Clinical Impression I: Musculoskeletal and Neurologic Presentations

Diagnosis or clinical impression is the single heaviest content area on Part III, and nearly every case in the other areas ends with the same silent question: what does this patient have? This chapter teaches you to read a musculoskeletal or neurologic vignette the way an experienced clinician does, by spotting the one or two clues that separate a common mechanical problem from its dangerous look alike, naming the most likely diagnosis, and knowing which alternative must not be missed and how fast to act on it.

Section 1Neck pain and headache presentations

Reading a neck pain vignette

Part III neck cases are built around three questions. First, is this local mechanical pain, pain from a nerve root, or a disorder of the spinal cord? Second, is there a red flag (trauma with instability risk, cancer, infection, inflammatory disease, vascular injury)? Third, does the headache, if present, come from the neck or from somewhere more dangerous? The examination items in the vignette are chosen to answer those questions, so read them as deliberately placed clues.

Mechanical neck pain (nonspecific neck pain, facet or myofascial dysfunction, sprain or strain) is the most common answer. It is pain in the posterior neck, sometimes into the upper trapezius or interscapular area, that changes with posture and movement, eases with rest, and is accompanied by restricted, painful segmental motion and local tenderness. The neurologic examination is normal. Facet pain tends to be unilateral, worse with extension and rotation toward the painful side, with referral in predictable maps (C2 to C3 to the suboccipital area, C5 to C6 to the base of the neck and upper trapezius, C6 to C7 to the scapula). Arm symptoms, when present, are vague and do not follow a dermatome.

Cervical radiculopathy is irritation or compression of a nerve root, most often by a posterolateral disc herniation in younger patients and by uncovertebral and facet osteophytes narrowing the intervertebral foramen in older ones. The pattern is arm pain that is often worse than the neck pain, following a dermatome, with paresthesia, and sometimes a myotomal weakness and a reduced reflex. Relief with the hand placed on top of the head (shoulder abduction relief sign) is a classic clue. Because cervical roots exit above the vertebra of the same number, a C5 to C6 disc affects the C6 root. C6 and C7 are the most commonly affected roots.

The examination cluster that best supports radiculopathy is the one described by Wainner: a positive upper limb tension test A (median nerve bias), cervical rotation toward the affected side of less than 60 degrees, a positive distraction test and a positive Spurling test. When three of the four are positive, the probability of radiculopathy rises substantially; when all four are positive, the positive likelihood ratio is about 30. The ULTT A alone has high sensitivity (around 0.97) and is good for ruling out, whereas Spurling has high specificity (around 0.9) and is good for ruling in.

Cervical spondylotic myelopathy is compression of the cord, usually by a combination of disc bulge, osteophytes and a buckled ligamentum flavum in a congenitally narrow canal, typically in patients over 50. It is the classic must not miss diagnosis disguised as neck stiffness. The patient describes clumsy hands (dropping things, difficulty with buttons and handwriting), numb hands that do not follow a dermatome, and an unsteady, broad based gait; neck pain may be mild or absent. Signs are upper motor neuron signs: hyperreflexia, a positive Hoffmann sign, inverted brachioradialis reflex, sustained clonus, a Babinski sign, and difficulty with tandem gait. Lhermitte sign (electric sensation down the spine with neck flexion) may be present. Cook's clinical prediction rule uses five items: gait deviation, positive Hoffmann, inverted supinator sign, positive Babinski and age over 45; three or more positive strongly rules in myelopathy. The management consequence is important: high velocity cervical manipulation is contraindicated, MRI is indicated, and the patient is referred for a spine surgical opinion, urgently if deficits are progressing.

Whiplash associated disorders

Acceleration and deceleration injuries are graded with the Quebec Task Force scale, and the grade drives both imaging and management decisions.

