Musculoskeletal Medicine in Primary Care: An Essential Guide for Examination, Diagnosis and Management

By Dr Solomon Abrahams

This book is designed to help MSK Physicians, Physiotherapists, Osteopaths, G.Ps and other respected colleagues in the examination, diagnosis and management of Common MSK pathologies presenting in primary care.

Chapters are sectioned according to the anatomical area of the body. Each chapter consists of Basic Anatomy, Subjective (including differential diagnosis and red flags) and Objective examination, Observation and Physical examination, special tests (and their reliability), Pathologies, key points and flow charts for triaging. Where possible, we have used evidence based research to suppliment the practice based experience within the book.

Some special chapters are dedicated to common pathologies seen in the elderly and children/ adolescents. Other chapters include Joint injections in primary care, Medicines that conflict with MSK diagnosis/management, common blood results and their meaning and common connective tissue disorders.

Where possible, we have supplemented chapters with Scans, X rays, Pictures and flow charts to help explain the simplicity of each pathology. The flow charts at the end of each primary chapter is to help triage pathologies.

• Language: English
• Publisher: Xlibris UK
• Release date: Feb 18, 2014
• ISBN: 9781493140060

Dr Solomon Abrahams

Dr Solomon Abrahams is clinical Director of Anatomie Physiotherapy clinic(s) based in London, UK. He has been practising for over 20 years in MSK medicine and currently practices from his main clinics in Harrow and Harley Street, London. Solomon has vast MSK experience with over 18 years of working within Primary care centres, Accident & Emergency departments and within Sports medicine departments. He also has over 15 years of experience working for an academy of Premiership football club. Solomon also lectures and examines at several Universities in London. He is clinical fellow at Hertfordshire University and formely has lectured at Kings College London, University College London and Cambridge University Medical School. Dr Abrahams has also published other material including over 40 different professional medical and research articles for prestigious medical journals and text books including Sports Medicine in Children and Adolescents.

Book preview

Copyright © 2014 by Dr Solomon Abrahams. PID 521162

Library of Congress Control Number: 2014902338

ISBN: Softcover            978-1-4931-4007-7

          Hardcover           978-1-4931-4008-4

          Ebook                 978-1-4931-4006-0

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Rev. date: 03/05/2014

Xlibris

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Contents

Cervical Spine

Thoracic Spine

Lumbar Spine

Hip, Pelvis, and Thigh

The Knee

Ankle Joint

The Foot

The Shoulder

Elbow Joint

Hand and Wrist Injuries

An Overview of Common Pathologies Seen in the Elderly in Primary Care

Common Pathologies Seen in Children and Adolescents

An Overview of Joint Injections

Connective Tissue and Rheumatic Disorders Seen in Primary Care

Common Medications Used in Primary Care

An Overview of Blood Tests and MSK Pathology

MUSCULOSKELETAL MEDICINE IN PRIMARY CARE

Examination, Diagnosis and Management

Author

Dr Solomon Abrahams, Ph.D., M.Sc., B.Sc., MCSP, SRP

Clinical Director, Anatomie Physiotherapy (London, UK) & Sponsors

PCT Lead Specialist in MSK Triage in Primary Care

Senior Clinical Fellow, School of Emergency Medicine, University of Hertfordshire, London, United Kingdom

Senior Visiting Lecturer, London Metropolitan Univeristy, United Kingdom

Former Lecturer at Univeristy College London, Kings College London and Cambridge University

External reviewer for Physiotherapy Journal, London, UK

Author of Sports Injuries in Children and Adolescents

Author of numerous publications in professional medical Journals

Xlibris Publishing

A Penguin Company 2014

1st Edition,

Sponsored by Anatomie Healthcare (Physiotherapy), London, U.K

Editors: Faye Triggs and Solomon Abrahams

Medical Illustrator: Isobel Kilbey

Photographer: Malcolm Hoppen

Front cover design: Malcolm Hoppen

Dedication

I dedicate this book to my family, who inspire me every day …

To my long-suffering wife, Gemma, and my gorgeous and precious daughters, Jessica and Amy. Thank you for putting up with me and I love you all.

I also dedicate this book to all my respected colleagues, who have advised me and supported me.

A special thank you to Malcolm Hoppen and Faye Triggs for their extra help, advice, and guidance.

Disclaimer Notice

The author wishes to express his thanks to you for purchasing this book. He hopes it helps in your clinical practice. This book is for guidance only, and the reader must take into consideration all aspects of the subjective history, followed by a thorough objective examination. This should be further confirmed using the appropriate scans, where necessary to help confirm the diagnosis. If in any doubt, the reader should ask for a second opinion and should use further investigations where appropriate. Where possible, evidence-based research has been used to support the literature; however, because of the ever-changing world of research, the reader does need to consider this and further read the more up to date clinical research where necessary. Care has been taken to confirm accuracy of literature, but the author, editors, and publishers are not responsible for any human errors or omissions that may appear in this publication. All authors are experts in their fields, but their views remain personal and do not reflect on their current or past employers, or title or place of work.

