Diagnoses Flowchart

Injury Sx Generator MOI Primary Clinical Dermatomes/ Special Tests/ Interventions

complaint Presentation Myotomes/ Examination
DTR’s
Forward Head -Weak DNF -Prolonged abnormal -Pain -More common in -Stretch tight muscles
Posture -Lengthened neck posture females -Strengthen weak muscles
extensors -Dull ache -Posture education
-Tight -Non-referring -Soft tissue work
suboccipitals
Upper Crossed -Weak DNF/ -Prolonged abnormal -Pain -More common in -Stretch tight muscles
Syndrome rhomboids/ posture females -Strengthen weak muscles
serratus/ low trap -Dull ache -Posture education
-Tight pecs/ -Non-referring -Soft tissue work
suboccipitals/
levator/upper trap
Spondylosis/OA -Neck -Spectrum of spinal -Pain (not -Spondylosis -Not typically -OA X-ray: narrowing of -Joint protection strategies
-Can feel into arm, degeneration (OA is radicular unless without OA affected joint spaces, osteophytes, (avoid extremes of
upper T-spine, and further progressed) around nerve) radiographic cysts (subchondral), motion)
upper scapular -Stiffness changes: hair loss sclerosis -Mobilize locally and
region (facet patterns, temp -LOM in SB usually first globally
referral) changes on skin, -SB and ROT equally -Strengthen
hyperhidrosis limited > BB -Improve motor control
-OA radiographic -Restore muscular/CT
evidence present in health
90% of people > 60
y/o
-40% of people with
OA are
asymptomatic
Acute Cervical -Meniscoid -Meniscoid is drawn -Sharp, -Reduced rotation -BB, ROT, SB limited -Opening and traction of
Facet Lock into the joint with localized pain ipsilaterally towards painful side the facet to allow
flexion (prolonged -Able to move freely -Palpable paraspinal meniscoid to reduce back
head position) and is into flexion spasm at level of into place
unable to retract with involvement -Indirect technique:
extension -Tender traction and ROT away
-Swelling -Direct technique: traction
and ROT towards
-Maintainence of ROM
gained
-Ice to reduce
inflammation/ pain
modulation
Cervical Facet -Progression of -Repetitive meniscoid -Dull ache in -Not typically
Syndrome facet joint entrapment cervical spine affected but can be
degeneration (microtrauma) -Coupled motion if degeneration
-Neck -DJD restriction (SB, compresses a
-Scapular referral -Facet arthropathy ROT, BB) nerve
-Active trigger -Would cause
points diminished DTR’s,
 radiculopathy,
muscle weakness
Cervical -Compression of -Younger: foraminal -Radicular sx -Sx progress central -Diminished -Quadrant +
Radiculopathy nerve root encroachment caused to distal DTR’s -Compression +
by disc herniation -Neck pain -Radicular sx into -Spurling’s +
-Older: stenotic -Decreased cervical arms and hands -Distraction +
(lateral mostly) ROM -Muscle weakness -Test cluster: upper limb
foraminal -Dermatomal, tension test, spurling,
encroachment caused myotomal, and DTR distraction, cervical
by osteophyte changes rotation <60 degrees to
formation ipsilateral side
Cervical Disc -Disc -Disc degradation: -Pain -Dull ache to severe -Disc degredation -C7 60% of all cervical -Traction of cervical spine
Syndrome -Neck disc degrades -Numbness burning depending (herniation): can HNP: weakness in triceps -Mobilization and muscle
-Can feel into arm prematurely after 1 on structures disc compress nerve and finger extensors, energy technique of
injury (30’s – 40’s) contacts and diminish numbness and pain cervical spine
-DDD: normal -Worse in the DTR’s, cause radiating into middle -Soft tissue release
degradation after morning because radiculopathy, and finger -Posture education
multiple injuries disc is rehydrated, muscle weakness -C6 25% of all cervical
(50’s – 60’s) worse at work due to -DDD: can HNP: weakness in biceps
-Acute: some static postures, and encroach on and wrist extensors,
combination of SB, can’t get foramen and numbness and pain
ROT, BB, and/or comfortable at night compress nerve radiating to thumb side of
axial compression and diminish hand (Median nerve
-Chronic: progression DTR’s, cause distribution)
from facet syndrome, radiculopathy, and -C5 3rd most common