Whether a trauma patient needs radiographs before any treatment is decided with the Canadian C spine rule. Any high risk factor (age 65 or older, a dangerous mechanism such as a fall from 3 feet or five stairs, an axial load, a high speed or rollover collision, or extremity paresthesias) mandates imaging. If no high risk factor is present, a low risk factor (simple rear end collision, sitting position in the emergency department, ambulatory at any time, delayed onset of neck pain, or absence of midline tenderness) allows the clinician to test active rotation; if the patient can rotate 45 degrees to each side, imaging is not required. The rule has a sensitivity close to 100 percent for clinically important injury.

Headache: primary types

Most headaches in a chiropractic office are primary headaches, and the board expects you to name them from their features.

The flexion rotation test is performed supine with the neck fully flexed to isolate C1 to C2, then rotated passively to each side. Normal rotation is about 44 degrees each way; a reduction to about 32 degrees or less, or a difference of more than 10 degrees between sides, supports C1 to C2 dysfunction and cervicogenic headache.

Red flag headaches and cervical artery dissection

The SNOOP mnemonic organizes the danger signs: Systemic symptoms or disease (fever, weight loss, cancer, immunosuppression), Neurologic signs or symptoms (confusion, focal deficit, papilledema), Onset sudden (thunderclap, peak within a minute), Older age at onset (new headache after 50), and Pattern change (progressive, positional, triggered by Valsalva, exertion or sex, worse on waking). Each flag points to specific diagnoses.

Cervical artery dissection is a tear of the intima of the vertebral or internal carotid artery, allowing an intramural hematoma that can narrow the lumen or send emboli. Its incidence is low (about 2 to 3 per 100,000 per year), but its early symptom is neck pain and headache, which is why patients with an evolving dissection seek chiropractic care. The board expects you to recognize it before treatment. Vertebral artery dissection causes unilateral posterior neck and occipital pain, often described as unlike any previous pain, followed (sometimes days later) by posterior circulation ischemia: the 5 Ds and 3 Ns (dizziness, diplopia, dysarthria, dysphagia, drop attacks; nausea, numbness, nystagmus) plus ataxia. Internal carotid dissection causes anterolateral neck, face or periorbital pain, an ipsilateral partial Horner syndrome (ptosis and miosis without anhidrosis, because facial sweating fibers travel with the external carotid), pulsatile tinnitus, and later anterior circulation signs (hemiparesis, aphasia, monocular vision loss). Risk factors include recent minor trauma, connective tissue disease, migraine, recent infection and hypertension.

Current understanding is that a dissection already in progress explains most cases in which stroke follows a visit. Premanipulative positional tests (such as the George or DeKleyn tests) have poor sensitivity and do not reliably detect at risk patients; the protection is a careful history for the dissection pattern, a cranial nerve and cerebellar screen, and blood pressure. If the clues are present, the impression is suspected dissection, manipulation is withheld and the patient goes to the emergency department.

Section 2Thoracic and chest wall presentations

The central question: wall or viscus?

Thoracic pain cases test one skill above all others: telling pain that comes from the spine, ribs and chest wall from pain that comes from the heart, lungs, aorta, esophagus, stomach or gallbladder. Viscera share segmental innervation with the thoracic dermatomes, so visceral pain is felt in the body wall. The clue is not the location but the behavior: musculoskeletal pain is reproduced by movement, posture, palpation and joint loading, while visceral pain is linked to exertion, eating, breathing in a nonmechanical way, or comes with autonomic and systemic symptoms. Remember that palpation tenderness does not exclude a myocardial infarction; about 1 in 7 patients with acute coronary syndrome has some chest wall tenderness, so the whole picture matters.

Musculoskeletal thoracic diagnoses

Thoracic segmental and costovertebral dysfunction causes sharp, localized paraspinal or interscapular pain, often after a twisting or lifting movement or a night of awkward sleep. It may wrap partway around the chest along the rib, and it catches with deep inspiration, coughing, rotation or lying on the affected side. There is tenderness over the costotransverse joint, painful rib springing and restricted segmental motion.

