History: Corporate executive, male, early 40’s with recent onset of cervical pain 6 weeks ago after weekend work trip.  Very sharp pain at the CTJ with referral to medial border of R scapula, plus some numbness/tingling down lateral arm to mid-forearm at times.  Symptoms have progressively worsened during past 6 weeks.  He has received chiropractic treatment 2-3X/week since onset with no relief.  Patient very upset at lack of progression and eager for a “fix.”

Aggravating: sitting > 30 minutes, sleeping in all positions, looking over L shoulder

Relieves: Massage temporarily

PMH: Insignificant

Major Objective Findings

AROM: Symptom reproduction with L rotation 75%

PROM: Symptom reproduction with L rotation, flexion 75%

Palpation: L>R upper trap, R levator scapula, R rhomboid

Joint: Stiff mid-upper T-spine with P-A, 1st rib B, decrease lower R cervical sideglide

Special Test: Distraction negative (painful), compression negative, Spurling R positive, Upper Limb Tension Test positive http://www.ncbi.nlm.nih.gov/pubmed/12544957

Neuro: Significantly weak R tricep weakness

SFMA (Selective Functional Movement Assessment): 

R shoulder ER: DN

Cervical: flexion DN, rotation R FN, rotation L DP

Differential Diagnosis: C7 discogenic, C7 facet joint, R upper trap trigger point

Treatment Initial Visit: After he had near full cervical flexion/L rotation, no numb/tingle

Manual: Upper thoracic manipulation, dry needling to B upper trap and R levator scap

http://www.ncbi.nlm.nih.gov/pubmed/23485766, http://www.ncbi.nlm.nih.gov/pubmed/23221367

HEP: repeated cervical extension every hour, foam roller/double tennis ball thoracic mobility, education on pain science and moving every 15-20 minutes

Treatment Second Visit: Patient 50% better since eval, had problem with tennis ball mob, very happy with progress

Manual: Same as evaluation, plus addition of IASTM with Edge tool along R upper trap/levator with patient in sitting (progressed from neutral to flexion/L rotation)

HEP: Reviewed tennis ball mob as patient did not have neck supported on pillow, added prone prop on elbows with repeated cervical extension (cue to drive mid-thoracic extension)

Treatment Third Visit: Patient even better, will be playing golf 3 rounds this weekend, near full AROM

Manual: Same as last visit

HEP: Added prone prop with extension/rotation B, encouraged cardio and general fitness

Overall this patient was clearly a rapid responder after 6 weeks of treatment that did not impact symptoms.  Hopefully the PT was a main driver in addition to the steroid pack.  Patient very happy with progress today and wants to follow up for one more visit after golf this weekend.  Biggest change in my practice has been high frequency, low volume HEP (Thanks http://www.themanualtherapist.com) Really think this helped in this case.  Please comment with questions or helpful thoughts to improve!