CASE STUDY AND QUESTIONS: To be completed by the 19 July

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. Tightness of upper traps and levator scapula crosses with the tightness of the
pectoralis major and minor. Weakness of the deep cervical flexors crosses with weakness of the
middle and lower trapezius. Creates joint dysfunction particularly at the atlanto-occipital joint, C4-5
segment, cervicothoracic joint, glenohumeral joint and T4-T5 segment
There is a ‘C’ scoliosis apex at T7,8 to the left (levosoliosis)
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 (radiculopathy or brachial plexus
lesion)

Questions
1. What further pertinent questions would you ask this patient?
- How old is ben?
- Anything other than anti-inflammatory drugs that provides relief?
- Has the pain been getting any better or worse over the past couple of days?
- Have you noticed any other signs or symptoms that you think may be related?
- Any previous treatments and the outcome of the treatment
- Lifestyle, quality of life, other medical history, type of medication
2. Based on the given information from the case history, what are your differential diagnoses?
Give reasons for each diagnosis given.
- Ankylosing spondylitis – SI involvement and cervical spine involvement, more common in
males
- Nerve root involvement – for pain, restriction in upper cervical spine and the right shoulder
depression test being positive
- Degenerative spine disease due to the spinal pain and stiffness and can cause ivf
narrowing and spinal stenosis
- Secondary Osteoarthritis – because of SI involvement and trauma jumping fence?
- Facet syndrome – aggravated with extension and lateral flexion
- Scoliosis – can lead to muscular changes throughout body and may be exacerbated from
jumping over the fence
3. What tests have been omitted in order to eliminate or confirm your list of differential
diagnoses mentioned in question 2?
 - Bakodys to test nerve root  looking to relieve nerve symptoms, Valsalva  intrathecal
pressure, doorbell sign  reproduction of symptoms, cervical compression tests, cervical
distraction test
- Belted adams  to rule in/out SI joint, adams test to test for structural/functional scoliosis
- O’donohgues maneuverer
- X-rays to look for spondylosis
- SMR  when any neurological involvement
- Lhermittes sign (flexion of the neck and extension of the leg)

4. Using only the information from the above case history and physical examination, what is the
likely diagnosis?
- Right sided IVF encroachment at C5-C6
5. Give a clinical impression (working diagnosis) from the information above.

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

- Gentle manipulation
- Soft tissue therapy
- Mobilization
- Rehabilitation  postural, ergonomics

7. Refer to the x-ray and indicate whether your treatment would change.

http://www.pivonkahealth.com/tag/cervical-arthritis
Spurs on front of vertebra so may have difficulty swallowing, loss of lordosis
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 True negative
Cervical Axial True positive
Compression
Cervical True positive
distraction test
Cervical sidebend True positive RH, false positive LH
Compression test
Cervical Rotation True positive
Compression test

Cervical Maximal Already performed

Compression test
Shoulder Already performed
Depression test
Shoulder True positive
abduction test
(Bakody’s)
Valsalva test True negative
LLermittes sign True negative
Brachial plexus True negative
tension test
Cervicogenic
dizzyness
Allen’s test True negative
Wright’s test True negative
(hyperabduction)
Adson’s test True negative
Halstead test True negative
(reverse adson’s)
Costoclavicular True negative
test
Provocation True negative
elevation test.
For the ‘likely diagnosis’ for case 1 complete the following table:

General Questions: Test your knowledge!!! 

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.
Peripheral nerve, distribution fits with radial/medial nerve distribution depending
on the side she is feeling it. No neck pain suggests it is not spinal cord or nerve
root
ii. Give a list of differential diagnoses starting from the most likely.
 Radial nerve compression
 Median nerve compression
 C6 nerve root
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

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.
- Aggravation with activity, sitting for long time,
- Aggravation in particular with hip adduction and interal rotation which increase the tension
- Some patients find relief when walking
iv. L5-S1 capsular strain referring pain down the right leg.
- Likely also have back pain and pain aggravated
- Pain getting up from chair and standing up straight

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

- Piriformis syndrome
- Facet syndrome
- SI joint
 Study Guide Questions: 1.4

Each week, sample study questions will be provided to encourage them to keep up to date
with the expected knowledge and to appreciate the types of questions and/or material they
will be expected to know for the final written examination. The answers can be discussed in
the ZOOM sessions at designated times during the term. This will give them an
opportunity to work through your resources.

Name of Test Interpretation/ what is a positive test and what

tissue and structures are loaded?

Lateral Flexion Alar Ligament Stress Test
Anterior Shear or Sagittal Stress Test
Atlantoaxial Lateral Shear Test
Rotational Alar Ligament Stress Test
Detects instability of atlantoaxial articulation and tests
integrity of alar ligament
Positive test: excessive movement or reproduction of
patients symptoms
Tests integrity of supporting ligamentous and capsular
tissues of cervical spine
Positive test: nystagmus, pupil changes, dizziness,
soft end feel, nausea, facial and lip paresthesia, lump
sensation in throat
Detects instability of atlantoaxial articulation
Positive test: nystagmus, pupil changes, dizziness,
soft end feel, nausea, facial and lip paresthesia, lump
sensation in throat
Detects instability of atlantoaxial articulation
Positive test: more than 20-30 degrees of rotation
without movement of C2 indicates injury to
contralateral alar ligament, excessive motion in
opposite direction indicates instability due to increase
in neutral zone in joint

Transverse Ligament Stress Test Tests integrity of transverse ligament

Positive test: Soft end feel, muscle spasm, dizziness,

One leg Standing (Stork Standing) Lumbar
Extension Test
Passive Lumbar Extension Test
Prone Segmental Instability Test
Test of Anterior Lumbar Spine Instability
Test of Posterior Lumbar Spine Instability
Modified Schober’s Method
nausea, paresthesia of the lip face or limb, nystagmus,
lump sensation in throat
Positive test: pain in the back and is associated with a
pars interarticularis stress fracture (spondylolisthesis)
Positive if in extended position patient complains of
strong pain in the lumbar region
Positive test: pain is elicetid in the resting position
only, the test is positive because the muscle action
masks the instability
Positive test: little or no movement
Assess transverse movement of the pelvis around the
hip
CHIR13009 CASE STUDY 1