Costochondritis causes anterior chest wall pain with tenderness at multiple costochondral junctions (usually the second to fifth), without swelling, in an adult; it is a diagnosis of exclusion in anyone with cardiac risk. Tietze syndrome is similar but with visible swelling, typically at a single upper costal cartilage (second or third) in a younger patient. Slipping rib syndrome involves the hypermobile 8th to 10th ribs, with a clicking or popping sensation and a positive hooking maneuver. Intercostal muscle strain follows coughing or a sudden twist and is focal.

Thoracic disc herniation is uncommon and usually at T8 to T12. It may cause band like radicular pain around the chest or abdomen, or, because the thoracic canal is narrow and the cord has a watershed blood supply, a myelopathy with leg spasticity, a sensory level and bladder symptoms. Any sensory level on the trunk is a cord problem and needs MRI.

Osteoporotic compression fracture is the classic must not miss musculoskeletal diagnosis in an older patient. The vignette typically describes a woman over 65, or a patient of any age on long term corticosteroids, with sudden midthoracic or thoracolumbar pain after minimal trauma (bending, lifting a grocery bag, sneezing, stepping off a curb), severe pain on standing and walking that eases lying down, and percussion tenderness over a spinous process. Height loss of more than 4 cm (or more than 2 cm in a year) and a fixed kyphosis suggest prior fractures. The next step is radiographs; a wedge with an intact posterior cortex is a stable fracture that can be managed conservatively with modification of care, whereas posterior cortex involvement, neurologic signs or a fracture above T7 in an older patient raises concern for a pathologic fracture from metastasis or myeloma. Spinal manipulation of the fractured segment is contraindicated.

Herpes zoster (shingles) is reactivation of varicella zoster virus in a dorsal root ganglion. Its trap is the prodrome: for 2 to 5 days the patient has burning, stabbing or itching unilateral pain in a thoracic dermatome before any rash, which looks like a rib or a radicular problem. Clues are the strictly unilateral band that stops at the midline, allodynia (pain to light touch of clothing), age over 50 or immunosuppression, and sometimes malaise. Then a cluster of vesicles on an erythematous base appears in the dermatome. Antiviral therapy works best within 72 hours of rash onset, so refer promptly; ophthalmic zoster (vesicles on the tip of the nose, Hutchinson sign) is an eye emergency. Postherpetic neuralgia is pain persisting 90 days or more after the rash.

Visceral mimics

Acute coronary syndrome (unstable angina and myocardial infarction) produces pressure, tightness or heaviness behind the sternum, often radiating to the left arm, jaw or between the scapulae, provoked by exertion or emotion and accompanied by dyspnea, diaphoresis, nausea or lightheadedness. Women, older adults and people with diabetes more often present with atypical symptoms: dyspnea, fatigue, epigastric discomfort or interscapular pain alone. Stable angina lasts a few minutes and resolves with rest or nitroglycerin; pain at rest or lasting more than 15 to 20 minutes is an emergency. The chiropractor's job is to recognize the pattern, call emergency services, keep the patient at rest, and (absent allergy or bleeding risk) aspirin may be advised per local protocol.

Aortic dissection causes sudden, tearing or ripping chest pain radiating to the interscapular back, at maximum intensity at onset, in a patient with hypertension, Marfan syndrome or a bicuspid aortic valve. Clues are a blood pressure difference of more than 20 mm Hg between arms, a pulse deficit, a new diastolic murmur of aortic regurgitation, or neurologic deficits. It is an emergency.

Pulmonary embolism presents with sudden pleuritic chest pain, dyspnea, tachycardia, sometimes hemoptysis, in a patient with risk factors: recent surgery or immobilization, long travel, pregnancy or estrogen use, cancer, or a swollen painful calf. Spontaneous pneumothorax occurs in a tall thin young man or a patient with emphysema: sudden unilateral pleuritic pain, dyspnea, reduced breath sounds and hyperresonance on the affected side. Pneumonia and pleurisy give pleuritic pain with fever, cough and crackles or a friction rub. A Pancoast tumor at the lung apex produces shoulder and medial arm pain (C8 to T1), hand intrinsic weakness and Horner syndrome in a smoker; it is often first treated as a thoracic outlet or cervical problem.