Contributing Authors

Mr Robert S. Lee, B.Sc., MBBS, FRCS (Tr and Orth)

Consultant Orthopaedic and Spinal Surgeon

Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA5 4LP, United Kingdom

Christian Schafer, B.Sc. (Hons) Podiatry, MChS, LA (Cert) (local anaesthesia)

Musculoskeletal Podiatrist Lead, Alexandra Avenue Health and Social Care Clinic Harrow Community Health Service

Ealing Hospital NHS Trust

Musculoskeletal Podiatrist, NHS Camden Physiotherapy Service, London, United Kingdom

Faye Triggs, B.Sc. (Hons)

Sports and Dance Therapist

Specialist interest in children and adolescent sport

Anatomie Healthcare Clinic(s), London, United Kingdom

Robert Harris, B.Sc. (Hons), MCSP, SRP

Senior MSK Physiotherapist, Anatomie Healthcare, Harrow, London, UK

Sarah Drew, B.Sc. (Hons), MCSP, SRP

Senior MSK Physiotherapist, Anatomie Healthcare, Harrow, London, UK

Lisa Graves, B.Sc. (Hons), MCSP, SRP

Senior MSK Physiotherapist, Anatomie Healthcare, Harrow, London, UK

Lisa Evans, B.Sc. (Hons), MCSP, SRP

Senior MSK Physiotherapist, Anatomie Healthcare, Harrow, London, UK

Malcolm Hoppen

Head of Design and Marketing, Anatomie Healthcare, Harrow, London, UK

Acknowledgements

I am grateful to Malcolm Hoppen and the staff of Anatomie Physiotherapy for the use of their sports medicine clinic(s); to Isobel Kilbey for her medical illustrations; to Andrew Caine, Zoe Hoppen, and Daniel Manzi for helping with the photographs; and also to all the contributing authors for their time, experience, and knowledge.

With Special thanks to Faye Triggs for her contribution and editing.

Introduction

Musculoskeletal disorders (MSK) make up more than 20% of all consultations in primary care medicine.[1] Further, these referrals are increasing yearly with some authors suggesting an increase of up to 30% in some parts of the country.[2] In 2008, the direct total costs of these expenditures in the United States accounted for more than $510 billion and an additional $339 billion in indirect costs, which included lost time off work.[2] Conversely, an estimated 73% of all MSK and orthopaedic referrals that end up in secondary care in the United Kingdom do not require any surgical intervention and arguably can be seen and managed within primary care, given the skills of the primary care physician, physiotherapist (Extended Scope Practitioner (ESP/ Triage), osteopath, chiropractor, and general practitioners (GPs).

The MSK field of medicine remains one of the most challenging fields in medicine due to the enormous array of pathologies that can affect the body. With the limited time the physician has for a consultation within the National Health Service (NHS), sometimes it remains even more difficult to differentiate between mechanical and non-mechanical pathologies and furthermore the difference between some MSK disorders.

Traditionally, the teaching of undergraduate medical students in medical school and MSK physiotherapy students in physiotherapy school[1] is somewhat brief and arguably does not prepare the clinician for the challenges in primary care. Indeed, physical therapy, as commonly practised, has historically been considered as a form of secondary care rather than primary care.[2] However, due to economical and efficient changes, physiotherapists, GPs (with specialist interests), nurse practitioners (specialists), and other colleagues are being fast-tracked into primary care.[2] Consequently, the role of MSK clinicians is gaining importance rapidly with some NHS trusts having direct access for patients to visit the MSK clinician without normal GP referral.

This book is designed to assist MSK clinicians working in primary care, where MSK pathologies often present. Further, certain MSK pathologies are common at certain ages, such as osteoporosis and wedge compression fractures presenting in more mature patients and Scheuermann’s disease presenting in younger patients.

This book is not designed to provide a comprehensive guide to all MSK pathologies, more so an overview of the more common MSK pathologies that present in primary care with easy-to-follow clinical tests to support the literature (where applicable). To facilitate and ease in understanding the MSK pathologies in primary care, the chapters are divided according to joint locations. Each chapter is further laid out into further subsections to include the following:

Anatomy

Basic anatomy is discussed as revision. Some sections have more details on anatomy depending on the complexity of the joint. Wherever possible, this has further been supplemented with diagrams and pictures.

