Acute wry neck

Case study reflection blog

The purpose of this case study is to assist our graduates to fully reflect on a client that they have seen throughout the week. This will also form part of information that we can distribute to clients where they can read up on real life cases where we have been able to help clients and allow them to be pain free! Clients are refered to as Mr.X/Ms.X to keep their privacy.

Title of blog: Acute wry neck

Section 1: About your client and how you diagnosed the condition (think about how they presented, what subjective and objective information did you gather to help you diagnose?)

Mr. X is a new client who presented to the clinic with pain in his upper neck (cervical) region, with symptoms mainly presenting on the right side. These symptoms are quite common for Mr. X who reported that it has happened before in the past and usually goes away after a few days. He reported no tingling or pins and needles down the limbs and reports that the pain is very isolated to the neck, with no associated headaches experienced. Mr. X is an office worker who has been working at home since the pandemic and is now going into the office 1-2 days per week. He reports that he now has a sit-stand adjustable desk he uses at home, however admits that his space setup could be more ergonomic to better help his posture. The presentation of his symptoms has lasted for 5 days and he has stated he wants manual therapy to help relieve his symptoms. Mr. X reports that his symptoms are at its worst with movement of his neck, particularly rotation towards the right. He has since reported that he has been avoiding movement in his neck where possible.

Upon further examination, Mr. X had his symptoms reproduced with AROM movement in cervical spine. Flexion and extension AROM was ¾ limited by pain, with rotation and lateral flexion achieving ½ AROM limited by pain on the right side. Upon palpation, Mr. X was quite tender around C3-C7 TP and upper trapezius R>L.

Section 2: Your diagnosis and about the condition (what is your possible diagnosis?)

Possible diagnosis:

Acute wry neck

Pathophysiology background:

While the exact cause of acute wry neck is still unclear, it is thought that it can be from poor postural positions or fast movements in the neck. There are two main types of acute wry neck presentations: Apophyseal and discogenic. Apophyseal relates to the facet joints in the cervical region that often present with pain being localised, and once the facet joint has been released they tend to allow more movement in the neck and reduce symptoms within about 2 weeks. Discogenic wry neck however involves the intervertebral discs between each vertebrae being under stress and can result in a bulge or tear like presentation. This can cause swelling and inflammation on the surrounding structures such as muscles and nerves, and therefore can be quite painful with movement. Movement in this discogenic presentation however is limited by pain, whereas apophyseal is more mechanically related.

Section 3: Differential Diagnosis (what is another condition to consider and why?)

There are several differential diagnoses that are common when individuals experience neck pain. Due to Mr. X’s subjective assessment, he did not experience any trauma to the neck which caused his symptoms, as well as no tenderness upon palpation of the cervical spinous processes. These objective measures and Mr. X’s symptoms should be monitored over the next week and if his symptoms are persistent, it may warrant further examination with imaging.

One differential diagnosis (while unlikely) that could be considered for Mr. X is atlantoaxial instability. This condition is the most significant complication of rheumatoid arthritis, which involves the transverse ligament of the atlas. The sharp-purcer test could be conducted to assess the integrity of the atlanto-axial joint and the associated ligament.

Section 4: Treatment (what did you do and why?)

Manual therapy was performed initially with the aim to loosen the muscles surrounding the neck in order to reduce pain and improve movement. Soft tissue massage through the upper trapezius, levator scapulae, sub occiput and the posterior thoracic region was performed on both sides with Mr. X tolerating it well. Upon reassessment of range of motion, Mr. X had improved range of motion in all planes.

Mr. X was also prescribed 2 exercises to complete at home to improve range and reduce pain levels. The first exercise included an upper trapezius/levator scapulae stretch with 10 second holds, with the second exercise being an isometric cervical rotation with 5 second holds. Both these exercises are to be completed in sets of 3, 4x daily.

Mr. X was also educated on the use of heat to increase blood flow to promote better healing. He was also educated on desk set up when working at home to help reduce flareups. Finally, regular movement within acceptable pain limits was recommended to Mr. X in order to improve range of motion and the ability to further strengthen the surrounding musculature.

Section 5: Plan (where to go from here? How many sessions might they need? What’s the goal?)

Once Mr. X’s pain has decreased, we can build on improving his range of motion and work on strengthening the cervical muscles. We are aiming for 2 sessions per week for 2-3 weeks for Mr. X to be relatively symptom free and be able to work pain free while maintaining his ongoing exercises and ergonomic work set-up for future use. Next session we are aiming to progress his exercises to include chin tucks (to strengthen the deep cervical flexors) while incorporating soft tissue massage to help relieve any associated pain. As each session progresses, we will be continuing with gentle ROM and stretching exercises that Mr. X can do while at work. Upper body strengthening exercises such as a shoulder press and row will be beneficial for Mr. X to complete with the aim to reduce the recurrence of wry neck flareups.