostobrachial neuralgia—a case of bizzare diagnosis?

Abstract

BackgroundIntercostobrachial neuralgia is a rare and bizarre diagnosis usually missed by many clinicians. The rare occurrence and absence of clear diagnostic criteria could be a result of this missed diagnosis. The symptoms could range from debilitating pain in the axilla, medial arm, and forearm at rest and with specific shoulder movements. The symptoms are very distinct from axillary web syndrome in which the patient could have thickening of subcutaneous tissue of axilla with affected shoulder mobility but absence of neural symptoms. The diagnostic and treatment procedure involving breast cancer may cause injury or lesion of the intercostobrachial nerve and is of particular interest to the surgeons, pain physicians, and physical therapists. The diagnosis is reached after excluding all the other possible diagnoses. The treatment of this post-surgical intercostobrachial neuralgia can range from cryoneurolysis, ultrasound-guided nerve block, steroid injection, and paravertebral nerve block. Lidocaine injection and avoiding certain positions like flexion and abduction are helpful in certain patients. Unfortunately, there is not much literature available on possible manual therapy treatments of this diagnosis. Therefore, this case report focuses on potential manual therapies to address this intricate diagnosis.Case presentationThe patient is a 38-year-old Asian female reported to an outpatient orthopedic physical therapy clinic with left medial arm and forearm pain for the past 5 years. Medical history included left breast lump removal surgery 9 years ago and cervical laminectomy C6–C7 with little success. The quick disability arm and hand scale showed a 36% disability score of function. The manual therapy approach targeted the cervicothoracic junction, second and third costovertebral joint, thoracic spine (T1–T8), and atlantooccipital joint (C0–C1). The patient showed significant improvement in function with a DASH score falling to 0% disability with a hands-on approach.ConclusionThe intercostobrachial neuralgia is usually undiagnosed by various practitioners, physicians, and surgeons. The clinicians must consider manual treatments to the second and third rib and soft tissue mobilizations around the axillary region. The patient demonstrated significant improvement in symptoms with this approach.