Subjective examination

This section is essential and plays a large part in the overall examination of the joint. Examples are given to the type of questions you may ask, and specific questions relating to the area are also included.

Objective examination

This section forms part of the overall examination and helps to gain more knowledge based on the subjective examination. Wherever possible, examples have also been included. Observation and basic manual handling procedures, such as range of motion (ROM) and muscle testing, are included.

Red flags

This is an essential section and really should be included in all spinal and peripheral examinations. It is essential to record all the information.

Clinical and specialist tests

This section helps the examiner clarify the subjective and objective assessments. These tests are largely unreliable as the evidence to support the reliability of most of the tests remains confusing. The tests are simple and quick, and wherever possible, photos have been added for further clarification. These tests help to support the hypothesis and diagnosis but should not be used in isolation.

There is a vast array of clinical and orthopaedic tests in literature, and where certain tests are not mentioned in this text is by no means an indication of the quality of the test; moreover, that controversy over the sensitivity and specificity of the testing procedures that still remains.

Pathologies (including scans and tests)

Different pathologies discussed in this section are commonly seen in primary care. Each section can include definition, pathophysiology, signs and symptoms, clinical tests (where relevant), and treatment and management. Some pathologies are more common or complex than others; hence, the depth of the individual pathologies discussed can vary.

Key points

Key points can be found at the end of every chapter. This is given in bullet points for quick analysis.

Flow charts

Flow charts have been added to provide the reader with a quick overview on how to identify different MSK pathologies on the first assessment. This should not replace a full examination but should be used in addition to a full assessment.

Additional to anatomical location, some special sections are also included in this book. They are as follows:

• Common pathologies in the elderly in primary care

• Common pathologies in children and adolescents in primary care

• Common joint injections in primary care

• Common connective tissue disorders seen in primary care

• Common medicines used in primary care

• Simple Blood results in primary care

These sections have no set format and are for information purposes.

References

[1] Warburton L. Musculoskeletal Disorders in Primary Care, 1st edn. Royal College of General Practitioners; United Kingdom, 2012.

[2] Boissonnault W. Primary Care for the Physical Therapist, 2nd edn. Elsevier Saunders; 2012.

Chapter 1

Cervical Spine

Solomon Abrahams

Introduction, Subjective examination, Objective examination, Clinical tests, Pathologies

Introduction

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Fig 1.1 The cervical spine vertebra

The cervical spine consists of 7 vertebrae and 14 facet joints (Fig 1.1). It is flexible and arguably the most functional part of the vertebral column. The principle movements are flexion, extension, protraction, retraction, rotation, and side flexion. As a result of the flexibility in the cervical spine, its stability can be compromised during traumatic events, such as whiplash-type injuries.

C1 (atlas bone) has no spinous process and is simply a flat bone which articulates with C2 (axis bone) via the odontoid process. This process is not only responsible for the stability of this joint but also contributes towards 50% of the rotation of the neck.

The superior facet joints of the cervical spine face upwards, backwards, and medially, whereas the inferior facet joints face downwards, forwards, and laterally to coincide with the superior facets.

The greatest ROM of flexion and extension is at C5 and C6. This is a very functional movement, hence the vulnerability of the joint in adults, particularly as they get older. The closest position of the facet joints occurs in extension, side flexion, and rotation to the same side. They are highly innervated by the recurrent meningeal or sinuvertebral nerve.

In a 20-year-old, the intervertebral discs account for 25% of the total 8 of the cervical spine. This reduces in height as the adult ages, and the disc heights reduce as they dehydrate and lose fluid. This is a natural phenomenon.

The most common pathologies that occur in the cervical spine in primary care are degenerative changes (spondylosis), facet joint arthrosis, and acute facet joints strains.

Subjective Examination of the Cervical Spine

Based on the information gathered from the subjective examination, the clinician can determine which tests could be performed or designed to confirm or refute their hypothesis on the source of a patient’s symptoms. A selection of the most appropriate questions, with the highest diagnostic utility, will increase the clinician’s confidence in ruling in or out sinister disorders. The subjective history is, therefore, arguably the most important part of any MSK examination. About 70% of the diagnosis can be confirmed with the right questions and most importantly, listening to the patient’s responses.

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Fig 1.2 Cervical pathologies are normally felt in the neck region

Location of Pain

Neck pain, although felt in the neck, can be caused by numerous other spinal problems. Neck pain may arise due to muscular tightness in both the neck and the upper back or due to pinching of the nerves emanating from the cervical vertebrae. For example, neck pain can refer down the arm, but just because someone has arm pain, we should not assume that this is definitely referring from the cervical spine as indeed there may be another pathology at work within the shoulder or arm.

Most neck symptoms originate around the C5/6 area. A neck pathology located around the side or front of the neck is unusual and may require a more extensive examination.

