21yo patient with chronic neck pain

[physiofi]

Hi all,

Have started seeing a patient recently (privately) and could do with some peer support / ideas as I'm not 100% what is going on. Basically, he's a 21 year old male with a 5 year history of neck pain following an injury in rugby. He can't remember what happened, just that he went down in a scrum, didn't think he lost consciousness. Went to his GP and was checked over - gave it a bit of relative rest and it had improved quite a lot although he hadn't gone back to playing rugby.

Initial onset pain was R-sided anterior shoulder and up back of neck, with what he describes as a "pulsing, hard tennis ball" at the back of his neck (?muscle spasm) and L-sided neck and pain in upper traps. It seemed things were improving although he got intermittent pain on and off depending on activity (he does a very manual and varied job). 2 years ago he had a nasty car accident - aquaplaned at 80mph and rolled the car. Went to A&E and had x-rays - all came back clear and was diagnosed with whiplash associated disorder/soft tissue injury.

It seems his neck pain has been worse since this, although in further questioning he can't really give any further info. The pain is still intermittent, he can't identify any specific aggs other than it comes on gradually throughout the day, always worse in the evening and depends on how much work he is doing. He tried to return to rugby in November (he also had further x-rays done at this time when he saw GP, which came back NAD again) 2011 but was unable due to pain. Saw the pitch side physio who gave him some neck exercises / thoracic extensions (from what he described) but these didn't help either.

On examination, he has no red flags / 5 D's. No P+N or numbness and slight increased neural tension in his right arm on testing with a radial bias. His shoulder ROM is full in all directions and asymptomatic. His neck ROM is full in all directions and asymptomatic (both passively and actively). He has very tight upper traps bilaterally and tight pecs R>L. Dermatomes and myotomes are all normal. No objective tests brought on any symptoms.

I've given him general neck exercises and retractions to regularly, advice on posture and pec/upper traps stretches to do for now.

I was just wondering does anyone else have any ideas as to what could be the problem? My initial [tentative] diagnosis is chronic neck pain due to this old rugby injury, ?scar tissue, which has been aggravated by the car accident. I'm not sure if there's a discal element to his symptoms...any advice or further opinions would be much appreciated!

Thanks,

Fi.

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[nmarman]

I am not convinced call hospital and request x-ray reports. Can't tell you how many times patients tell me there was nothing on X-ray and when I look there is significant degeneration. I saw a Aussie rules case that had a tvp fracture who was also told that everything was normal when they should of said you have a fractured spine but it is stable so we arn't going to do anything for you.
Look for tvp misalignment in x ray and deep palpating while laterally flexing the cervical spine to examine this.
Are there any neurological signs at all?

[CBonella]

You didn't mention whether an MRI had been done or whether you had done any functional analysis...i.e. does his tension & postural alignment change when doing activities that bring on the discomfort (ergonomics in all positions & during activities, not just clinically based ROM testing) From age 16 -> 21 there's a lot of "growing" going on, both physically & emotionally. Sometimes you add an emotional element & everything changes.
What has he been doing/tried for the pain (i.e. oral or topical meds, moist heat &/or ice...etc?)? It sounds like the locus is @ the cervical end of the musculature. I find active stretching w/resistance sends stronger signals to opposing muscles to release & Theraband Academy has a routine/regimen for "chronic neck pain" on-line. As long as you register to receive their newletters as a qualified professional, they are free for the printing, & you could positionally adapt them to add more of a stretch where it's needed. Also, you didn't mention if Ultrasound had been tried. I find it focuses nicely on the tight, constricted tendons for more effective release.
Just some tid-bits to think about...Good Luck!

[Canuck Physio]

I would tend to agree that Xrays aren't everything. What we fail to see is the joint positions, joint anomalies, ligament sprains/scar tissue as already mentioned. Neural symptoms are appearing without a clear cause. A CT scan or MRI would be more revealing than simple Xrays. The problem does now appear chronic. Manual therapy of the neck would be necessary at this time.

[GrantP]

agree xrays are only gross tool for boney injury. CT will give some more info on bones if worreid re this especailly upper Cx. MRI will give some indication of any ligamentous instability or active inflammation etc.

'On examination, he has no red flags / 5 D's. No P+N or numbness and slight increased neural tension in his right arm on testing with a radial bias. His shoulder ROM is full in all directions and asymptomatic. His neck ROM is full in all directions and asymptomatic (both passively and actively). He has very tight upper traps bilaterally and tight pecs R>L. Dermatomes and myotomes are all normal. No objective tests brought on any symptoms.'

nothing of concern here though - did you also combine movement test Cx ROM ie fully flex and rotate left and right and fully extend and rotate left and right to check function under load and to stress upper Cx and lower Cx? if discal would seem unlikely or very mild from your notes above.

if so maybe the neck is actually clear, especially if you confident on you r manual testing of instability and the problem is postural, work associated pain?

what you have initiated sounds great, follow-up with neural flossing and maybe also try acupuncture?

good luck

[marj]

Given that your only objective signs involve muscle impairments, and the symptoms come on late in the day and with activity, I would focus on a detailed evaluation of muscle length, strength, especially endurance and also examine activation patterns with upper limb movements, including upper limb movements with load. Also, check relevant activation of postural muscles and strength, endurance of scapula thoracic muscles.

What sports, work is he participating in? This may give you additional ideas

Interested in hearing what you find. I would not expect such chronic symptoms to resolve with stretching alone.

[Canuck Physio]

Interested in hearing what you find. I would not expect such chronic symptoms to resolve with stretching alone.

Exactly and absolutely... Mobilise and re-stabilize...

[physiofi]

Hi all,

Thanks for all the replies and all your ideas! With regards to investigation, he has not had an MRI yet and he's unable to have one at present - basically his doctor won't refer him on for further investigation until he has had physio [in the NHS] and he's unable to attend any physio appts in the NHS due to work commitments and being unable to get any time off, hence him having some private sessions.

I hadn't done combined movements on testing so will have to assess this when I see him again. To add to my original post, I've been doing massage and focusing particularly on upper traps/cervical musculature as he seems to be very tense and imbalanced around this area. His symptoms have decreased a lot since I've seen him last and he says he feels his pain is settling, not as bad as it was previously even at the end of the day in work (and he's been doing more manual work the past 1-2 weeks).

He's not participating in any sports at the moment, he's tried to return to rugby previously but the neck pain had returned within 10 minutes of starting to play. He goes to the gym about 2-3 times weekly, just on crosstrainer/treadmill, not doing any weights or anything too strenuous (and this doesn't affect his pain).

Was definitely thinking about moving on to scap setting and looking at his shoulder girdle stability and core stability as a whole next. I'm not trained in acupuncture but all your ideas are v helpful! Thanks for the responses. I'll keep you posted on how things progress.

[msk101]

I'd like to suggest adding deep neck flexor strength ++++. start with basic supine retractions and go from there into neutral sitting then head forward. make sure it's a retraction not an extension.