Week 1 Case 1: Ben

Presenting Complaint:
Ben complains of left sided neck pain with intermittent radiations to the left deltoid.
The pain does not extend below the left elbow. The pain seems to be aggravated by
extended periods of computer work. This complaint is of 4 days duration and came
on suddenly after jumping a fence to catch his dog. There has been no previous
history of neck pain except it feels stiff every now and then. He has been taking anti-
inflammatory drugs with temporary relief.

Physical Examination
Observation: Upper cross syndrome with muscle hypertonicity in left cervical
paraspinal muscles and left deltoid.
There is a ‘C’ scoliosis apex at T7,8 to the left (levoscoliosis)
Cervical ROM: Lateral flexion to the left is painful around the C5,6 level.
Palpation: The right sacro-iliac joint is restricted into flexion. T4-8 segments are
restricted into flexion and right rotation. C5-7 is stiff and restriction in all directions
Right cervical maximum compression testing is positive for pain on the left side at
C5,6 level. Right shoulder depression testing is positive for the left side at C5,6

Questions
1. What further pertinent questions would you ask this patient?

- What type of pain are you experiencing?

- How old are you?
- Course?
- Have you had any previous treatment for this injury?
- Can you remember any previous episodes of this injury occurring?
- Are there any associated symptoms with this injury?
2. Based on the given information from the case history, what are your
differential diagnoses? Give reasons for each diagnosis given.

- Cervical Spondylosis due to the pain and stiffness occurring in the

patient’s neck. Cervical spondylosis results in a narrowing of the space
required by the spinal cord and the nerve roots that pass through the spine
to the rest of the body. Ben is experiencing intermittent radiation to his left
deltoid which could be an indication of nerve root compromise
(radiculopathy) and potential impingement. Depending on bens age his
cervical disk size may shrink and dehydrate which could result in
osteoarthritis developing and bony projections such as bone spurs could
become apparent.

- Cervical Sprain due to sudden injury to the muscles of bens neck,

causing a spasm of the cervical and upper back muscles. This could be
due to poor posture brought on by the apparent scoliosis along with the
fact he jumped over a fence.

- Cervical Radiculopathy due to a nerve root being irritated due to

compression of a structure (protruding disc, arthritis of the spine, or mass
or cyst). Symptoms can include pain, weakness or changes in sensation
such as tingling or numbness in the arms.

- Cervical Facet Syndrome due to axial neck pain which does not radiate
down past the shoulders and is usually unilateral. Pain can be present
when extending or rotating and tenderness upon palpation. Symptoms can
include radiating pain locally, into the shoulder or upper back and rarely
into the front or down the arm like disc herniation might.

3. What tests have been omitted in order to eliminate or confirm your list of
differential diagnoses mentioned in question 2?

- Shoulder Decompression Test if the pain is reproduced could be

indicative of nerve root compression or irritation or foraminal
encroachments such as osteophytes
- O’Donoghue Manoeuvre tests for cervical sprain; pain during resisted
motion could indicate muscle strain whilst pain during passive motion
could indicate ligament sprain.
- Cervical Axial Compression Variation Tests utilized to test for
compression of cervical nerve roots and facet joint irritation. A positive test
could indicate an intervertebral disc lesion; Increase local pain could
indicate joint damage, facet lock or ligament strain. Increased peripheral
pain could indicate increased pressure on nerve roots (IVF
encroachment/radiculopathy)
- Cervical Distraction Test useful in accessing facet joint integrity along
with nerve root compression. If there is pain relieved as a result of the
movement then it is positive for nerve root compression and facet joint
pressure.
- Valsalva is utilized to create intrathecal pressure
 - Doorbell Sign used to investigate if midthoracic pain is of cervical origin
or if arm symptoms have a neurological component.
- SMR Testing is important to perform whenever there is any neurological
nerve involvement occurring.

4. Using only the information from the above case history and physical
examination, what is the likely diagnosis?

- Cervical Spondylosis C5-C6 right sided IVF encroachment with nerve root
pain that is affecting the deltoid muscle.

5. Give a clinical impression (working diagnosis) from the information above.

- Scoliosis and postural defect are noted. The final diagnosis would be a

C5-6 joint syndrome (spondylosis). The complaint arose with no trauma or
previous history of the issue and began 4 days ago. It is noted that the
injury presented after Ben jumped over a fence suddenly. The prognosis is
positive, and a short recovery period is likely. Within Ben’s history, it is
noted that he has a postural dysfunction (Upper Cross syndrome) with
orthopaedic tests resulting positive for a cervical maximum compression
test and shoulder depression test. It was also detected that a ‘C’ shaped
scoliosis with an apex of T7-8 was aggravated during the fence incident.

6. Using only the information stated above, how would you treat/manage Ben?

- Massage and soft tissue work

- Trigger point therapy
- Mobilization
- Roll Towel
- Gentle Adjustments
- Rehabilitation (address ergonomic concerns/postural training)
 7. Refer to the x-ray and indicate whether your treatment would change.

- Treatment would change to include gentle mobilizations/manipulations.