The Onset of Pain

An important question to ask is how the pain started or began. If pain came on suddenly, it may indicate some traumatic involvement, which requires further questioning. For example, this could include prolapsed discs, fractures, facet joint pathology, ligamentous strains, torticollis, and whiplash-type injuries.

Pain which comes on gradually, or with no clear onset, may indicate a postural abnormality, disc bulges (postural or otherwise), spondylosis (including exacerbations), spondylolythesis, osteoporosis, arthrosis (including exacerbations), instability/hypermobility, and neuralgia.

What Type of Pain?

Different types of pain may indicate different types of pathology.

Sharp pain: may indicate an acute facet joint or severe ligamentous strain.

Constant pain or ache: may indicate a degenerative pathology.

Nagging and throbbing pain: may indicate a bony pathology, and a shooting pain may indicate nerve involvement.

Frequency, Duration, Intensity, and Severity of Pain

Frequency of pain can indicate the seriousness of a particular pathology. For example, if the pain is becoming less frequent, it may indicate that the condition is recovering or calming down. Similarly, a pain which is becoming more frequent may indicate a pathology which is worsening. A pain which is more frequent may indicate a slower prognosis, whereas less frequent pain can indicate a speedier prognosis.

A longer duration of pain can indicate a pathology which may take time to recover. A short duration may indicate a quicker recovery time. Intensity of pain – normally taken with an arbitrary scale such as the visual analogue scale (VAS), where a figure between 0 and 10 is given (0 being no pain and 10 being maximum pain) – can give us an indication of the seriousness of the pathology. A pain which is 10/10 may indicate a bony pathology such as a fracture. A low-intensity pain may indicate a muscular strain or dormant spondylosis. Obviously, we must appreciate that there will be cultural interpretations of pain, and pain itself remains subjective.

An intermittent pain may indicate a joint or mechanical pathology, whereas a constant pain may indicate a degenerative pathology or even a non-mechanical pain such as infection.

Mechanism of Injury

The patient should always be asked about the possible mechanisms of injury. This may not have been something that happened recently; it could have happened a few days before the onset of pain, and the patient may not recall. If the patient cannot remember an incident, always ask if anything has changed in the last few days/weeks at work or at home that may have triggered the pain. For example, if someone has changed computer workstation recently or is doing more computer work, this can be enough to trigger neck pains, postural pains, and even headaches. If the patient has recently changed pillows, this can take time to start affecting the neck and put strain on mechanical structures.

Another example is a whiplash-type injury, which involves sudden flexion–extension movements beyond normal limits, which can cause multiple ligamentous damage, disc and facet damage, and even bone damage in some cases.

If there is a clear mechanism of injury, and if appropriate, ask the patient to try and replicate the movement so you can analyse the type of structures, which may have been damaged.

Duration of Symptoms

Identifying when the symptoms first appeared can give us an idea of the chronicity or acuteness of the pathology. Normally, acute injuries of the neck respond well to treatment and management if started early and can clear relatively quickly. If the pathology has been going on for a long time and is chronic, this may change the prognosis to a longer recovery time and give an indication of the pathology.

For example, ligamentous strains and muscular strains considered acute are not normally long-term and therefore duration of symptoms are likely to be a fairly short history. Postural neck pain normally takes time to come on; hence, there may be a chronic history. Spondylosis is normally chronic but can go through exacerbations. There is likely to be a history of neck stiffness or pain. Cervical spine headaches, postural disc bulges, and work-related upper limb disorders (WRULDs) are other such pathologies that may have a long-term history.

Age of Patient

Age can be one of the best indicators of potential pathology. Spondylosis, arthrosis, osteoporosis, fibromyalgia, and degenerative changes rarely affect anyone under the age of 30. Prolapsed discs, instability, ligamentous strains, and torticollis normally affect younger patients below the age of 30. Postural and work-related disorders can affect persons at any age but tends to be slightly more common in the under 50s.

Occupation of Patient/Social History

The occupation of the patient can sometimes give the clinician an indication of likely pathologies. A sedentary patient who works with computers all day may have a postural or work-related pathology. A mechanic or a painter, who spends a lot of time looking up, may have some facet pathology or arthrosis.

Socially, a patient who plays a lot of sports may have instability issues and muscular or ligamentous strains, depending on what the mechanism is.

Aggravating and Easing Factors

Asking the patients what aggravate their pain is very important and can point the clinician in the direction of a correct diagnosis.

• Pain at the end of the working day may indicate a postural pathology (especially if the patient works with computers).

• Pain on turning the head may indicate a facet joint or discogenic pathology.

• Pain at end of range of movement may indicate a degenerative pathology such as spondylosis or arthrosis.