exposure to whole muscle weakness cervical HNP: shoulder
body vibration pain and weakness in
deltoid and into upper
arm, not usually
numbness and tingling
-C8 HNP: weakness with
handgrip, numbness and
pain radiating to little
finger side of hand (ulnar
nerve distribution)
Cervical -Spine -Damage to the spinal -Weakness -Flexion makes it -LMN findings at -Weakness and -Traction in flexion if
Myelopathy cord usually C5-C6 -Paresthesias better level of lesion clumsiness in hands tolerated
(spinal cord widest -Pain -Extension makes it -UMN findings -Paresthesias in hand -Neuromuscular re-
and canal narrowest) worse below level of -Decreased cervical education
-Older: osteophyte lesion ROM -HVLAT contraindicated
and ligament -Hyper-reflexia -Weakness or stiffness in -Soft tissue release
thickening causing -Extrasegmental legs -Surgical decompression
central stenosis paresthesias -Unsteady gait
-Younger: central (typical -Pain
HNP dermatomal -Slight hesitancy on
-Sudden onset: MVA, patterns not always urination
axial load evident) -Lhermitte’s sign
-Quadrant +
-Compression +
-Spurling’s +
 -Distraction: could
alleviate or provoke
-Babinski
-Hoffman’s not as
common
-Test cluster: abnormal
gait, Babinski, Hoffman,
Inverted supinator sign, >
45 y/o
Whiplash -Cervical muscles: -MVA -Neck pain -Fatigue -Altered muscle -Conservative approach
SCM, semispinalis -Athletic injuries and/or occipital -Vertigo recruitment patterns: fatty -Protective
and splenius -Trauma headaches -Visual disturbances infiltration -Bed rest 2-3 days
capitis, upper trap -Falls -Neck stiffness -Depression -Sensorimotor: joint -Modalities
-Cervical -Insomnia repositioning errors, -Pain-free ROM
ligaments: alar, -Hyper-irritability balance disturbance, -Gentle isometrics
transverse, -WAD: pain > 3 dizziness
tectorial, months -Sensory hypersensitivity
interspinous -WAD I: neck pain,
-Disc stiffness, tenderness,
-Facet: contusion, no signs
occult fracture, -WAD II: neck pain,
recurrent stiffness, tenderness,
meningeal nerve, some point
meniscoid tenderness or LOM
-CNS/PNS -WAD III: neck
pain, stiffness,
tenderness,
neurological signs
-WAD IV: neck
pain, fracture or
dislocation
Cervical Fractures -Neck -Compression: pure - Middle column can -Spinal cord injury -Depends on extent of
flexion (failure of the protrude into the possible leading to damage to ligaments
anterior column) canal, resulting in UMN signs (PLL), disc and/or none
-Burst: intense axial paralysis or death -Extrasegmental -We will see after
load (failure of paresthesias, stabilizstion
anterior, middle, and hyper-reflexia
posterior columns)
Thoracic Facet -Facet -Trauma -Localized pain -Not typically -Common patterns: -Stretching
Syndrome -Associated rib -Posture -Possible facet affected but can be -T1 extension restriction -Mobilization
(costotransverse referral pain if degeneration due to forward head -HVLAT
joint positional compresses a posture -Muscle energy technique
fault) nerve -T3-T7 flexion (basically PNF contract-
restriction/rib dysfunction relax or hold-relax)
-T8-T12 extension
restriction
T4 Syndrome -T4 -Unknown -Headache -Hand clumsiness -Altered -AROM/PROM WNL -Traction: cervical and
-Onset may coincide -Pain, pins, -Heaviness in upper dermatomes and pain-free thoracic
with new job that and/or needles extremities although not -Neurological findings -PA mobs
requires frequent into hands typical thoracic negative -Thoracic HVLAT above
stooping or bending spine presentation -Pas stiff mid T spine and below T4
 -Hands feel and may -Hot or cold hands to -Postural correction
objectively be tough
swollen -Tender mid T spine
-T2-T7 dull, -Deviation/prominence of
intermittent mid SPs (not just because
back pain skinny, actual
-Headache morphological changes)
-Glove distribution
pain or pins and
needles
-Worse at night and
better changing
position or getting
up
Peripheral Nerve -Nerve -Compression -Paresthesias -Pain progresses to -Diminished
Entrapment -Traction -Muscle anesthesia DTR’s
-Friction weakness -Numbness constant -Radicular sx
-Anoxia -Motor weakness -Muscle weakness
