Thoracic Outlet Syndrome: The chiropractor will review relevant anatomy and come away with a simple and effective method of evaluation for thoracic outlet syndrome, as well as a framework for clinical management.
Case History: The Chainsaw Artist: The chiropractor will discover co-management strategies and review lumbar spine surgery statistical insights and factors slowing recovery.
Case History: A Dad Through the Decades: This course covers treating a patient with multiple medical conditions and how they influence overall care.
Case History: An Unlucky Bus Driver: The chiropractor has many considerations for a patient’s general health and these factors inform not only our clinical decisions, but also our treatment approaches. This course is a great overview of several conditions we see often in practice and reminds us of these important decisions.
Mystery Patient #33: Improve your differential diagnosis skills with this difficult patient’s case.
Ehler-Danlos and Marfan’s Syndrome: We don’t see them often, but when we do we need to know the ramifications of their existence. Brush up on why we need to know about them.
Rib Cartilage Injury: Learn identification and treatment strategies for these common injuries.
A Complex Wrist Injury: Anatomy, imaging, and case histories combine to give an in depth review of how to manage wrist injuries in your practice
Thoracic Outlet Syndrome
I. Thoracic outlet anatomy:
II. 3 types of TOS
III. Examination for TOS
IV. Patient Case History
A. Presentation
B. Exam
C. Radiographic findings
D. Treatment Description
1. Adjustments and therapies manual, lighter on the neck. 80% response, but…
2. She returns: About 4 mo later
3. The arm fatigue was present and her worst complaint was the click in her neck.
4. My impression was that she had been better off than she really was.
a) Patient’s pulses were normal, but ULTT was positive for numbness and pain in the left arm (symptomatic side), also spasm and ROM in neck were much better. But her affect was much declined.
b) Surgical referral
1) Surgeon ordered an ultrasound of the upper extremities= normal
2) Surgeon said I cannot help you.
