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) (apex is the most severe
part of scoliosis)
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 is he experiences – sharp, achy, dull?
How old is Ben? – helps with differential diagnosis
Are there are aggravating or relieving factors?
Is the pain getting better or worse on a VAS?
Any associated symptoms?
Show me the ergonomics of your seated posture at work?
Any previous episodes of pain?
Any previous treatment, outcome of treatment?
Medical history, life style factors (yellow flags)?
Mechanism of injury?

2. Based on the given information from the case history, what are your
differential diagnoses? Give reasons for each diagnosis given.
Facet Jt syndrome – did the injury occur through extension and lateral
flexion?
SCM and anterior scalene strain – Lateral flexion to the left is painful
Spondylosis from C spine
Radicular pain from C5-C7
CHIR13009 CASE STUDY 1

Scoliosis can lead to muscular changes in the body. Pain could be

compensation from scoliosis that was exacerbated
3. What tests have been omitted in order to eliminate or confirm your list of
differential diagnoses mentioned in question 2?
Bakody’s to test if it’s a nerve root.
Cough Valsalva
Doorbell sign – to see if pain in the brachial plexus pain is reproduced
Cervical compression into flexion to low lower cervical and into maximal
compression to load IVF.
Adam’s test – structural or functional
O’Donoghue’s differentiates muscle and ligamentous strain
Cervical kemps to try and rule out/in facet joint syndrome
Cervical distraction to see if pain increases or decreases
X-ray for spondylosis
Russ sign – sign of cervical instability where the patient holds their own head
in slight flexion – x-ray
Lhermitte’s sign – any shooting pain for meningeal irritation

Could also to nerve testing – SMR

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

Acute Right side C5-C6 IVF encroachment from spondylosis (or aggravated
by scoliosis) affecting NRs affecting lateral flexion cervical spinal muscles and
causes deltoid muscle

NEED TO INCLUDE TIME (EG> ACUTE>CHRONIC), SIDE AND TYPE in

final diagnosis.

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

Scoliosis will be a contribution factor in this diagnosis that will complicate it
SI Joint restriction may play a role
Upper cross syndrome – muscular imbalance between deep neck flexors,
traps and rhomboids
Restrictions indicate arthritic changes
Don’t have a full medical history so don’t know if he has any other
complicating factors

See moodle document

6. Using only the information stated above, how would you treat/manage Ben?
Short-term treatment - Soft tissue work – Trp therapy, gentle stretching,
mobilisation, trial of gentle adjustments and possible traction (could include a
C5/C6 pillar push)

Mid-term Give some advice on posture and ergonomics in the workplace and
try to treat the upper cross syndrome
CHIR13009 CASE STUDY 1

Long- term - regain cervical lordosis through cervical towel (lay neck over
towel to create gentle traction)

7. Refer to the x-ray and indicate whether your treatment would change.
Spurs of anterior vertebra may create a difficulty in swallowing
There is a loss of cervical lordosis with narrowed disc spaces.
With arthritic changes – may want to start treatment more gently.

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

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 positive – indicates major cervical trauma or instability
CHIR13009 CASE STUDY 1

Cervical Axial Would be a true positive as cervical axial compression tests the
Compression lower cervical spine and Ben is experiencing pain at C5-C7
Cervical True positive for nerve root impingement if distraction improves
distraction test pain or a false positive if pain increases with distraction
Cervical sidebend Compresses facets to the side -> likely to be a true positive for
Compression test facet sprain/strain
Cervical Rotation Compresses facets to the side -> likely to be a true positive for
Compression test facet sprain/strain
Cervical Maximal Already performed
Compression test
Shoulder Already performed
Depression test
Shoulder True positive to test
abduction test
(Bakody’s)
Valsalva test May be positive if there is a disc problem but will be a true
negative if there is a facet problem
LLermittes sign Looking for neuromeningeal irritation
Brachial plexus Likely to be a true positive due to radicular symptoms to the
tension test elbow

Cervicogenic Maybe positive if Ben fell and stuck his head as he jumped over
dizzyness the fence which would indicate major damage to the neck
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:
CHIR13009 CASE STUDY 1

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.
As the pins and needles symptoms are isolated to the first three digits, it is most
likely to be a peripheral nerve entrapment.
ii. Give a list of differential diagnoses starting from the most likely.
C6 Nerve entrapment
Carpal tunnel syndrome
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.

As Sally also experiences back pain with intermittent pins and needles to the
back of the leg and foot, she is likely to be experiencing radicular pain due to
sciatic nerve compression at L5-S1.

Could also be piriformis syndrome with sciatic nerve entrapment

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.
Increased pain on prolonged sitting and walking upstairs, dull
ache in the piriformis muscle/hip. Reduced Rom in the Hip
iv. L5-S1 capsular strain referring pain down the right leg.
L5-SI would have tenderness over the facet joints whereas piriformis
myalgia would be tender in the piriformis muscle
L5-S1 would test positive in Kemps, lumbar extension with sharp
superficial

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

Piriformis syndrome would have increased pain on prolonged sitting and
walking upstairs, dull ache in the piriformis muscle/hip. Reduced Rom in the Hip
L5/S1 facet sprain/strain
CHIR13009 CASE STUDY 1