Introduction
Neck pain occurs in 80% of the population at some point of their life. It is the 2 nd most common MSK
problem, with slight tendency towards female.
Observations
Bumps – Thyroid nodules, lymph nodes near SCM, papules (pimple commonly),
angiomas/haemangiomas, tumours, moles
Bruise – (purple, blue, green, yellow, brown) Redness – Eczema, psoriasis
Scars, Swelling (Thyroid swelling, vascular swelling pulsatile), muscle wasting, Fasciculations
Discoloration – Yellow can indicate jaundice, bluish can indicate cyanosis and might be
linked to Raynaud phenomenon
Bakody’s sign (Radiculopathy: compression of a cervical nerve root – abducting arm, hand on
head which elevates the suprascapular nerve and reduces traction on a compressed nerve,
relief of pain indicates cervical extradural compression), Rust Sign (Cervical instability –
patient stabilizing head with hand to prevent any motion of the head & neck, indicating a
serious condition, sharp purser)
Alignment
Anterior View – Midline of the neck, look “loosely” at the height of ears, is patient in
a side flexed position. Possible adaptation (acute) from contralateral nerve root
compression. Possible maladapted position (Chronic). SCM/Lev Scap spasm or
torticollis.
Lateral View – Forward head posture -> TMJ issues as jaw being pulled forward, neck
pain as increase stress on soft tissue & bones, text neck syndrome, Lordosis
Posterior View – Ear level like anterior, Spinal alignment (Thoracic scoliosis may
affect neck alignment lateral flexion), torticollis (infant, spasm, contracture of SCM,
Infantile Torticollis is a condition that patients have a twisted neck. It can be due to
the shortening of sternocleidomastoid muscle congenitally, muscle spasms, neck
injury or infection), Wry neck (self -limiting short period of time)
Palpation Prone or seated
Posterior
External Occipital Protuberance (EOP) (Part of Traps)
C2-C3,4,5,6,7 (Most prominent sometimes, Extension or rotation to be sure)
Facet’s/ articular pillars 1.3cms-2.5cms lateral to SP’s
Paraspinal and Sub-occiptial muscles, Lev Scap, Upper traps
Lateral
Mastoid (SCM, Splenius Cap, Longissimus cap)
TVP’s (Lev Scap 1-4, Anterior scalene 3-6)
Lymph Node
Carotid Artery
TMJ
Anterior – Hyoid Bone, Thyroid Gland, SCM, First rib, Scalenes
Active/Passive ROM
the most common injury that cause neck pain is whiplash injury. Whiplash is about high impact force
causing sudden hyperflexion or hyperextension of the neck. It may result from road traffic accidents
and the impact may lead to whiplash-associated disorder. Symptoms generally are pain, stiffness, and
limited ROM. In severe cases, there may be neurological or psychological problem. Keeping neck
movements as normal with gentle mobilizations help with recovery.
For cervical myelopathy, it involves the compression of the spinal cord, which Hoffman sign may be
present, and patient usually have severe limited ROM of the neck.
Cervical Flexion 50-70
Extension 50-90
Lateral Flexion 40-50
Rotation 70-90
*Note Range of motion alone can be described as a “Special test”. Moving to end ranges for example
should not produce radicular symptoms. Hyperflexion/Hyperextension (Jackson’s test) Cluster of
Wainner
RIMs (Don’t let me move you) Ask patient to keep head in certain positions. Apply the force
(Rotation, Lateral Flexion, Rotation) Often applied from mid ranges.
Special Tests
• Best test clusters to rule in/out Cervical Radiculopathy
• Wainner et al (2003): 1) ULTT (median nerve)
• 2) Cervical Rotation <60º
• 3) Distraction Test
• 4) Spurling’s Test
• Rubinstein et al (2007): High Likelihood +’ve Spurling’s, Distraction, and Valsalva
• Low Likelihood -’ve ULTTs
• Thoomes et al (2017): High Likelihood +’ve Spurling’s, DistarctionTraction, and Arm
Squeeze
• Low Likelihood -’ve ULTTs and Arm Squeeze
Arm squeeze test (Bicep squeeze then Acromioclavicular area and anterolateral subacromial area.
Patients scores VAS on each area. Bicep squeeze must be 3 or more points higher compared to other
two sides)
Wainner’s interpretation – 3 positives 65%/ 4 positives up to 90%
If ULTT1 negative less than 3%!