Section 3Low back and pelvic presentations

Triage first

About 90 percent of low back pain is nonspecific mechanical pain, roughly 5 to 10 percent is radicular, and only 1 to 2 percent is serious pathology (fracture, cancer, infection, cauda equina syndrome, inflammatory disease, aneurysm or visceral disease). Board vignettes over represent the last group, so read every low back case for its red flags before you name a mechanical diagnosis.

Disc herniation and radiculopathy

Lumbar disc herniation peaks in the 30s to 50s and about 95 percent occur at L4 to L5 or L5 to S1. A posterolateral herniation compresses the traversing root (the lower number): an L4 to L5 disc affects L5, and an L5 to S1 disc affects S1. A far lateral (foraminal) herniation compresses the exiting root (the upper number), so an L4 to L5 far lateral disc affects L4. Pain is worse with sitting, bending, coughing and sneezing (raised intradiscal and intrathecal pressure), and the patient may lean away from the side of the lesion (antalgic list).

The straight leg raise is positive when it reproduces leg pain below the knee between about 30 and 70 degrees. It is sensitive (about 0.9) but not specific; the crossed SLR (raising the well leg reproduces pain in the affected leg) is highly specific (about 0.9) and suggests a large or sequestered fragment. The slump test is slightly more sensitive. A positive femoral nerve stretch (prone knee bend) points to L2 to L4 roots. Centralization of symptoms with repeated movements predicts a good prognosis.

Cauda equina syndrome

Cauda equina syndrome is compression of multiple lumbosacral roots below the conus, usually by a large central L4 to L5 or L5 to S1 disc herniation, and less commonly by tumor, abscess, hematoma or severe stenosis. The clues are saddle anesthesia (perineum, buttocks, inner thighs), urinary retention with overflow incontinence (the most consistent finding, about 90 percent), fecal incontinence or reduced anal tone, sexual dysfunction, and bilateral or alternating sciatica with progressive leg weakness and reduced ankle reflexes. Back pain alone with any new bladder or perineal change is enough to act. This is a surgical emergency: send the patient to the emergency department for same day MRI, because outcomes are best when decompression occurs within about 48 hours, before retention is established. Conus medullaris syndrome (T12 to L1) causes more symmetric, early sphincter dysfunction with mixed upper and lower motor neuron signs and less pain.

Stenosis, spondylolisthesis and the sacroiliac joint

Central lumbar stenosis results from disc bulge, facet hypertrophy and ligamentum flavum thickening, usually at L4 to L5, in patients over 60. Its hallmark is neurogenic claudication: bilateral buttock and leg aching, heaviness or numbness provoked by standing and walking (extension) and relieved by sitting or flexion (the shopping cart sign). The best history items are relief with sitting and absence of pain when seated; a wide based gait and a positive Romberg add specificity. Lateral recess and foraminal stenosis give unilateral radicular pain with similar positional behavior.

Spondylolisthesis is forward slippage of one vertebra on the one below. Isthmic spondylolisthesis follows a pars interarticularis fracture (spondylolysis), almost always at L5 on S1, in adolescents who repetitively hyperextend (gymnasts, divers, football linemen, cricket bowlers). Degenerative spondylolisthesis is due to facet arthrosis with an intact pars, occurs typically at L4 on L5, is more common in women over 50, and often causes stenosis. Clues are extension pain, hamstring tightness, and a palpable step off (above the slipped level in isthmic slips, because the posterior arch stays behind; at the slipped level in degenerative slips). The Meyerding grade (I under 25 percent, II 25 to 50, III 50 to 75, IV 75 to 100, V spondyloptosis) is discussed with imaging.

