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When The Physical Exam May Not Be Enough

I’ve been presenting cases of important diagnoses made simply by physical exam. A ganglion cyst, a foot ulcer, and a dissecting abdominal aortic aneurysm were all correctly identified with a basic physical exam. However, there are times when a physical exam may not be enough – and reliance on it alone can be quite misleading.

A middle aged man was referred to our sports rehabilitation clinic after undergoing an unsuccessful orthopedic surgical procedure. He had been lifting heavy weights at his gym for some time, and was complaining of weakness in his right arm. He eventually got an appointment with an orthopedic surgeon, who noted that his right biceps muscle was severely reduced in its bulk. Assuming he had ruptured his biceps tendon, he was scheduled for repair the next week.

The surgeon was baffled after opening the arm and exploring the anatomy – the biceps tendons were both perfectly in tact, though the muscle was indeed quite atrophic.

What he didn’t realize was that the man had not ruptured his tendon, but had severely impinged his musculocutaneous nerve where it travels through the coracobrachialis muscle. The heavy weight lifting had caused his coracobrachialis muscle to hypertrophy to a point where the nerve supplying the biceps muscle was actually crushed by the size of the muscle.

The man slowly regained nerve function and was fine so long as he didn’t lift heavy weights again. The only long term side effect that he suffered was a surgical scar on the inner side of his right arm.This post originally appeared on Dr. Val’s blog at

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3 Responses to “When The Physical Exam May Not Be Enough”

  1. scanman says:

    Great story. But this is a real tough one to diagnose. I don’t think they would have gotten it even if an MRI was done. Must have involved a lot of retrospective analysis.

  2. moof2 says:

    I’m curious. How is such a problem diagnosed?

  3. ValJonesMD says:

    The diagnosis could have been made with electrodiagnostic studies. It is also possible that the examiner missed some sensory complaints during the physical exam. Here’s an example of how some orthopedists made the correct diagnosis.

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