c) I sent her for ortho evaluation of facet joints
1) She happened to see a retiring surgeon
2) additional testing
E. Surgery performed
F. Follow up
Case History: The Chainsaw Artist
I. Initial Presentation with right mid thoracic pain
II. MVA: Rearended.
A. driver, seat belted
B. Treated for a 4-5 months
III. I see him again intermittently, 1x/year or two for several years
IV. WC Injury due to lifting heavy
A. Symptoms
B. Xrays
C. Treatment
V. Slip and fall on the ice
A. LBP w/right leg pain and right knee pain
B. I see him a handful of times and then he disappears. New job, divorce, remarry, etc.
VI. Next time I see him a couple years later: 9 mo post lumbar fusion.
A. He has been in excruciating pain since the surgery
B. CT scan shows
C. Surgery required to correct…No surgery until fusion is complete!
E. Treatment considerations
F. He improves and disappears
VII. Surgery finally able to happen
VIII. SI Joint pain comes back again
IX. Additional surgery
X. 20% of lumbar spine surgery patients have a repeat surgery in 10 years.
A. Risk factors:
B. Huge increase (doubled) in lumbar fusion surgeries early 1990’s compared to late 1990’s
Case History: A Dad Through the Decades
I. Vietnam: Freiberg’s infarction left foot
II. Severe Lumbar spine stenosis w/radiculitis
A. Conservative care for 10 years Chiro, Acu, PT, Injections, Vicodin
B. Lumbar Spine Decompression Surgery
C. Maintenance
III. Knee replacement on the right
IV. Biceps tendon tear
V. Fell off of bike and broken hand and dislocated fingers
VI. Psoriasis
VII. High Cholesterol
VIII. Statin drug reaction and resolution
IX. Kidney stones
A. episodes
B. treatment
A Case History: An Unlucky Bus Driver
I. Initial Presentation with right mid thoracic pain
II. Repetitive Strain injury with school bus driving
A. the following Spring = similar pain, but much worse (now burning), and affecting a broader area.
B. Same modalities. Some help. Treated for about one week.
III. Rearended by a co-worker @ 40mph
A. Headache, Dizziness, Neck, MBP, LBP, right radicular leg pain, wrists, right foot and ankle
B. X-rays right away:
C. T/spine MRI: 4 herniations and a bulge, also DJD/DDD at essentially every spinal level.
D. Referral to get her some relief
F. Difficult to function: sit up straight, wear bra, drive, laundry, get dressed, all significant; waxed and waned.
G. Referral to neurologist for headaches and dizziness: Warren Hammer wrote a Case Study about the suboccipitals and compression of the vertebral artery= dizziness
H. Dizziness slowly relapsed after a few months: she fell down a flight of 12 or 13 stairs= broken fibula.
I. All issues flared back up: HA, neck, back, etc.
J. Slow progress
IV. 9 mo after MVC…slipped on ice coming off of her school bus
V. Breast cancer
A. Support structure in the meantime
B. Be mindful of the past and upcoming procedures
Mystery Patient #33
I. History: 38 yo female whom I have seen for 9-10 years.
A. Vitals
B. She has a history of
II. Mystery condition: #33 presents on a Monday morning with LBP so severe she is in tears, 10/10 pain.
A. In the year before this she has begun to use a portable electric wheel chair at work.
B. Exam
C. Treatment= She gets zero relief, which is rare for her.
D. Day 4 = no improvement. She can’t work, can barely sleep. She now cannot heel walk. There is right foot drop. I refer for same day MRI as this has progressed.
E. Lumbar MRI=
F. Differential Diagnoses
G. Additional MRI options
H. MD says to go to ER.
I. She spends 10 hrs in the ER. They refused… lumbar puncture.
III. What mistake did I and her MD make?
IV. What would you do next?
A. Refer to whom?
B. Any ideas on what is going on? I didn’t yet.
V. Two weeks later…Neurologist does…
A. NCV/EMG=normal
B. lab results
C. Mystery condition identified
D. Primary symptoms
E. Secondary symptoms
F. Etiology
G. Treatment
Ehlers Danlos and Marfan’s Syndromes
I. Ehlers-Danlos Syndrome (EDS): Case History
II. Presentation of Maria
III. Rare connective tissue disorder: skin fragility and hyperelasticity, articular hypermobility, and vascular fragility (1 per 5000 births).
A. 13 subtypes (I-X). Typed with genetic testing.
B. A variety of complications arise
C. Radiological Findings to note
IV. She has chronic pain
V. I treat her a dozen times. She gets some short term relief, for which she is grateful, but ultimately she has so much pain that she decides to move onto other options.
VI. Surgical consultation
VII. Surgery performed
VIII. Ongoing poor quality of life
Marfan’s Syndrome
I. 4-6 per 100k births: Connective tissue disorder causing abnormal collagen production.
II. 3 systems affected: skeletal, ocular, cardiovascular
III. Radiographically:
IV. Case Histories
A. Scuba class
B. Tall middle age man
C. Teenage basketball player
Rib Cartilage Injury
I. Patient with 3 year history of severe rib pain after injury
II. Rib cage Anatomy review
III. Responded well to chiro adjustments and therapies
IV. Poor diet, lots of alcohol intake = pro-inflammatory
V. He could not do much for a while due to pain
VI. He goes back to school and has another injury
VII. He is able to be about 80-90% functional with treatment 1x/mo.
VIII. Interesting recommendation along the way @ VA
IX. Examples of other patients
X. Adjusting strategies
A. costosternal
B. costovertebral
XI. Exercises
A. Pec major, and minor
B. Mid/Low trap
C. foam roller for increasing extension of thoracic spine
A Complex Wrist Injury
I. FOOSH injury can lead to a variety of problems
A. scaphoid fracture
B. subluxation
C. S-L ligament tear-
D. Additionally
II. Patients
A. 40 yo female gets into head on crash @ 55 mph
B. Exam
C. Imaging
D. Referral
E. Injuries in a standard pattern we expect from this, but the main pain is her left wrist.
III. 52 yo female teacher fell playing soccer, FOOSH but thumb first
initial pain in 1st MCP joint
A. better with adjustment, then pain moves to mid wrist
B. x-ray =
IV. 60 yo RN falls at work after catching her foot on broken cabinet door
neck and back pain, with right wrist pain.
A. Fell again 2 wks later= R>>, but also L wrist pain
B. x-rays =
V. 35 yo female real estate industry lifts water bottle onto cooler
no images, but suspect she had partial tearing.