• Pain on the right side of the neck, which is aggravated by right rotation, may indicate a discogenic (which may be a bulge, prolapsed, or dehydrated disc), facet joint, or stenosis-type pathology rather than a simple ligamentous strain.

• Pain that is relieved in flexion may indicate a facet joint pathology, whereas disc prolapses do not like extension of the spine.

• Pain on reading (where the neck may be in flexion), which comes on over time, may indicate postural or ergonomics pathology.

Constant pain which appears to be aggravated by anything may not be mechanical in origin and may require further investigation. Pain aggravated by movement may indicate a bony pathology or an acute disc prolapse.

Easing factors can also give the clinician an idea of diagnosis. Pain eased by rotation away from the painful side may indicate a disc prolapse on that side or a facet joint pathology. Pain eased at weekends or whilst away on holidays may indicate a work-related disorder or postural abnormality.

24-hour Pattern

Gaining prospective of a 24-hour pattern of pain can be very useful. Feeling pain first thing in the morning, accompanied with some stiffness, may indicate spondylosis, arthrosis, or a degenerative pathology. Equally, ask about pillows and how many pillows the patient has to sleep with as well as whether this has changed recently. For example, sponge pillows do not tend to mould to the contours of the neck and can push the neck into side flexion, whereas feather pillows are more adaptable to the contours of the neck.

Pain that awakens the patient at night may indicate a more serious pathology, such as serious nerve compression or something more sinister that would require further investigation. Pain in the latter part of the day may indicate a postural, work-related, or even bony pathology such as osteoporosis.

Clicking or Locking of the Neck

Clicking of the neck can be normal and should not be regarded as pathological. However, some pathology may give rise to extra clicking in the neck, such as spondylosis, arthrosis, instability, hypermobility, and facet pathology. Locking of the neck can indicate subluxing facet joints or facet arthrosis.

Past History and Family History

Past history may give us a few clues to the current pathology. For example, spondylosis, arthrosis, and degenerative disease normally go through exacerbations. Work-related and postural abnormalities can also come on and off over the years. A past history of any surgical intervention, a previous prolapsed disc, or fracture may increase the possibilities of accelerated spondylosis, arthrosis, or degenerative disease.

Family history can also indicate a potential pathology. Family history of spondylosis, arthrosis, torticollis, osteoporosis, fibromyalgia, hypermobility, and instability can lead to a genetic predisposition, not necessarily just in the parents but also in the siblings.

Previous Investigations

A previous investigation may guide you towards or indeed exclude any particular pathology. For example, previous X-rays which are normal may indicate a non-bony pathology, such as ligamentous, muscles, or minor joint/nerve irritation. Pathologies such as spondylosis, spondylolythesis, and fractures should show up on an X-ray.

Blood tests which are normal will exclude any rheumatic pathologies, infections, possible osteopenia, or serious pathology. Investigations to consider if pain remains persistent include full blood count (FBC), vitamin D levels, calcium levels, erythrocyte sedimentation rate (ESR), and CPK. In patients with neuropathic symptoms, blood sugar, vitamin B12, thyroid function, and bone profile can be investigated.

Current Medications

Some medications can cause muscular aches and pains or neuropathic symptoms such as tingling in the neck. Such medications include statins (which have been linked with myopathy) and steroids (systemic steroids can cause bone fracture and increase risk of infection).[2]

Neurological Symptoms

Not all neck symptoms manifest itself as neck pain. Pins and needles and numbness in the peripheral limbs can be associated with peripheral nerve compression. Normally, these symptoms tend to distal to the neck and sometimes over a dermatomal pattern; hence, dermatomes should be tested if these symptoms exist. Bilateral tingling or paraesthesia may indicate cord compression and should always be checked, subjectively and objectively. If nerves are compressed or damaged, repair rates are very slow, at a rate of 1 mm per day, and will affect prognosis.

Special Indications

Dizziness, fainting, diplopia (double vision), and drop attacks may indicate damage to the vertebral artery and should be treated seriously.

Dysphasia may indicate damage to the cerebral hemisphere, possibly due to hypoxia or increased intracranial pressures.

Dysphagia may be indicative of C3 anterior osteophytes, occlusion of the upper oesophagus, or cerebral damage/increased intracranial pressures.

Diplopia, blurred vision, hemianopia, and nystagmus may all be indicative of increased intracranial pressure.

Colour changes in the upper limbs on one side may indicate vascular occlusion, including thoracic outlet syndrome, which is compression of the brachial plexus by an elevated first rib. Testing of this will be described later.

Any lower limb abnormalities such as poor balance, giving way of the legs, or numbness may indicate spinal cord compression.

