CHIR13009 CASE STUDY 1

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.
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

Questions
1. What further pertinent questions would you ask this patient?
a. Occupation and age. > 50 –60 osteoarthritis
b. Posture at work- ergonomics, sleeping posture
c. Onset – mechanism of injury
d. Previous Accidents
e. MH
f. How much pain VAS – course
g. NSAIDS, any other medications
h. Relieving factors
i. Previous treatments and outcomes
2. Based on the given information from the case history, what are your
differential diagnoses? Give reasons for each diagnosis given.
Right C5- C6 facet syndrome from jarring injury
Spondylosis- osteoarthritis C/C6
Compensation to T scoliosis= cervical sprain strain

3. What tests have been omitted in order to eliminate or confirm your list of
differential diagnoses mentioned in question 2?
a. O’Donagues- cervical sprain strain
b. Compression distraction – cervical disc
CHIR13009 CASE STUDY 1

c. Adam’s – scoliosis
d. Maximal cervical compression – facet syndrome
e. Cervical distraction- cervical capsulitis
f. SMR missing
g. Cervical xray series – DJD (reduced disc space , osteophytes)

Additional ideas:

Cervical rotation compression test

Cervical side bend compression test

Cervical Distraction test

Valsalva test

Doorbell sign (gentle please)

Rust Sign

Llermittes sign

4. Using only the information from the above case history and physical
examination, what is the likely diagnosis?
A C5/6 facet syndrome
5. Give a clinical impression (working diagnosis) from the information above.
The clinical impression is where you demonstrate your understanding of the cause and
progression of the complaint. It is where the discussion takes place relating to the
history findings examination and lab findings. For example, a final conclusion (final
diagnosis) may be C5/C6 joint syndrome. What factors have caused the facet pain to
start?
 Any local degenerative pathology
 Occupational or postural stress
 Congenital defect
 Aberrant biomechanics

If biomechanics is involved, this must be mentioned in your clinical impression.

Subluxations can be referred to as neurophysiological changes or fixations (aberrant
motion) however please be reminded that further research needs to be conducted in this
area.
The clinical impression should restate the diagnosis then include the predisposing,
complicating and aggravating factors.

Complicating Factors
Any recognizable physical conditions not caused by the primary condition already
described in the diagnosis, but probably affecting the primary condition. Examples
would include diabetes, arthridities, heart disease, hypertension etc

Aggravating Factors
Any lifestyle factors which would cause stress to the body and hinder it’s ability to
CHIR13009 CASE STUDY 1

resolve the condition. Stress in the from of physical, emotional, mental or chemical
factors would be listed. This would also include mental strife, undue stress, increase
workload requirement, poor sleeping habits, poor personal hygiene, poor attitudes etc.s

(ACA Journal of Chiropractic June 1991)

Based on the clinical hx that Ben is a computer office work with no previous history of trauma
and that the incident occurred in the past 4 days. The injury came on quickly as result of
jumping the fence and jarring the cervical spine. The prognosis is good for relatively speedy
recovery. This is however aggrav by a C shaped scoliosis apex at T7-8. On examination
preexisting postural dysfunction (Upper cross syndrome) and orthopedic test were +ve right
shoulder depression testing and max foraminal compression

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

STM, trigger point for hypertonic paraspinal muscles

Rehab upper cross syndrome and postural retraining
Trial of manipulation

Mid term goals to improve scoliosis and improve spinal biomechanics

7. Refer to the x-ray and indicate whether your treatment would change.
CHIR13009 CASE STUDY 1

http://www.pivonkahealth.com/tag/cervical-arthritis

Treatment include cervical towel to improve posture and cervical curve

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 Major cervical injury, holding your head, upper cervical
instability , Rh Arthritis = serious pathology Vizniak p 142
Cervical Axial C5- C6 reproduction of pain
Compression
Cervical To do
distraction test
Cervical sidebend To do
CHIR13009 CASE STUDY 1

Compression test
Cervical Rotation
Compression test Done C5- C7
Cervical Maximal Already performed
Compression test
Shoulder Already performed
Depression test
Shoulder To do
abduction test
(Bakody’s)
Valsalva test Disc
LLermittes sign Meningeal
Brachial plexus Nerve tension testing
tension test
Cervicogenic NA
dizzyness
Allen’s test NA
Wright’s test NA
(hyperabduction)
Adson’s test Na
Halstead test Na
(reverse adson’s)
Costoclavicular Na
test
Provocation Na
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.
CHIR13009 CASE STUDY 1

 median nerve entrapment (carpal tunnel) p 116 Vizniak

 radial nerve entrapment Vizniak p 97

ii. Give a list of differential diagnoses starting from the most likely.
 median nerve entrapment
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.pain L5
S1 nerve root – radicular , aggrav by compression and at night
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 – referred pain syndrome to the knee, vague pain no
discrete pattern
L5- S1 – capsular strain, specific dermatomal pattern
4. What musculoskeletal (MSK) conditions can give this pain distribution?
Sciatica- piriformis entrapment of sciatic nerve