A. tape, ice, neutral position
VI. These can occur other ways too
A. push open heavy door
B. push-ups
C. essentially impact in wrist extension
VII. Treatment suggestions
A. Exercises
B. Adjustment considerations
C. Surgical considerations
VIII. I think we can support these injuries conservatively
I. Case History: A Dad through the Decades
1. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.895-904, Williams & Wilkins, 1996.
2. Kelempisioti, A. Et al. (2011). Genetic susceptibility of intervertebral disc degeneration among young Finnish adults. BMC Medical Genetics. 2011, 12:153.
3. Yang, X. Eet al. (2019). CHRNA5/CHRNA3 gene cluster is a risk factor for lumbar disc heriantion: a case-control study. Journal of Orthopedic Surgery and Research. 2019 14:243.
4. Ji, D. Et al. (2019). Correlation fo EYS polymorphisms with lumbar disc herniation risk among Han Chinese population. Molecular Genetics & Genomic Medicine. September 2-19., V7, Issue 9 e890.
5. Grotle, M. Et al. (2019). Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019;9:e028743.
6. Jung, J. Et al. (September 2020). The long-term reoperation rate following surgery for lumbar stenosis. Spine: Sept 15, 2020; v45:i18:p1277.
7. R.K. FUCHS, S.J. WARDEN, C.H. TURNER, 2 – Bone anatomy, physiology and adaptation to mechanical loading, Editor(s): Josep A. Planell, Serena M. Best, Damien Lacroix, Antonio Merolli, In Woodhead Publishing Series in Biomaterials, Bone Repair Biomaterials, Woodhead Publishing,2009, Pages 25-68.
8. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
II. Case History: Chainsaw Artist
1. Teichtahl, A.J., Wluka, A.E., Wijethilake, P. et al. Wolff’s law in action: a mechanism for early knee osteoarthritis. Arthritis Res Ther 17, 207 (2015). https://doi.org/10.1186/s13075-015-0738-7
2. Kelempisioti, A. Et al. (2011). Genetic susceptibility of intervertebral disc degeneration among young Finnish adults. BMC Medical Genetics. 2011, 12:153.
3. Yang, X. Eet al. (2019). CHRNA5/CHRNA3 gene cluster is a risk factor for lumbar disc heriantion: a case-control study. Journal of Orthopedic Surgery and Research. 2019 14:243.
4. Ji, D. Et al. (2019). Correlation fo EYS polymorphisms with lumbar disc herniation risk among Han Chinese population. Molecular Genetics & Genomic Medicine. September 2-19., V7, Issue 9 e890.
5. Grotle, M. Et al. (2019). Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019;9:e028743.
6. Jung, J. Et al. (September 2020). The long-term reoperation rate following surgery for lumbar stenosis. Spine: Sept 15, 2020; v45:i18:p1277.
7. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
8. Khurana VG. Adverse impact of smoking on the spine and spinal surgery. Surg Neurol Int. 2021 Mar 24;12:118. doi: 10.25259/SNI_6_2021. PMID: 33880223; PMCID: PMC8053459.
III. Case History: An Unlucky Bus Driver
1. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
2. Xin J, Wang Y, Zheng Z, Wang S, Na S, Zhang S. Treatment of Intervertebral Disc Degeneration. Orthop Surg. 2022 Jul;14(7):1271-1280. doi: 10.1111/os.13254. Epub 2022 Apr 29. PMID: 35486489; PMCID: PMC9251272.
3. Burton, Kim., Adams, Michael A.., Dolan, Patricia., Bogduk, Nikolai. The Biomechanics of Back Pain. United Kingdom: Elsevier Health Sciences, 2012.
4. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
5. Hammer, W., Functional Soft Tissue Examination and Treatment By Manual Methods : The Extremities, Aspen Pub., Rockville, MD, 1991.
6. Dock, Daniel, “Whiplash Trauma”. Duluth, MN: Self Published, 1995.
IV. Case History: Ehlers-Danlos and Marfan’s patients
1. Dean, J. (2007). Marfan syndrome: clinical diagnosis and management. European Journal of Human Genetics. 2007, 15, 724-733.
2. Gilliam, E. Et al. (January 2020). Urogenital and pelvic complications in the Ehlers-Danlos syndromes and associated. Hyper mobility spectrum disorders: A scoping review. Clin Genet. 2020 January; 97(1): 168-178:10.1111.