Instability (Of atlas on Axis) *Torn or stretch Transverse Alar Ligament - Sharp-Purser Test
Derjine’s Triad (Coughing, Sneezing, Bearing Down) – Very broad test but may increase interforamen
pressures and exasperate a nerve root compression
Foraminal Compression Tests :-
Spurling’s Compression Test – Compression or Compression to symptomatic side (Combined
compression and side flexion force) – Radicular symptoms suggest nerve root, local symptoms may
suggest Facet joint issue.
Thump Test – 7kg’s force!
Brachial Compression Test – (Used for Both radiculopathy and TOS testing)
Cervical Distraction test – Positive is reduction of symptoms
Doorbell Sign Push test – Push laterally on Nerve root areas
Slump Test
Cervicogenic Headache test – Cervical Flexion rotation test (Both pain provocation and ROM) First
part is soto-hall test
TOS Tests :-
Adsons (Anterior scalene moving posteriorly)
Reverse Adsons (Middle scalene moving Anteriorly)
Costoclavicular (Sub clavicular area)
Hyperabduction ( 2 parts , sub pectineal area)
Roos or EAST test (All stressed)
Cluster of Wainner | Cervical Radicular Syndrome tests
3 positives 65%/ 4 positives up to 90%, ULTT1 negative less than 3%
ULTT (median nerve)
High sensitivity
Shoulder girdle fixation and depression
Shoulder abduction 90 ° and elbow flexion 90 °
Shoulder external rotation
Forearm Supination
Wrist Extension
Finger Extension
Elbow Extends gently
Symptoms reproduce tingling & pain
Cervical Rotation <60º
High sensitivity
Ask pt rotate head to affected side
Normally to 80°
Distraction
High specificity
Fingers hook under occiput and pull
Symptoms reproduce
Jackson’s compression
Good specificity
Pt lateral flex neck to affected side
Apply downward pressure
Spurling’s
If Jackson’s test unremarkable, head return to neutral
Examiner one hand on pt head, another delivers short sharp vertical blow down
Valsalva Manoeuvre
Increase intraspinal pressure and may exacerbate neuropathies/ radicular pain
Weak clinical value (High specificity)
Pt sit, take deep breath and hold
Exhale in 2-3 seconds with increasing force
Positive if arm pain or paresthesia reproduced
Dejerine’s Triad (Coughing, Sneezing, Bearing Down) – Very broad test but may increase
interforamen pressures and exasperate a nerve root compression
Cervical Nerve Root Compression tests
Arm squeeze
Moderate clinical value (High sensitivity & specificity)
Grasp middle third of affected arm & squeeze 3 time
Apply pressure on acromioclavicular & anterior lateral subacromial
Positive if arm squeeze is 3 points more painful than others
No pain in shoulder pathologies, Nerve root compression C5-T1
Upper cervical instability test
Prevalence rate 0.6%, associated with inflammatory conditions (RA, ankylosing spondylitis, trauma,
congenital deviation – Down Syndrome & Marfan’s disease)
Sharp Purser
Test transverse ligament of atlas, ensuring dens of C2 stay in touch with
anterior arch of atlas
Pt sit, neck slightly flex
Examiner palpate and push C2 spinous process, another at
forehead
Excessive motion/ sliding/ clunking – torn/lax stretched
transverse ligament
Foraminal Compression Tests
Jackson’s compression/ Spurling’s
Good specificity
Pt lateral flex neck to affected side
Apply downward pressure
If Jackson’s test unremarkable, head return to neutral
Examiner one hand on pt head, another delivers short sharp vertical
blow down
Thump Test – 7kg’s force
When downward pressure applied
Narrowing of intervertebral foramina
Compression of the facet joints & intervertebral disc
Local pain – facet joint irritation, capsulitis, foraminal encroachment/ disc protrusion
without nerve root irritation
Radicular pain – pressure on nerve root by foraminal encroachment or by disc prolapse
TOS Test
Morley / Brachial Plexus Compression
Compress supraclavicular fossa for 30 seconds
Reproduction of aching sensation
Cervical Distraction test
One hand on chin, one cup occiput, pt sit
Pull upwards
Decrease or relief of pain – foraminal encroachment/ disc derangement
