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muscle on the right. There was trigger point radiation down the right arm with palpation that reproduced his symptoms.

Active and passive range of motion of the neck was painful in all planes and restricted 90% of normal. Resisted range of motion was painful in all planes.

Orthopedic tests including Spurlings was positive on the right for radiation to the right arm. Neck traction test was positive for increased pain.

Neurological evaluation of the upper extremity for light touch, sharp and dull, temperature was normal bilaterally. Reflexes of the upper extremities were 2+ bilaterally for the biceps, triceps and brachial radialis.

A five view radiograph of the neck done on February 1, 2010 which was read by radiologist, I. C. Everything, M.D. The results were 1. Right convex curvature of the cervical spine secondary to muscle spasm. 2. Clinical correlation for a cervical disc herniation is necessary. Consider MRI or CT scan. 3. No evidence of fractures, dislocations or bone pathology.

After a clinical course of treatment, the patient was re-evaluated on March 16, 2010. The patient’s neck did not have a right lateral convexity but was now normal. The muscle spasms of the right upper back and neck were non-painful to palpation. Active and passive range of motion was full and non- painful. Spurlings and neck traction test were negative.

Assessment:

1. Cervical Sprain/Strain 2. Myofascial Pain Syndrome 3. Rule out Cervical Spine Disc Herniation

Plan & Discussion:

The patient was initially seen on February 1, 2010 with neck and right arm pain which was described as a constant and severe, sharp stabbing pain. The objective tests showed muscle spasms and trigger points in the right shoulder cervical spine area with associated compensations. The neck range of motion was severely limited. The patient had x-rays done and was given a clinical course of treatment consisting of home ice therapy for the first 48 hours, acupuncture, massage and passive range of motion. As the inflammation decreased, moist heat was used prior to treatment with spinal manipulation and stretches being introduced followed by home ice therapy. As the patient’s muscle spasms resolved, the neck curvature returned to normal, the trigger point in the teres minor muscle resolved and the patient’s symptoms reduced significantly. The patient was discharged after 12 office visits on March 16, 2010 with mild neck pain which is managed with home therapies including ice, heat, and massage.

800-549-5993

Copyright 2010 by Dr. Kevin McNamee, DC, LAc. Please do not duplicate in any manner.

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