Neck Pain | Headaches | Dizziness
CERVICOGENIC HEADACHE:
Headache: There are many different types of headaches. Migraines, tension headaches, cluster headaches, built up neck pain and headaches, the list goes on. Ranging from mild discomfort to agonising pain and altered senses.
Cervicogenic headache is commonly associated with movement relating to dysfunction neck joints and muscles, secondary to a cervical musculoskeletal injury. Symptoms are often experienced as a headache, with referral from the neck and back of the head, and often on one side. C2-3 is common a location of tenderness due to the association of cranial nerve innervation (trigeminal number 5) within the area.
Tension Headache:
Tension headache are a common type of neck pain and headache experienced with classification as either episodic or chronic, depending on the regular occurrence of symptoms. Symptoms experienced >15 days in a month for three consecutive months is classified as chronic. Usually symptoms are reported as pressure or tightness around the head or neck, and may be experienced on one or both sides of the head. Initial management with anti-inflammatories and analgesics may be beneficial.
VERTIGO:
Cervicogenic Vertigo:
BPPV:
Benign paroxysmal positional vertigo (BPPV) is a type of vertigo that may be experienced following a change to the position of the head. The inner ear contains small crystals that regulate the bodies awareness of movement relative to gravity. When these crystals are affected, symptoms of BBPV arise with individuals often reporting dizziness, nausea, eye twitching and nausea amongst other symptoms. Symptoms may be experienced by movement of the head, sudden movement or rolling movements that trigger the posterior semi-circular canal. BPPV symptoms may be further aggravated by stress, poor sleep or changes in barometric pressure.
CERVICAL FACET JOINT ARTHROPATHY:
Arthropathy is the disease of a joint and may include inflammation or degradation of the joint. Commonly cervical facet joint arthropathy is marked by neck stiffness, pain with movement and local swelling. This condition usually affects older individuals due to the degenerative arthritic nature of the condition.
CERVICAL DISC PATHOLOGY:
Acute cervical disc with nerve root compression usually presents with moderate to severe pain, that is easily irritated. The pain is reproduced with movement of the neck that compresses the exiting nerve roots. Associated neural signs including pins and needles/ numbness and/ or weakness may be present. Movement of the arm (shoulder, elbow or wrist) that increases neural tension may cause an increase to symptoms.
WHIPLASH ASSOCIATED DISORDER (WAD):
Whiplash is a common acute injury experienced in motor vehicle accidents (MVA) involving a sudden acceleration-deceleration mechanism to the cervical spine. Whiplash in sport may also present in incidents where the neck is suddenly impacted by an opponent of with contact to the ground. The whiplash mechanism results in bony and soft tissue injuries of varying degree. In whiplash, the lower cervical spine and upper thoracic spine extend, while the upper cervical spine flexes, with the result force compressing joints. Due to the speed of whiplash, the body is too slow to respond to the movement.
TMJ: Temporomandibular joint dysfunction is commonly characterised by clicking, locking, pain and reduced range of motion. There may an involvement of postural dysfunction involving the cervical and thoracic spine, in addition to an imbalance of muscle activity, specifically the muscles used to masticate (chew food). The condition may include intra and/ or extra articular involvement.
BELL’S PALSY:
Bell’s palsy is caused by dysfunction of cranial nerve VII (facial nerve) resulting in facial paralysis. The condition is idiopathic in nature, meaning no conclusive cause has been established. Commonly the facial nerve is affected by inflammation of the cranial nerve, with limited blood supply to the exiting nerve. Commonly an individual will present with decreased muscle control on the affect side of face. Partial or full paralysis of the affected side may be reported.
ACUTE WRY NECK:
Wry neck is characterised by a sudden onset of sharp neck pain and limited movement. Often symptoms commence on waking or following abrupt, quick movements. Typically, a history of change to typical movements or abnormal positioning is reported before the onset of pain. The most common report is a change in pillow, bed or sleeping on the lounge before waking with symptoms.
Shoulder Pain
Rotator Cuff
Tendinopathy & Tears
Rotator Cuff Pathology
The shoulder joint is a fascinating, intricate joint that relies on the coordination of a huge number of muscles around the scapula (shoulder blade) and humerus (arm bone) to function normally. Unlike most joints of the body, the shoulder relies on active (muscular) structures for stability as opposed to bony congruency.
Impingement
External Impingement
Primary vs Secondary
External impingement may be caused by any one of many structures surrounding the shoulder creating an impingement of the glenohumeral joint. External impingement may be either primary or secondary. Primary impingement is characterised by abnormalities of the superior structures of the shoulder, leading to impingement of the subacromial space, often seen in older adults aged over 35 years. Secondary impingement is more common in younger individuals, where muscular imbalances, lack of control, and increases to training volume contribute to the development of the condition.