Sneezing, coughing, and laughing increase pressure within the intrathecal space of the cord and therefore increasing pain may indicate a space occupying lesion, which may warrant further investigation.

Always ask about possible non-mechanical pathologies of the spine, arguably the 2 most significant include tuberculosis (TB) or infection. Fever, cough, weight loss, malaise, and night sweats may indicate underlying infection. Pain at night, which wakes the patient, should be treated seriously as it can be asymptomatic with tumours. Other relevant questions are: does the patient wear glasses or contact lenses? If patients work excessively with computers, when was the last time their eyes were checked?

Headaches

Headaches can be referred from the cervical spine. Normally, they tend to be more occipital and are referred to the back of the head from the upper cervical spine. They tend to be associated with tenderness of the upper cervical spine. C1 headaches tend to be occipital, whereas C2 tend to be more temporal. The clinician should be aware that headaches can also be due to sinusitis, migraines, trigeminal and temporal neuralgia, temporomandibular joint (TMJ), eye strain, dental pathology, and even constipation. On rare occasions, tumour and meningitis can also cause headaches.[1]

Objective Examination of the Cervical Spine

General observation of the patient includes neck and back posture, while standing and sitting. This includes observing any kyphosis of the thoracic spine or lordosis of the lumbar spine.

Any abnormalities here may have an adverse affect on the cervical spine. A loss of lordosis in the cervical spine may indicate paravertebral spasm or degenerative changes in the cervical spine.[3]

Any protraction of the chin may indicate postural abnormalities. Symmetry of shoulder heights should be checked: both should be equal. If the patient dominates on the right side, there may be some slight elevation of the right shoulder; a noticeable rise with tenderness may indicate muscle spasm on that side. Any scoliosis should be observed in the cervical spine as it is sometimes seen in prolapsed discs or fractures.

If necessary and if the patient works with computers or remains in a stationary position for long periods, ask them to take a photo showing them at their workstation as this may give you clues to any poor ergonomic set-up which may be provoking their pains.

Examination of the cervical spine should include active flexion, extension, rotation, and side flexion. Sometimes, and where appropriate, a combined movement can be examined (to try and elicit the pain), such as extension and rotation. Overpressures at the end of range of all movements can determine the type restriction and in some cases the pathology. For example, a 52-year-old patient who has restricted rotation to the right and a firm rigid overpressure may indicate spondylosis. A springy end-feel in flexion may indicate a muscle or ligamentous/capsular restriction. If any neuropathic symptoms are present, always check the dermatomes, myotomes, and reflexes of the upper limb.

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Fig 1.3 Dermatomes of the spine

Segments superior to C4 do not refer down the upper limbs. Therefore, sensory nerve distribution in adults include C5 (predominantly the axillary nerve), which supplies the lateral aspect of the upper arm. C6 supplies sensation to the lower arm and some parts of the hand as it innervates the thumb, index finger, and radial portion of the middle finger. C7 supplies part of the middle finger, via the radial nerve. C8 supplies the ring finger and parts of the little finger, and T1 supplies most of the medial arm via the branch of the medial brachial cutaneous nerve.

The motor nerves are similar again. C5 normally supplies the deltoid muscle and some of the biceps. C6 motor nerve supplies the bicep muscle and some of the wrist extensors. C7 motor nerve can be tested with triceps, wrist flexors, and finger extensors. C8 can be tested by resisting the small interossei muscles and finger flexors, whilst T1 tests finger abduction. A muscle grading system of 5 is normal, grade 4 is good against some resistance, grade 3 is fair with normal resistance against gravity only, grade 2 is poor with movement with gravity eliminated, grade 1 has a slight flicker of movement, and grade 0 has no movement whatsoever.[4]

Any significant abnormality here, such as muscle wasting on one or both sides, may indicate neural stenosis at the level of the myotome being tested.

Rotation of the neck beyond 50 degrees kinks the vertebral artery so care must be taken before rotating the spine fully to ensure there is no occlusion. This can be tested via the vertebral artery test (VAI), which will be described later.

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Fig 1.4 Palpate costoclavicular space

Palpation should include spinous process, facet joints, and interspinous process. Stiffness, tenderness, or reproduction of pain should be noted. Reproduction of symptoms may indicate pathology at that particular junction, for example C5/C6. When doing accessory movements of the spine, such as a posterior–anterior accessory movement (PA), particular attention should be noted to the end-feel of movement. Extreme stiffness may indicate degenerative disease, whereas a very soft end-feel may indicate hypermobility, instability, or possibly an unstable spondylolythesis. Palpation of the cervical nodes anteriorly and posteriorly may indicate underlying infection or disease, and palpation of the thyroid gland may indicate an enlarged gland.[4]

Resisted movements of the cervical spine can be achieved using the same movements above but resisting the action. Any increased pain may indicate a muscle strain.

