NOT EVERY NECK PAIN IS CERVICAL RADICULOPATHY
Patient Profile:
- Age and gender: 51-year-old female
- Occupation: Church sister
- Complaint: Right-side trapezius pain for the past 2 weeks.
History:
About 2 months ago, she started going to the gym. After performing an 80kg deadlift for 3 reps, she gradually developed pain in her right trapezius area. Fearing that she might worsen the pain, she avoided going to the gym.
But before the leg day in the gym, she had done upper body workouts like chest press, shoulder press, lateral raises, with heavier weights than usual. However, she did not feel any pain on that day. The pain started the next day after the deadlift, so she feels like the deadlift caused her pain.
Past medical history:
A year ago, she experienced a severe, shocking, and tingling sensation in both her palms during weight-bearing on the wrist. She visited multiple hospitals and was diagnosed with carpal tunnel syndrome. She had a strong belief in Varma treatments, so she underwent them for six months. She felt that she had recovered, but she still feels that there is a reduction in grip strength in both hands.
Past surgical history:
Eight years ago, she underwent a hysterectomy. She has a strong fear related to that surgery, which affects her confidence while exercising in the gym.
Physical activity status:
- She started going to the gym only for the past two months, yet she has not been consistent due to excessive soreness and fatigue.
- For the past 2 weeks, she has been sedentary due to this pain.
Sleep: Her sleep is disturbed due to pain. She can’t lie down on her right side.
Stress: She has a lot of stress due to her personal life issues and this pain.
Reason for consultation:
She wants to know the reason for that pain and wants to improve her overall fitness and well-being, so she visited us.
Pain Analysis:
| Category | Details |
|---|---|
| Intensity | 4/10 (tolerable) |
| Onset | Sudden |
| Aggravating Factor | Lying on the right side & all overhead activities |
| Relieving Factor | Rest |
| Location | Right side upper trapezius |
| Duration | Acute – 2 weeks |
| Character of Pain | Mechanical (load-induced pain) |
| Irritability | High (Immediately after exercise, pain arises) |
| Sensitivity | Low (After taking rest, pain subsides quickly) |
| Lifestyle Factor Impact | Mild impact. She avoided the gym due to this pain. |
| Fear of Movement Analysis | Pain & movement-related fear are present |
Psychosocial factor analysis:
- Cognitive – she had a wrong belief regarding exercise due to pain & surgery
- Affective -The pain is causing her significant emotional distress and worry.
- Social – She is living alone, and has lots of personal life stress
Our understanding of the patient’s problem from history and pain analysis:
She had a history of overloading in gym activities. So, that might have triggered her pain. However, she reported a history of carpal tunnel syndrome. So, we need to diagnose the exact reason for pain with a physical examination.
PHYSICAL EXAMINATION:
Observational findings: Nil
ROM analysis
- There is not much significant reduction in shoulder and neck ROM between the right & left sides, but Right-side neck lateral flexion is painful, and the right side shoulder external rotation (ER) ROM is reduced.
- End range of motion in all the right shoulder movements is painful (pain felt in the right trapezius)
Stability screening
- There is no noticeable strength difference between the right and left sides in exercises such as shoulder press, floor chest press, lateral raises, and triceps extension, except for the right side-lying external rotation and right side neck lateral flexion, which are relatively weak.
- However, while performing all these exercises on the right side, she experienced pain in the right trapezius after a few reps, whereas on the left side she performed comfortably without pain.
(Our understanding – Right shoulder ER mobility & strength is comparatively less, due to this, during all the overhead exercises, her right trapezius is getting overused.)
Palpation: Right upper trapezius & SCM are painful
Special tests:
- Tinel sign – Negative (Done to check status of carpal tunnel syndrome she mentioned in history. It’s not present now)
- Upper limb tension test – Negative.
- Spurling test – Negative.
- Cervical distraction test – Negative.
INVESTIGATION: Nil
DIFFERENTIAL DIAGNOSIS:
- Cervical radiculopathy
- No neurological symptoms such as numbness/tingling
- Upper limb tension test, Spurling and distraction tests are also negative. So cervical radiculopathy was ruled out.
- Acromio-clavicular joint pathology
- There is no localized pain over the AC joint.
- No pain in Horizontal adduction.
- No history of injury. So, AC joint pathology- ruled out
- Rotator cuff tear/Labral tear
- All the AROM of the shoulder is preserved.
- No pain in the shoulder joint
- No history of night pain & swelling.
- No history of injury
- So, ruled out.
DIAGNOSIS:
The diagnosis is NON-SPECIFIC NECK PAIN – (Rotator cuff related)
Reasons:
- Sudden progression of the load in gym activities, especially in the upper body workouts. Her right-sided posterior Rotator cuff muscles are comparatively weak. So, her right trapezius is getting overloaded.
- Right upper trapezius activation is also painful. So it indicates overloading of it.
- There are no symptoms of severe cervical spine or shoulder joint pathologies or radiculopathy symptoms.
- She had a high fear of movement & she was psychosocially affected, which also influenced her pain.
TREATMENT PLANNING:
Needs & goals: To be pain-free & to improve her strength & fitness
Totally, 6 sessions planned.
- 1st week – 3 days
- 2nd week – 2 days
- 3rd week – 1 day
Detailed treatment plan strategy:
1st week plan:
- Patient education provided regarding her negative beliefs on deadlift exercise, hysterectomy surgery fear related to pain, and also provided the psychological support, positive reinforcement to do the exercises.
- Improving Shoulder external rotation ROM.
- Unilateral rotator cuff & trapezius strengthening with adequate resistance to avoid overloading of the trapezius.
2nd week plan:
- Progressively overload the unilateral rotator cuff & trapezius strengthening.
- Overall body strengthening to achieve her goal.
3rd week plan:
- Explained clearly regarding Load management – advised to listen to the body & progressively overload the exercises every time.
- Strength & conditioning guidance provided – about Proper workout plan & how to do progression and Regression & RPE scales to achieve a better outcome in strength and fitness.