FY: Neck Pain: MD Evaluation (6 week Program)

  • 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
    • Enjoys Golf
  • 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