Palpation of the surrounding muscles should be noted for tension, trigger points, spasm, heat, and, of course, pain. Palpation of the costoclavicular space, sternoclavicular (SC) joint, and acromioclavicular (AC) joint should also be done. Tenderness over these areas may indicate a primary or secondary problem associated with them or may not even be associated with the patient’s symptoms. Within the costoclavicular space is the first rib and brachial plexus. Any specific enlargement of glands should also be noted around the neck area, and if symptomatic, blood tests should be instigated. Palpation of the TMJ may indicate pathology of the TMJ.

If pain refers down the arm, all peripheral joints should be checked to see if the neck is referring pain down the arm(s), or there may be a secondary pathology in the peripheral joints. This diagnosis can be achieved using special tests.

One should never assume that just because the patient has neck pain and shoulder pain, that the shoulder pain is definitely coming from the neck. Gross tenderness of the triceps may indicate C6/7 pathology, and tenderness of biceps may indicate C5/6 pathology.[4]

Red Flags of the Cervical Spine

A thorough subjective assessment is essential when clinically reasoning pathology of the spine. A patient who presents with symptoms that cannot be diagnosed through MSK assessment requires a ‘red flag’ assessment. A ‘red flag’ is the term given to the identification of dangerous or potentially dangerous findings in a patient’s history or examination. If a red flag is present within an examination, patients are often referred to medical specialists for immediate treatment.[4] Red flag questions should be asked in all assessments and should cover items such as history of cancer, unexplained weight loss, diabetes, pins and needles, and 24-hour pattern.

A cervical spine subjective assessment should be carried out in great detail. Ruling out specific symptoms aids the practitioner when clinically reasoning a pathology that is causing dysfunction and pain in the upper quadrant.

Ruling out vertebrobasilar insufficiency (VBI), where blood flow to the hindbrain is limited at the vertebral arteries and basilar artery, is important when assessing the cervical spine.[4,5] The major red flag questions asked in the subjective assessment are relevant to Coman’s ‘5 Ds and 3 Ns’: Dysarthria (weakness of muscles in the face, causing difficulty with speech), Diplopia (double vision), Drop attacks (sudden falls), Dysphagia (difficulty swallowing), Dizziness, and Nausea, Numbness, Nystagmus (uncontrolled movement of the eyes).[4,5]

If patients reveal these symptoms, further questions should be asked include when the symptoms are worse, how long they last, and the aggravating and easing factors. Cervical rotation to the left and right is a test for VBI.

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Vertebral Artery Insufficiency Test

This is a simple test for vertebral artery occlusion[4] (Maitland, 1973[10]).

Patient: In sitting position.

Examiner: The patient’s head is rotated to one side for 15 seconds and then the other side. The head is then kept still, and the shoulders rotated bilaterally for 15 seconds whilst maintaining neck position in neutral. See photo in subjective history.

Positive test: If the patient experiences dizziness in both cases, this may indicate vertebral artery occlusion, whereas if it ensues only when the neck is rotated, this may indicate inner ear pathology.

Consistent with: Vertebral artery occlusion or vascular occlusion.

Notes: This test is not completely reliable. Diagnostic ultrasound or CT scan should be considered.

The vertebral artery kinks at 50 degrees of rotation, so rotation is important with the VBI test. The practitioner should hold the rotation for 10 to 15 seconds or until symptoms are provoked and then rest for 10 seconds before testing the opposite motion.[7,8] These movements can be assessed in supine or sitting position, and symptoms will differ due to the effects of gravity in sitting.

Patients reporting a trauma to the head or neck should be assessed for ligamentous instability of the upper cervical spine.[6] Symptoms of this include drop attacks, facial, occipital numbness, nystagmus produced by head or neck movements, and reduced active ROM.

There are also red flags that can suggest compression of the spinal cord; this is known as myelopathy. The symptoms of myelopathy are disturbances to normal gait, weakness in the hands, loss of sexual function, and loss of bowel function.

Summary of Red Flags

• Diplopia, dysphasia, dysphagia, dizziness, dysarthria, drop attacks/fainting, hemianopia.

• Waking at night with neck pain/head pain.

• Worsening neck pain/headaches with other associated symptoms (non-mechanical), with and without treatment.

• Night fever and sweats or consistent pyrexia.

• Persistent headaches and neck pains worsening or non-mechanical-related.

• Bilateral numbness of upper or lower limbs or loss of function in upper limb (such as grip).

• Extreme unexplained weight loss with constant headaches and/or blurred vision.

• Systemic illness or PMH of cancer in the local area (e.g. breast and/or lung).

