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Case study: Right-sided cervical spine pain

This is an excerpt from Clinical Guide to Musculoskeletal Palpation by Michael Masaracchio & Chana Frommer.

History

A 45-year-old female presents to your clinic reporting right-sided cervical spine pain that runs down the right arm. She reports that the symptoms began about 2 months ago while she was at work. She reports an increase in symptoms over the past month, with symptoms moving farther down her right arm and into her thumb. She states this is worse at the end of the day, after having been at work and on the phone and computer. She reports minimal relief after a hot shower. She says she thought the problem would get better on its own, but it has not, and she is now seeking help. She is married with two children, ages 6 and 8 years. She works as an administrative assistant (part-time) and is right hand dominant. She walks the family dog (40 pounds, or 18 kilograms) two times a day, takes a spinning class two times a week, and plays tennis once a week.

  • Based on this information only, what are the three most likely diagnoses?

Examination


  • Based on the subjective and objective information together, what are the two most likely diagnoses? Give your rationale for eliminating the third diagnosis.
  • What structures should you palpate on this patient based on your differential diagnoses?
  • Given all the information presented, what would you expect to find upon palpation of those structures?

Case Solution and Discussion

Potential Diagnoses Based on History

  • Cervical radiculopathy
  • Mechanical neck pain
  • Thoracic outlet syndrome

Potential Diagnoses Based on History and Examination

  • Cervical radiculopathy
  • Thoracic outlet syndrome

Mechanical neck pain: The positive Spurling's test, positive distraction test, positive quadrant test, and positive median nerve upper limb tension test, as well as decreased biceps and triceps reflexes and decreased sensation in digits 1 and 2 (C6-C7 dermatomal distribution) are all indicative of neurological involvement. Therefore, by definition, this diagnosis, which is purely mechanical in nature, can be ruled out.

Structures to Be Palpated

  • Radial pulse
  • First rib
  • Spinous and transverse processes C1 to C7
  • Upper trapezius
  • Levator scapulae
  • SCM
  • Scalenes
  • Pectoralis minor

Palpation Findings

  • Muscle spasm right upper trapezius, levator scapulae, SCM
  • Tenderness to palpation C3 to C7 spinous processes
  • Tenderness to palpation right first rib

Clinical Reasoning

  • Cervical radiculopathy: The patient's report of pain down the right upper extremity in a dermatomal pattern, and in addition the positive tests (Spurling's, distraction, and quadrant tests), the limited side-gliding of the vertebrae, and tenderness to palpation of C3 to C7, are more indicative of a C6 to C7 radiculopathy.
  • Thoracic outlet syndrome: The patient's report of pain down the right upper extremity, diminished sensation, and an elevated first rib are signs and symptoms of thoracic outlet syndrome. However, due to the negative Roos' and cervical rotation lateral flexion tests, as well as positive nerve root signs, thoracic outlet syndrome is less likely.

Read more from Clinical Guide to Musculoskeletal Palpation by Michael Masaracchio and Chana Frommer.