Sacroiliac joint pain is felt below L5 over the PSIS and buttock, sometimes into the posterior thigh, rarely below the knee. No single test is reliable, but the Laslett cluster (distraction, compression, thigh thrust, sacral thrust, Gaenslen) is useful: three or more positive of the five gives a positive likelihood ratio of about 4, especially when centralization is absent. Pregnancy and the postpartum period, leg length difference, and trauma (falls onto the buttock) are typical stories.

Inflammatory back pain and the mimics

Inflammatory back pain (ASAS criteria) is chronic back pain beginning before age 40, insidious in onset, improving with exercise but not with rest, with pain at night that improves on getting up; four of these five features give a sensitivity of about 77 percent and specificity of about 92 percent. Supporting clues are alternating buttock pain, enthesitis (heel), uveitis, psoriasis, inflammatory bowel disease, a family history, a good response to NSAIDs, raised CRP and HLA B27. The spondyloarthropathies are covered in Chapter 8; the impression step here is to recognize the pattern and refer for rheumatologic evaluation rather than treating it as mechanical pain for months.

Visceral and vascular causes of back pain are nonmechanical: pain that does not change with position or activity, night pain, colicky pain, and pain with systemic symptoms. Abdominal aortic aneurysm (men over 65, smokers, hypertension, family history) may cause deep back, flank or abdominal pain and a pulsatile, expansile mass above the umbilicus; a widened aortic shadow or curvilinear calcification on a lateral lumbar film is a clue. A symptomatic or tender aneurysm, or pain with hypotension and syncope, means rupture or impending rupture: call emergency services. An asymptomatic aneurysm of 3.0 to 5.4 cm is referred for surveillance; 5.5 cm or more, or growth over 1 cm per year, is referred for repair. Avoid forceful lumbar manipulation and deep abdominal work in known aneurysm. Renal colic (writhing, colicky flank pain radiating to the groin with hematuria), pyelonephritis (fever, flank pain, costovertebral angle tenderness), pancreatitis, and gynecologic or prostate disease are discussed with visceral referral in Chapter 8.

Section 4Extremity presentations

How extremity vignettes are built

Extremity cases almost always give you three things: the patient's age, the mechanism (overuse, a specific traumatic event, or insidious onset), and one discriminating examination finding. Combine them and the diagnosis usually falls out. Always ask two further questions: could this be referred from the spine or a viscus (neck for shoulder pain, hip for knee pain, heart or diaphragm for left shoulder pain), and does it need imaging before treatment?

Rules that decide imaging

The Ottawa ankle rules call for ankle radiographs when there is pain in the malleolar zone and any of: bone tenderness along the distal 6 cm of the posterior edge or tip of the lateral malleolus, bone tenderness along the distal 6 cm of the posterior edge or tip of the medial malleolus, or inability to bear weight for four steps both immediately and in the office. Foot radiographs are needed for midfoot pain with tenderness at the base of the fifth metatarsal or the navicular, or inability to bear weight. Sensitivity is close to 100 percent, so a negative rule safely avoids imaging. The Ottawa knee rule calls for a film after acute knee injury in a patient aged 55 or older, with isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight for four steps.

Section 5Neurologic presentations

Localize first, then name

Neurologic vignettes reward the habit of localizing the lesion before guessing a disease. Weakness, sensory change and reflexes together place the problem in the brain, cord, root, plexus, peripheral nerve, neuromuscular junction or muscle.

Peripheral neuropathy and entrapment

Diabetic polyneuropathy is the most common neuropathy: symmetric burning or numbness starting in the toes, loss of vibration (128 Hz tuning fork) and of 10 g monofilament sensation, and absent ankle reflexes. Loss of protective sensation means daily foot inspection and podiatry referral because of ulcer risk. Other causes to name from clues are vitamin B12 deficiency (vegan diet, metformin, proton pump inhibitors, gastric surgery, pernicious anemia; posterior column loss with a positive Romberg and macrocytosis), alcohol, hypothyroidism, chemotherapy, and Guillain Barre syndrome, which is an ascending symmetric weakness with areflexia over days, often 1 to 3 weeks after a diarrheal or respiratory illness. Guillain Barre is an emergency because of respiratory failure.