3. Fikree, A. Et al. (2017). Gastrointestinal involvement in the ehlers-danlos syndromes. Am J Med Genet Part C Semin Med Genet 175C:181-187.
4. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pgs. 607-608, 611-613, Williams & Wilkins, 1996.
V. Case History: Thoracic Outlet Syndrome
1. Sanders, R. (2007). Diagnosis of thoracic outlet syndrome. The Society for Vascular Surgery. Doi:10,1016
2. Qaja, E. Et al. Arterial thoracic outlet syndrome secondary to hypertrophy of the anterior scalene muslce. Journal of Surgical Case Reports.2017;8, 1-4.
3. Sanders, R. Et al. (2017). Pectoralis minor syndrome: Subclavical brachial plexus compression. Diagnostics 2017, 7,46.
4. Connolly, M. (2021). Anatomy and embryology of the thoracic outlet. Thoracic Surg Clin 2021 February;31(1):1-10. 5. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.239, Williams & Wilkins, 1996.
VI. Case History: Rib Cartilage Issues
1. Lou-Ren, C, et al. (21 Oct 2021). Anatomy, Cartilage. NCBI Bookshelf. 2021.
2. Grubbs, H. Et al. (21 May, 2022). Wound Physiology. NCBI Bookshelf. 2022.
3. Kollar, T. (17 March, 2020). Mechanosensitive aspects of cell biology in manual scar therapy for deep dermal defects. International Journal of Molecular Sciences. 2020, 21, 2055; dos:10.339/ijms21062055
4. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
5. Everts P, Onishi K, Jayaram P, Lana JF, Mautner K. Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020. Int J Mol Sci. 2020 Oct 21;21(20):7794. doi: 10.3390/ijms21207794. PMID: 33096812; PMCID: PMC7589810.
6. Bradley S. Polkinghorn, Christopher J. Colloca, Chiropractic management of chronic chest pain using mechanical force, manually assisted short-lever adjusting procedures, Journal of Manipulative and Physiological Therapeutics, Volume 26, Issue 2, 2003, Pages 108-115.
7. Wang HJ, Zakhari S, Jung MK. Alcohol, inflammation, and gut-liver-brain interactions in tissue damage and disease development. World J Gastroenterol. 2010 Mar 21;16(11):1304-13. doi: 10.3748/wjg.v16.i11.1304. PMID: 20238396; PMCID: PMC2842521.
VII. Case History: Wrist Injury
1. Murphy, B. Et al. (2020). The epidemiology of scapholunate advanced collapse. American Association for Hand Surgery. 2020, Vol 15(1) 23-26.
2. Stabler, A. Et al. (1990 Nov). Carpal instability and secondary degenerative changes in lesions of the radio-carpal ligaments with various etiology. Handchir Mikrochir Plast Chir. 1990 nov;22(6):289-95.
3. Lane, R. Et al. (27 June, 2022). Scapholunate Advanced Collapse. NCBI Bookshelf. 2022.
4. Terzis, A. Et al. (28 May, 2021). Inter-rater reliability of magnetic resonance imaging in comparison to computed tomography and wrist arthroscopy in SLAC and SNAC wrist. Journal of Clinical Medicine. 2021, 10, 3592.
5. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.755-765, Williams & Wilkins, 1996.
VII. Case History: Patient Mystery #33
1. Tsokos, G., Systemic Lupus Erythematosus: Basic, Applied and Clinical Aspects, 2nd Ed., April 2021, Academic Press.
Kyle Hagel, DC
Dr. Hagel has over 20 years of practice experience with a diverse practice background that includes Evaluation and Management of Auto Injuries, Functional Muscle Evaluation, Sports Medicine, Postural Reeducation, Structural Correction, Disc Injury Management, Spine and Extremity Bracing, Neuropathy Pain Management, Weight Loss, Functional Medicine, and Acupuncture. He also has benefitted greatly from working cooperatively with Physicians, Physician Assistants, and Nurse Practitioners in an integrated clinic for the last 14 years and continues to do so.
Educating patients has always been very important to Dr. Hagel in his practice. Patients that understand their condition make better decisions about their care. He is excited to now be involved in chiropractic continuing education and helping other doctors to do the same for their patients.