NAME OF TEST For Cases 1 indicate the likely outcome

for the following tests. Indicate whether
it is likely to be a true positive, false
positive, true negative, false negative
Rust Sign Patient holds head; with both hands, in
slight flexion for major injury = RA or
trauma
Cervical Axial Compression True positive.
Cervical Distraction Test True positive.
Cervical sidebend compression test True positive.
Cervical Rotation Compression Test True positive.
Cervical Maximal Compression Test Already performed
Shoulder Depression Test Already performed
Shoulder Abduction Test (Bakody’s) True negative
Valsalva Test True negative
LLermittes Sign True negative
Brachial plexus tension test False positive
Cervicogenic Dizzyness True negative
Allen’s Test True negative
 Wright’s test (hyperabduction) True negative
Adson’s test False positive
Halstead test (reverse adson’s) False positive
Costoclavicular Test False positive
Provocation elevation test. n/a

1. A 58-year-old female presents with pins and needles in the first 3 digits of the right
hand. There is no cervical pain. 

i. Is this pain likely to be coming from the spinal cord, nerve root, nerve trunk or an
entrapment of a peripheral nerve? Explain your answer. Entrapment of a peripheral
nerve is most likely due to the pattern and distribution of S/S. 

ii. Give a list of differential diagnoses starting from the most likely. Carpal tunnel
syndrome or Pronator teres syndrome. 

2. Sally is 34 years old with 4 children. She suffers intermittent pins and needles to
the back of the leg to the foot. The pins and needles are aggravated by sitting and
occasionally occurs at night. The symptoms can be traced. Sally also experiences
low back pain. Is Sally likely to be suffering referred or radicular pain? Explain your
answer. Using ONLY this information give an aetiology for Sally’s symptoms.
Radicular pain is most likely the cause due to the distribution of pain and likely
diagnosis. Sciatic nerve pain is expected as the pain distribution fits the same profile
and is worse at night. As well as shooting type pain, neurological symptoms. 

3. Using your physical examination procedures differentiate between the following

conditions: 

iii. Piriformis myalgia with pain down the posterior aspect of the right leg to the knee. 

iv. L5-S1 capsular strain referring pain down the right leg. 

Piriformis myalgia is caused by microtrauma to the buttocks, whereas L5-S1

capsular strain

What musculoskeletal (MSK) conditions can give this pain distribution?

- SI syndrome.
 Name of Test
Lateral Flexion Alar Ligament Stress Test
Anterior Shear or Sagittal Stress Test
Atlantoaxial Lateral Shear Test
Rotational Alar Ligament Stress Test
Transverse Ligament Stress Test
One leg Standing (Stork Standing) Lumbar
Extension Test
Interpretation/ what is a positive test and
what tissue and structures are loaded?
This test detects instability of the
atlantoaxial articulation & tests the integrity
of the alar ligament. A positive result would
show excess movement or reproduction of
symptoms
This tests the integrity of supporting
ligamentous & capsular tissues of the
cervical spine. A positive test includes
nystagmus, pupil changes, dizziness, soft
end-feel, nausea, facial or lip paresthesia,
lump in throat sensation.
This test detects instability of the
atlantoaxial articulation. A positive finding
includes nystagmus, pupil changes,
dizziness, soft end-feel, nausea, facial or lip
paresthesia, lump in throat sensation.
Detects instability of the atlantoaxial
articulation and stresses the alar ligament. A
positive finding may include 20-30 degrees
of rotation without movement of C2
(indicates an injury to the contralateral alar
ligament), or excessive motion in the
opposite direction (indicates instability due
to an increase in ‘neutral zone’ in the joint).
This test stresses the transverse ligament
which helps to hold the odontoid process f
C2 against the anterior arch of C1; indicates
hypermobility at the atlantoaxial articulation.
A positive finding results in a soft end-feel,
muscle spasm, dizziness, nystagmus, pupil
changes, soft end-feel, nausea, facial or lip
paresthesia, lump in throat sensation
This test is used to assess the lumbar spine
for instability. Positive test results include
pain in the back & is associated with a pars
interarticularis stress fracture. Unilateral
stress fractures cause pain when standing
of the ipsilateral leg. If rotation is combined
with extension and pain results, it indicates
a possible facet joint pathology on the side

Passive Lumbar Extension Test
Prone Segmental Instability Test
Test of Anterior Lumbar Spine Instability
Test of Posterior Lumbar Spine Instability
Modified Schober’s Method
of rotation.
This test is used to assess the lumbar spine
for instability. Positive finding includes
strong pain in the lumbar region with heavy
feeling in the low back, or it feels as if the
low back is ‘coming off’ & pain stops when
the legs are lowered to starting position.
(important to note that numbness or
prickling sensations are not signs that result
in a positive finding).
This test is used to assess the lumbar spine
for instability. Positive test is confirmed if
pain is elicited in resting position only due to
muscle action asking instability.
This test is used to assess the lumbar spine
for instability. Positive result is due to
notable segmental movement.
This test is used to assess the lumbar spine
for instability. Positive test findings are
confirmed with notable segment movement.
This test measures the amount of flexion in
the lumbar spine. A positive finding results
when less than 5cm increase in length on
forward flexion is recorded. May suggest
and ankylosing condition.