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? How did it
happen did you twist as you jumped the fence or did you fall? Have you ever
been to a chiropractor before for this issue or anything else? What is your
occupation? Did this treatment work? Are there any relieving factors? Can you
describe the type of pain experience? Age. How would you rate your pain on
a scale 0 being no pain 10 being the worst pain you have ever experienced?
Are you experiencing any other associated symptoms? What is your previous
medical history?

2. Based on the given information from the case history, what are your
differential diagnoses? Give reasons for each diagnosis given. Ankylosing
spondylitis. Nerve impingement around c5/6. Possible facet joint syndrome.
Scoliosis could have exacerbated that area
3. What tests have been omitted in order to eliminate or confirm your list of
differential diagnoses mentioned in question 2? Bakodi or distraction to
eliminate or rule in nerve root involvement, then Valsalva and door bell. Do Cx
compression tests. Adams to help distinguish between SIJ and lx. Ott sign to
rule out AS. O’Donahue’s to test if it is function or structural scoliosis.
CHIR13009 CASE STUDY 1

4. Using only the information from the above case history and physical
examination, what is the likely diagnosis? SMR because of the neurological
involvement.
5. Give a clinical impression (working diagnosis) from the information above. R
Acute C5-6 IVF encroachment with nerve root pain affecting cervical
paraspinal muscles and deltoid.
6. Using only the information stated above, how would you treat/manage Ben?
STT to start, gentle mobilisation if treatment is progressing well and
symptoms are minimising could move to gentle manipulation ie activator.
Long term manage would be addressing ergonomics and start to give
exercises to strengthen paraspinal muscle and recreate lordosis curvature.
7. Refer to the x-ray and indicate whether your treatment would change. Most
likely would start a little softer.

http://www.pivonkahealth.com/tag/cervical-arthritis
CHIR13009 CASE STUDY 1

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 False negative They present holding their neck to prevent flexion:
Major trauma
Cervical Axial True positive because he is suffering from an IVF encroachment
Compression and axial compression reduces the IVF which will in turn
reproduce symptoms.
Cervical True Positive: Should have a relief when test is performed as it
distraction test opens the IVF should free the nerve pain.
Cervical sidebend True Positive on the right
Compression test
Cervical Rotation True positive on the right
Compression test

Cervical Maximal Already performed

Compression test
Shoulder Already performed
Depression test
Shoulder True positive
abduction test
(Bakody’s)
Valsalva test True positive
LLermittes sign False positive
Brachial plexus True negative as it may reproduce pain down the arm but isn’t
tension test associated to his disorder.
Cervicogenic True negative: may produce symptoms but not associated with
dizzyness his condition
Allen’s test True negative
Wright’s test False positive: test for thx outlet syndrome but may produce
(hyperabduction) symptoms
Adson’s test False positive: as above
Halstead test False positive:
(reverse adson’s)
Costoclavicular False positive
test
Provocation False 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. Peripheral nerve involvement. This is because of
the 3 fingers with no cx pain would indicate that it would be a
peripheral involvement. Nerve root entrapment would present
with cx pain and nerve trunk would present with more board
involvement.
ii. Give a list of differential diagnoses starting from the most likely.
Radial never palsy, early CTS, and C7 trunk
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 would be the cause as the pain in following a specific nerve
root ie Sciatic nerve root

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. Bonnets test will help confirm for piriformis
involvement by stretching the piriformis muscle aggravating
sciatic nerve distribution to confirm for piriformis myalgia.
iv. L5-S1 capsular strain referring pain down the right leg. Kemps
test would help confirm capsular strain, SMR would confirm no
disc involvement

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

- QL strain, disc herniation (sciatic nerve), SIJ