A 59-year-old well-nourished white woman presented to the clinic with chief complaints of neck pain as well as upper and lower back pain. According to the patient, the pain began after a rear-end motor vehicle collision approximately 2 years prior. She was restrained by the seatbelt and did not go to the emergency department. However, she visited her primary care physician within 1 week of the collision and was given medication for her pain. Results from a radiographic image taken at that visit were normal.
At presentation, the patient described constant burning and tingling sensations as well as undiminished pruritus along the medial border of her left scapula. The patient stated that the pruritus began 3 to 4 months after the collision. On a subjective scale of 0 (no discomfort) to 10 (worst discomfort), she rated her level of discomfort as a 6 or 7. The patient had also noticed an area of hyperpigmentation that had been increasing in size during the past year.
About 1.5 years before presenting to the clinic, the patient received a series of epidural steroid injections (3 injections, 6 months apart) to her cervical and lumbar regions to manage the pain related to this condition. The injections provided some immediate relief, but pain returned. For her pruritic symptoms, the patient took an oral antihistamine and used an over-the-counter hydrocortisone cream as needed, to minimal relief.
The patient stated she had mild chronic back pain before the accident. Her medical history was also positive for bulging disks in the cervical and lumbar spine and for degenerative disk disease, restless leg syndrome, and hypertension. Family history was positive for heart disease, hypertension, and type 2 diabetes mellitus. The patient denied past or present tobacco or illicit drug use and stated that she rarely consumed alcohol. She denied any previous operations or hospitalizations.
On physical examination, the patient was awake, alert, and cooperative with cranial nerves grossly intact. Her vital signs were normal.
Visual inspection of the patient's back revealed a macular patch of brownish discoloration that was 4 cm in diameter just below the inferior angle of her left scapula at the level of vertebrae T6 and T7. Palpation and range-of-motion screening revealed restriction in the cervical and lumbar spine. Osteopathic examination findings included neutral, sidebent left, rotated right vertebral segments C7 through T6 as well as extended, rotated right, and sidebent right vertebral segment L3. The patient's fifth rib on the left side had inhalation somatic dysfunction (ie, exhalation restriction) and was tender on palpation. Tissue texture changes were observed in vertebrae T2 through T7 with tenderness at the tips of the spinous processes, and an appreciable ropy and fibrotic texture at the left scapula. The patient had sensitivity in four of 18 fibromyalgia tender points.
The patient denied any symptoms of fatigue or sleep disorder, lowering the suspicion of fibromyalgia. There was no evidence of synovitis on examination. She also denied any morning stiffness or pain in her hands or feet. The patient was not screened for autoimmune disorders because she had no other symptoms.