• Vertebral artery insufficiency.

• Meningeal signs.

Differential Diagnosis of the Cervical Spine[2]

• Thoracic outlet syndrome

• Tumour (metastasis)

• Fracture

• Instability

• Shoulder pathologies (SC joint, AC joint)

• Thoracic spine pain

• TB– infection

• Lung pathology (apical)

• Polymyalgia rheumatica (PMR)

• Systemic illness/inflammatory disorder (prolonged morning stiffness and swelling)

• Cervical myelopathy

Pathologies of the Cervical Spine

Contusions

Contusions of the neck remain rare but are more common in sports or traumatic events such as rugby, wrestling, and martial arts. They are normally direct blows from an object such as an arm or a flying object.

Contusions anteriorly can affect the larynx, cricoid, thyroid, and upper airway, causing distress, panic, and pain. This injury causes haemorrhage and oedema, which can cause a choking-like symptom that can be very scary.

Airway obstruction should always be treated as an emergency, and ensuring a clear airway should always be the priority. Ice should always be applied on any soft tissue contusion to reduce further bleeding and improve prognosis.

Any contusion to the anterior neck should be treated as a head injury, due to potential damage of the vertebral artery.[3]

Contusions posteriorly can also be quite alarming. Cord concussion can occur, causing temporary paralysis (motor and sensory), but normally, full recovery does occur within a few days. Any patient with this should be sent to hospital, to also exclude other potential damage including fractures of the spinous process, which would be particularly painful on palpation.

Contusions rarely cause spinal cord damage unless followed by hyperflexion or hyperextension, as seen in traumatic whiplash injury.

Strains and Sprains

Strains and sprains of the neck are common. Any form of hyperflexion or hyperextension injury can cause soft tissue injury as discussed in the introduction earlier. Damage to the ligaments, joints, and muscles can occur, and if the injury is violent, nerve damage and spinal cord damage can also be present.

There will always be a mechanism of injury in these patients, and injuries like these normally take 6 weeks to repair. Strains and sprains are graded according to their severity.[5]

Grade 1 strain

The most common strain of the neck is grade 1 strain, 30% disruption of the soft tissues. This normally causes pain, but movement is 75% normal, with no neurological signs/symptoms, and function is not normally affected to any great extent.

These injuries should be treated initially with ice (followed by heat after 24 hours), analgesics where necessary, and advice to try and keep the neck moving within pain-free range. As with any injury to the neck, someone should be present when giving advice, warning them if symptoms worsen or last more than a week, to visit their GP.

Grade 2 strain

Grade 2 strains (30–70%) tend to be less common but more serious. Pain in the neck, moderate restriction in movement, and more neck spasm are common.

Sometimes, the patient may exhibit neurological symptoms, which can be unilateral or bilateral due to the tethering of soft tissues in proximity to the nerves or resultant oedema of the damaged area. Headaches, shoulder pain, and vertigo may accompany the other symptoms, but only temporarily.[3] A full neurological examination should be undertaken, with any extreme pain or localised tenderness to be further explored for fracture.

These injuries normally cause distress, and as such, the usage of a soft collar for 48 hours is sometimes warranted and justified. Further reassessment should be considered after a few days to allow initial pain, distress, and spasm to calm down and allow a more thorough assessment.

Treatment with ice (and eventual heat) and rest for the first few days should be advised, followed by encouragement of movement within the pain-free range. Once pain has settled, rehabilitation of the muscles should be encouraged due to the atrophy of muscles caused by pain inhibition and immobility.

Return to activity and function should be encouraged once full ROM has been re-established.

Grade 3 strain

Grade 3 strains (70% + damage to soft tissue structures) are the most serious and should be treated like a head injury in the initial stages. Any worsening signs including extreme tiredness or more serious symptoms should be sent for further examination.

Severe pain, severe restrictions in movement of the neck, and severe spasm of muscle with neurological symptoms are more common. Spinal shock can also be common, indicating damage to the spinal cord rather than complete resection.

Initially, these injuries should be collared due to any distress the patient may feel. Pain control (analgesics) should be considered, along with ice (heat after 24 hours) and encouragement of movement. Emphasis should be placed on the fact that the patient should not become reliant on the collar or the immobility of the spine. Patients with grade 3+ strains should not return to full activity for a minimum of 4–6 weeks following the onset of injury or unless a scan reveals full recovery.[5]

Fractures and Dislocations

Fractures and dislocations of the cervical spine are rare in primary care and sometimes can cause neurological pathology. However, some fractures can be missed, so revision of common fractures and dislocations can be helpful.

Fractures of C1 (Jefferson fracture)

Fractures of C1 tend to be rare, but severe axial compression, such as a fall directly on top of