Increase pain – muscle strain, spasm, ligamentous pain
Doorbell Sign Push test
Push laterally on Nerve root areas
Pain – cervical nerve root irritation
Neurodynamic test
Slump
Hand at back, thoracic and lumbar flexion
Bring chin to chest, push pressure at head flexion
Pt actively extend leg on affected side
Sharp pain down the spine – herniated disc/ nerve root
entrapment
Cervicogenic Headache test
Cervical Flexion rotation
Passive flex cervical and apply pressure
Reduce space in intervertebral foramina
Pain reproduce/ increase – cervical radiculopathy/ disc herniation
(Both pain provocation and ROM)
Soto-hall test
Put pressure on sternum and passive flex head
Nerve root compression, if localize may be ligamentous sprain
TOS Tests
Adson’s (Anterior scalene moving posteriorly)
Head rotate and extend, arm external rotate & extend
Deep breath in hold up to 30 seconds
Examiner palpate changes in radial pulse
Decrease space in interscalene triangle
Reproduce symptoms/ disappearance of radial pulse –
compression of neurovascular bundle
Reverse Adson’s (Middle scalene moving Anteriorly)
Head rotate another side
Costoclavicular Manoeuvre / Exaggerated Military Brace / Eden’s
Palpate radial pulse
Draw patient shoulder down and back
Change in pulse/ symptoms onset
Wright's / Hyperabduction Manoeuvre (2 parts, sub pectineal area)
Arm abduction & external rotation to 90°
Elbow flex no more than 45° and hold for 1 minutes
Decrease retro pectoralis minor space 1st part
Check radial pulse & symptom onset
Repeat with hyper abduction
Implicate costoclavicular interval 2nd part
Decrease radial pulse/ reproduction of symptom
then positive
Roo’s or EAST test (All stressed)
Abduct arm, external rotate, flex elbow
90°
Elbow slightly behind frontal plane
Pt open and close hand for 3 mins
Neurovascular sign, heaviness, ischemic
pain, arm weakness, hand numbness/
tingling, discoloration
Special awareness from history:
Recent acute respiratory infection
Hyperhomocysteinaemia
Vitamin deficiencies (B6, B9 or B12)
Low BMI
Low cholesterol and very high cholesterol
Smoking
Pulsating tinnitus
Family history of arterial anomalies and/or CAD
Family history of connective tissue disorders (i.e. Ehlers-Danlos Syndrome Type IV,
Osteogenesis Imperfecta or Loeys-Dietz Syndrome)
≥ 2 Distinct Symptoms Should Warrant Referral to ER to Query ICA Dissection
Recent significant head, neck or thoracic trauma
New ipsilateral periorbital, frontal or upper back pain
Distinct, new and continued headache
Partial Horner’s Syndrome
Retinal and/or cerebral ischemic symptoms
If < 2 symptoms, progress to physical examination
≥ 2 Distinct Symptoms Should Warrant Referral to ER to Query VA Dissection
Recent head, neck or thoracic trauma
New, ipsilateral suboccipital neck pain
Distinct, new and continued headache
Brainstem ischemic symptoms
Cerebellar ischemic symptoms
If < 2 symptoms, progress to physical examination
If ≥ 2 Positive Physical Tests are present, refer directly to ER
Cranial Nerve Palsy IX, X, XI, XII (CAD) or Cervical Radiculopathy (C5-6, more specific to
VAD)
Hypertension > 140/90
Neck Swelling
Midline tenderness suggestive of fracture
If the above historical and physical findings are negative, the authors recommend
minimizing end-range cervical manual therapies (especially rotational techniques), to be
as specific as possible to the affected vertebral segment, to minimize force/amplitude
Generic Red Flags
Trauma
Night Sweats
Fever / Recent Infection
Intravenous Drug Abuse
Unexplained Weight Loss
Severe and progressing levels of Pain
Night Pain (different quality to day pain)
Diffuse, non-mechanically-reproducible Pain
History of Cancer, TB, HIV or Inflammatory Arthritis
Head & Neck Red Flags
Bilateral Nerve Root Involvement
Multiple Nerve Root Involvement
Complex Neurological Findings
Signs of CNS Involvement
dysphagia, dysarthria, diplopia
positive cranial nerve findings
Hoffman’s reflex
ataxia, dizziness, nausea
Loss of Consciousness
New Headache
Nuchal Rigidity