Common entrapments are median nerve at the carpal tunnel (thenar weakness, sensory loss on the radial three and a half digits sparing the thenar eminence, because the palmar cutaneous branch passes above the tunnel), ulnar nerve at the cubital tunnel (little and ulnar ring finger numbness including the dorsal hand, interossei weakness, Froment sign) or at Guyon canal (dorsal ulnar hand spared), radial nerve at the spiral groove (wrist drop, "Saturday night palsy," triceps spared), common peroneal at the fibular head (foot drop with weak eversion, sensory loss on the dorsum, from leg crossing or rapid weight loss), and the lateral femoral cutaneous nerve at the inguinal ligament (meralgia paresthetica: burning anterolateral thigh with no weakness, tight belts, obesity, pregnancy). Distinguish peroneal palsy from L5 radiculopathy: L5 also weakens inversion (tibialis posterior) and hip abduction, and often brings back pain.

Multiple sclerosis, stroke and TIA, Parkinson disease

Multiple sclerosis is a demyelinating disease of the central nervous system, usually in women aged 20 to 40. Episodes are separated in time and space: optic neuritis (painful monocular vision loss with pain on eye movement), internuclear ophthalmoplegia, transverse myelitis, sensory loss, Lhermitte sign, fatigue, and the Uhthoff phenomenon (worsening with heat such as a hot shower). Examination shows upper motor neuron signs. Refer for MRI (periventricular, juxtacortical, infratentorial and cord lesions) and neurology.

Stroke is sudden focal deficit: face droop, arm drift, speech change (BE FAST: balance, eyes, face, arm, speech, time). Middle cerebral artery strokes affect the face and arm more than the leg, with aphasia if dominant; anterior cerebral artery strokes affect the leg; posterior circulation strokes cause vertigo, ataxia, diplopia, dysarthria and crossed signs (ipsilateral face, contralateral body, as in Wallenberg lateral medullary syndrome). Thrombolysis is time limited, so call emergency services and note the time last known well. A TIA resolves, usually within an hour, without infarction; it is a warning, with stroke risk highest in the first 48 hours, so it needs same day emergency evaluation. Amaurosis fugax (a curtain over one eye for minutes) is a carotid TIA.

Parkinson disease is loss of dopaminergic neurons in the substantia nigra, usually after 60. The cardinal signs are bradykinesia plus rest tremor (4 to 6 Hz pill rolling, reduced with action), rigidity (cogwheel or lead pipe) and later postural instability. Early clues include asymmetric onset, micrographia, hypomimia (masked face), reduced arm swing, a soft voice, constipation, loss of smell and REM sleep behavior disorder. The gait is shuffling and festinating with en bloc turning and freezing. Contrast essential tremor: a bilateral action and postural tremor, often familial, improved by alcohol, with head or voice involvement and no bradykinesia. Patients with Parkinson disease are at high risk for falls and osteoporotic fractures.

Vertigo and dizziness

Start by asking what "dizzy" means (spinning vertigo, presyncope, disequilibrium) and then sort by timing and trigger.

The Dix Hallpike test takes the seated patient quickly into supine with the head turned 45 degrees to one side and extended about 20 degrees over the table edge; a positive test is vertigo with upbeating torsional nystagmus toward the lower ear after a short latency, lasting under a minute and fatiguing on repetition. The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is used in continuous vertigo: an abnormal head impulse, unidirectional nystagmus and no skew is reassuring (peripheral), while a normal head impulse, direction changing nystagmus or a skew deviation (any one "INFARCT" finding) suggests stroke, with sensitivity higher than early MRI.

Words worth knowing