Glenoid Labrum Injuries
The glenoid labrum is a fibrous tissue attached to the rim of the glenoid, acting to increase the stability of the glenoid. The labrum also aids proprioception, muscular control and spreads load across the joint surface. The shoulder capsule, glenohumeral ligaments and long head of bicep all attach to the glenoid labrum. Labrum injuries are divided into SLAP (superior labrum anterior to posterior) and non-SLAP injuries, in addition to stable or unstable classification.
Dislocation
Dislocation of the glenohumeral joint is a common traumatic injury resulting from the arm being forced into excessive abduction and external rotation. There may also be internal trauma affecting the glenoid labrum (Bankart lesion) or fracture (Hill-Sachs lesion). Presents like this to us: Acute trauma, with a sudden onset of pain. Injury maybe direct or indirect in nature. Popping out sensation and associated audible noise at time of injury. It feels like this at rest and with sport to you: Acute pain, limited range of motion and strength compared to the unaffected side.
Instability
Shoulder instability may be either atraumatic or post-traumatic. Post-traumatic instability is characterised by a specific event leading to the development of symptoms, often a forceful abduction and external rotation injury. Subluxation or dislocation of the shoulder may have occurred, and poor recovery following the event. An atraumatic instability is common in individuals with capsular laxity, seen in repetitive sports/ activities.
Adhesive Capsulitis
Adhesive capsulitis (frozen shoulder) is characterised by loss of shoulder range of motion, coupled with pain on movement and at night. The cause of adhesive capsulitis is unknown; however, the condition commonly affects individuals aged 40-60 years, women more than men, diabetics, thyroid conditions, and may present in post-operative shoulders.
Ac Joint
Acute acromioclavicular (AC) joint injuries occur due to trauma, often a result from either a direct force onto the edge of the shoulder or from an indirect force to the AC joint (e.g. fall onto elbow driving the upper arm up and disrupting the AC joint. The AC joint is stabilised by the acromioclavicular joint and coracoclavicular ligaments.
There are six grades of AC joint injuries used to classify severity:
Sprain of AC ligaments
No instability
Rupture of AC ligaments and CC ligaments are intact.
Clavicle is unstable to stress
Complete rupture of both AC and CC ligaments
Deformity present, clavicle presents elevated
Distal clavicle is displaced into trapezius muscle
Posterior deformity
Rupture of AC and CC ligaments with disruption of deltoid and trapezius fascia
Clavicle elevated, scapular displaced downward
Inferior displacement of the distal clavicle
Severe trauma, commonly accompanied by other injuries
Sc Joint
Sternoclavicular joint pathologies are often the result of trauma to the shoulder resulting in disruption of the ligaments that support and maintain the joint. Subluxation or dislocation of the joint may occur.
Clavicle Fracture
Clavicle fracture commonly occur in the middle-third of the bone from direct or non-direct contact to the shoulder. An acute clavicle fracture is usually very painful.
Presents like this to us: tenderness and swelling, bone deformity may be present. Pain inhibition limiting shoulder and arm range of motion and strength on the affected side.
Bicep
- Tendinopathy & Tenosynovitis
The bicep, in particular the long head of biceps, is susceptible to overuse injuries. The long head of bicep attaches to the top of the glenoid, passing through the bicipital groove. Often injury occurs in periods of high training volume, coupled with dysfunctional training form in movements such as bench press or dips.
Nerve Entrapments
Nerve entrapments to the suprascapular nerve, long thoracic nerve or axillary nerve may result in shoulder pain. The suprascapular nerve innervates the supraspinatus and infraspinatus rotator cuff muscles, and is the most common nerve entrapment of the shoulder. Symptoms are often described as a deep pain that is poorly localised at the back/ side of the shoulder. Symptoms may refer into the arm or neck, with associated shoulder weakness.
Thoracic Outlet Syndrome
Thoracic outlet syndrome is the compression of neurovascular structures through the thoracic outlet from the neck. Commonly compression occurs between the clavicle and first rib, however may occur between the anterior and middle scalene, or the coracoid process and the pectoralis minor.
Fractures
Fractures of the shoulder joint are less common than other shoulder conditions. Fractures are classified on level of severity and complexity of disruption to the bone. Commonly non-displaced fractures are conservatively managed in a sling or brace, with gradual introduction of range of motion and strengthening exercises as tolerated.
Hand | Wrist | Thumb Pain
Acute Wrist Fracture
1. Distal radius/ ulna
Distal radial fractures are commonly experienced during high-velocity sports. In younger individuals, the force to fracture bone is greater, often resulting in the combination of injury to surrounding ligaments. You can expect to experience local tenderness, combined with hand and wrist pain and weakness on grip strength.
Scaphoid
Scaphoid fractures are the most common fractures in the hand. The fracture diagnosis if often delayed or missed and can have significant consequences long term. The scaphoid is a carpal bone at the base of your thumb and is most commonly fractured in those aged between 10-70 yrs old with a fall onto an outstretched hand. Young children and the elderly are more likely to break another bone – the radius.