-Cutting progresses to muscle
wasting
-Warm, flushed skin
progresses to cold,
white skin
-Scaly skin
progresses to thin,
smooth, shiny skin
-Dry, brittle nails
-Loss of sweat
glands
Thoracic Outlet -Neurovascular -Trauma -Diffuse pain -Worse with arm -Possible -Adson’s test for tight -Treat the cause of TOS
Syndrome bundle as it exits -Repetitive overhead -Paresthesia elevation diminished DTR’s, scalenes or cervical rib (can’t treat cervical rib)
through thoracic activities -Numbness -Hand/arm doesn’t radicular sx, and -Costoclavicular test for -Reduce pain and
outlet -Developmental: -Weakness feel like their own muscle weakness elevated 1st rib inflammation
-Feel sx in arm, scapula descends -Heaviness -Unusual fatigue when sx provoked -Hyperabduction/Wright -Avoid cervical traction
shoulder, head, pulling on soft tissue -Fatigue with elevated test can also be used for -Postural correction
chest, axilla and causing -Swelling positions elevated 1st rib and tight -OMT: mob 1st rib,
peripheral nerve -Discoloration -Changes in skin pec minor scapulothoracic mobility,
entrapment temperature -Roos test for general scapular
(involved vs. TOS test strengthening/motor
uninvolved side) control exercises
-Pec stretch
-Surgery (try to avoid if
possible): cervical and 1st
rib excision, scalene
release
Thoracic -Spine -Hyperflexion -Severe pain -Hyperkyphosis -T9-T11 most common -Alleviate pain with
Compression -Axial compression -Risk factors: -X-ray: increased graded return to loading
Fractures -Fractures as a result -Older female radiolucency, thinning of -Engage stabilizing
of metabolic bone -Estrogen deficiency cortical margin, musculature (back, abs,
disease (osteoporosis) -Poor diet trabeculae number and diaphragm)
-Alcoholism thickness decreased
 -Smoking -Possible reduced -Early movement to
-Sedentary lung/heart capacity prevent secondary
-Chronic steroid use -Cervical hyperextension impairments (ex:
compensation pneumonia)
-Painful ambulation -Avoid extension
(can’t dissipate forces -Increase loading
properly due to -Increase aerobic
spinal/pelvic endurance
malalignment) -Increase strength
-Light traction above and
below fracture
Rib Fracture -Rib -Direct blow -Localized -Evidence of trauma -Difficult to assess on x- -Protection with bracing
-Severe coughing tenderness -Pain with ray, callus often first to help reduce rib
(geriatrics) -Pain on deep movement evidence excursion and
-Overuse (golf, inspiration -PA tenderness/pain approximate bones
baseball high rotation -Relative rest
forces) -Analgesics
Scheuermann’s -Spine -Defect of ring -Diffuse back -Hyperkyphosis -Sharp angulation of -Anterior stretching (pecs,
Disease apophysis of pain kyphosis with trunk FB abdominals)
vertebral body in -Additional -Extensor strengthening
adolescents made complications include -Severe cases: bracing or
noticeable from: burst fracture, spinal fusion
-Axial loading of compression fracture,
spine (ex: heavy associated scoliosis,
backpack) Schmorl’s nodes
-Obesity (vertebral body
-Possible multiple degeneration allowing
microtrauma to disc to extend into body)
epiphysis (ex: heavy
lifting, high contact
sports like football,
lacrosse, soccer)
Scoliosis -Spine -Functional: habitual -Structual Idiopathic: -Non-structural: correct
poor posture, pain assess if there are cause of scoliosis
and muscle spasm, fractures, other structural -Strucutral: refer to
leg length impingements/occlusions, orthopedic surgeon,
discrepancy (actual visceral organs impaired, perform regular
shortening or nerves impaired, check assessment, and treat what
apparent shortening leg length you can typically after
from pelvic obliquity) -Adam’s Test: check for surgery
-Structural Acquired: rib hump -Scoliosis 20-40 degrees:
osteopathic – bracing
fractures, thoracic -Scoliosis > 50 degrees:
surgery, rickets, spinal fusion
osteomalacia;
neuropathic – polio,
paraplegia,
Friedreich’s ataxia
-Structural
Congenital:
osteopathic –
hemivertebrae,
osteogenesis
imperfecta;
neuropathic – spina
bifida,
neurofibromatosis;
myopathic –
amyotonia congenita
-Structural Idiopathic