Cervical Exam

[David Brown]

I recently worked with a patient with a referral for neck/thoracic and shoulder pain that had been ongoing for several years that began following rapid breast enlargement due to fluid retention after a surgery. I was excited to have an opportunity to implement much of what I learned in the cervical course series and use what I learned to better diagnose and treat the patient. During the course of the subjective exam, I learned that the patient following surgery a few years earlier had shifted from a bra size of 34DD to 34JJ in the course of months and this rapid increase in breast weight caused her to adopt a forward shoulder posture with protracted scapulae, mid cervical flexion, and upper cervical extension.
I was nervous initially as a man, to navigate the discussion of breast size as it relates to the patient’s symptoms, but I quickly realized that the patient believes this is what is driving her symptoms and simply keeping the conversation professional allowed it to be easy and informative. Moreover, the patient was very open and content to discuss these matters because she has seen many healthcare providers (her PCP, plastic surgeons, orthopedic surgeons, etc) pertaining to this pain so at this point she just wants to feel better. The patient was knowledgeable about her situation and was aware that she had undergone postural changes as she felt she lacked the strength to combat the anterior pull that gravity was imposing on her chest. I noticed that her bra straps had created an indention in her upper traps and when I inquired about how her symptoms changed with moving the straps off of her shoulder she stated that this greatly reduced her symptoms. She also stated that when she retracted her shoulders and put her neck into a more neutral position, her symptoms were also greatly reduced. The only problem was she had no ability to maintain this position over the course of an entire day.
Going into the objective exam, I felt that I had a good idea as to what was driving the pain, and was excited to try and implement a smooth cervical exam incorporating what I had learned in the cervical course. I quickly discovered that the patient’s pain was tied to end-range cervical rotation and sidebending (both of which were full AROM) and were both worsened with overpressure, but were relieved when I placed her arm on the opposite shoulder with contralateral side bending and ipsilateral rotation. This drove me to think her pain was primarily myofascial in nature. Just this simple maneuver and the subsequent relief in symptoms, brought a smile to the patient’s face as she found another way to at least control her symptoms. Planar flexion/extension did not aggravate sx, nor did quadrants. Because her sx were relieved but not abolished with the myofascial differentiation, I still wanted to perform a PPIVM assessment of her neck to rule out any involvement of the cervical spine. Her UT and paraspinal musculature was so sensitive to the touch I was unable to sufficiently assess the cervical spinal segments so I decided to instead treat the myofascial tissues in the area in a supine position for 10 minutes or so. The patient reported her neck felt better and was more able to move through AROM with reduced associated pain with end range movements. Again, she was happy that I was able to make an acute difference to her discomfort and I felt that I was able to get a good buy-in.
Overall I viewed this as a positive experience and was grateful for the patient’s openness and willingness to discuss the changes her body had undergone in response to her surgery as this conversation could have gone in a different direction and been a greater challenge to address. I felt apprehensive initially but quickly felt comfortable as the exam went on and glad I was able to utilize some of my newly learned skills with a patient with cervical and thoracic neck pain.

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