Hook of hamate
Hamate is one of the eight carpal bones in your hand. It is a triangular bone consisting of a body and a hook. The hook of hamate can be fractured by a single trauma eg the golf club hitting the ground and the non-dominant hand absorbing the force of the club or in racquet sports such as tennis. It can also be fractured by repeated micro-stress being transmitted to the hook of hamate or via a direct impact eg falling on a hand whilst holding something.
Acute Wrist Dislocation
1. Capral bones
Dislocation of the carpal bones is an uncommon result from severe ligament damage, commonly involving the lunate. Dislocation may occur due to a fall onto the outstretched hand, forcing the hand into dorsiflexion under force. You can expect to feel severe pain and present with a clear deformity. Initial management involves imaging of the dislocation to determine the severity.
2. Scapholunate
FRACTURES (HAND)
i. Metacarpals
Metacarpal facture to the base of the first metacarpal is common trauma from a hard object.
ii. Phalanges
Fractures to the phalanges are split into proximal, middle and distal fractures. Proximal fractures can lead to functional impairments, due to the disruption to the flexor and extensor tendons. Middle fractures may be associated with tendon avulsion of the flexor tendon. Distal fractures are commonly associated with crush injuries and typically slower to heal.
iii. MCP joints
MCP joint injuries are commonly experienced at the first MCP joint (thumb). Ulnar collateral ligament sprains, also known as a skier’s thumb, are the result of an abduction and hyper extension stress to the thumb. A rupture to the UCL will result in gross laxity to the first MCP.
LIGAMENT & TENDON INJURIES
i. UCL/ RCL
Skiers thumb: The UCL of the Thumb is the acute injury of the base of the thumb on side closest to the palm. It occurs when the thumb is forcefully abducted or pulled backwards which can happen when a skier lands on an outstretched hand whilst holding a ski pole. It can also happen in football, rugby and more often in sports that require a stick or bat.
ii. PIP joint sprain
PIP joint sprains involve the collateral ligaments of the PIP joints from force directed sideways to the joint. Distinguishable features of a partial tear include pain, however a end feel to the ligament. In comparison, ruptured ligaments present with no end feel.
iii. Mallet finger
Mallet finger is a condition that occurs when the fingertip is hit by an object (eg a ball) and the finger is forcibly bent forwards causing damage to the tendon that straightens the fingertip. It can also cause a fracture as the tendon pulls off the bone.
iv. Boutonniere deformity
A Boutonniere deformity can occur at both the fingers and toes. It occurs when the fingertip cannot bend and the joint at the middle of the finger/toe cannot straighten. It is associated with pain and swelling from the middle joint to the fingertip.
Elbow Pain
LATERAL
i. Tendinopathy
Tennis Elbow – Wrist Extensor Tendinopathy
Tennis elbow (Lateral elbow tendinopathy) is a tendon overloading injury, where micro-tearing of the tendon and subsequent degeneration occurs. This condition affects the wrist extensors, that orgonite at the lateral epicondyle of the humerus.
MEDIAL
i. Tendinopathy
Golfer’s Elbow – Wrist Flexor Tendinopathy
Golfer’s Elbow (Medial epicondyle tendinopathy) is a tendon overloading injury, where micro-tearing of the tendon and subsequent degeneration occurs. The condition affects the wrist flexors, which all originate at the medial epicondyle of the humerus.
POSTERIOR
i. Olecranon bursitis
Olecranon bursitis may be caused by a single or repeated trauma, often occurring during a fall onto the elbow on a hard surface. This condition is commonly seen in students who rest their elbow on hard desks for long periods. The olecranon bursa is filled with fluid and blood, becoming inflamed due to trauma
ACUTE INJURIES
i. Fracture
X-ray will be used to determine the severity of an acute fracture. Early intervention is important for elbow fractures due to the higher rates of complications in the area compared to other joints. Unstable fractures will require an orthopaedic review. Symptoms often include stiffness and loss of elbow extension during early onset or during immobilisation
FOREARM
i. Fracture
Fractures in the forearm to the radius or ulnar may vary in severity and will often require medial and orthopaedic review. Typically, a fracture occurs due to a fall onto an outstretch hand/ arm. X-ray is a standard form of imaging used to assess fracture severity. A period of immobilisation is required and may include time in a sling to eliminate movement if required.
HUMERUS
i. Stress reaction
Stress reactions are a less common condition, seen in ball throwing sports, tennis players, bodybuilders and weightlifters. The majority of fractures occur during adolescence and associated with an increase in activity. Management of stress reactions follows standard guidelines for simple stress fractures, including the reduction and cessation of aggravating factors until asymptomatic, before a gradual return to activity and sport.