- Subjective:
- Neck Pain since march 2017 following vacation in Aruba after a white water rafting trip
- Had chiropractic treatment for about a month with no significant relief
- Went to physical therapy where treatment was focused on a potential 2nd rib problem with no significant benefit
- Pain is located on the L side of the neck which is a 5-7/10 at worst
- Described as a stabbing/aching sensation
- She has some concerns as to what the source of the pain is
- Pain does not limit her activity an does not seem to be impacted by golf or other activities
- PMH: hypercholesterolemia, hypertension, GERD, hypothyroidism
- Past Surgical history:
- Foot surgery, C-sectionx2
- Social History
- Objective Findings
- Full neck motion inot flexion and extension
- Pain with end range extension
- Full Right rotation without pain
- Left rotation with 50% limitation with L sided neck pain
- Full shoulder flexion and abduction
- Good upper extremity strength
- Tender to palpation over L cervical paraspinals and cervical facet joints
- Left sidebend with R rotation reproduced left facet pain
- Imaging
- Facet joint arthrosis in upper cervical segments
- Straightening of cervical curvature
- Loss of disc height at C6-C7
- Assessment
- L sided neck pain mid to upper cervical
- mild cervicogenic headache
- Pain with L rotation, sdiebend, and extension
