weeks later, the patient began complaining of dull pain in the right side of his neck. This was also accompanied by mild fever and a slight increase in respiratory rate. The patient was given pain medication, which was ineffective in resolving his pain. Fur- ther testing revealed an elevated white count with subsequent CT scan. A pulmonary embolism was found in the lower lobe of his right lung. This is a good example of how pulmonary issues can cause neck pain. finished 18 holes. It subsided on the drive home. Today the pain is worse with activity and better when the client sits. Question What red flags are present in this case? What other questions or observations might be used to confirm the presence of angina? Discussion The location of the pain along the anterior neck is a red flag, as this is a possible symptom of angina. Most cervical conditions, such as facet joint dysfunction, radiculopathy, and mechanical strain, create pain in the posterior or lateral aspects of the neck and/or the upper back/upper extremities. Another red flag is the fact that the pain came on while the patient was active and that it continues to be exacerbated by activity and relieved by rest. Again, these symptoms are associated with cardiac problems. Questions the therapist might ask include whether the client has a history of cardiac disease, what medications he is taking (to help determine if medications are being used to address cardiac risk factors such as hyperlipidemia or hypertension), and whether any symptoms are present in the jaw or upper extremity (which might, again, indicate cardiac involvement). Important observations in- clude the presence of shortness of breath, dizziness, fatigue, nau- sea, and sweating, which are also associated with angina. Finally, obesity is a risk factor associated with heart disease (Obesity and Heart Disease: What You Should Know, n.d). Abdominal aortic aneurysm This condition is rare compared to myocardial ischemia (Carvallo Goodman et al., 2018). Abdominal aortic aneurysm occurs most often in men in the sixth or seventh decade of life (Carvallaro Goodman et al., 2018). Symptoms of an impending or actual rup- ture of an aortic aneurysm include rapid onset of neck or back pain; pain that radiates to the chest, between the scapulae, or to the posterior thighs; pain is not relieved by change in position; and pain described as “tearing” or “ripping” (Carvallaro Good- man et al., 2018). Case Study: Arnold Anderson Mr. Anderson, a 71-year-old retired male, presents to physical therapy as a walk-up client, and he complains of sudden-onset neck pain that began this morning. During the intake process, the client filled out a pain body diagram that shows his pain is not only located in his neck; it is also present in the area between his scapulae. The pain is intense and constant. He cannot describe anything that relieves his pain. When asked, he states that his pain does not increase with activity, nor is it relieved by rest or a change in position. Question What red flags are present in this case? What diagnosis might explain these symptoms? Discussion The client’s age is a red flag, as onset of neck pain in the sixth or seventh decade of life is associated with possible abdominal aortic aneurysm. Other red flags include sudden onset of severe neck pain and the report that his pain is not relieved by rest or a change in position. All these signs and symptoms are consis- tent with a diagnosis of abdominal aortic aneurysm. One sign/ symptom that can further solidify the possibility of an abdominal aortic aneurysm is the presence of a pulsating feeling in the belly (Symptoms, 2018).
Viscerogenic pain is characterized by being poorly localized and is often described as being deep, squeezing, or colicky. By con- trast, somatic pain is described as well localized; intermittent or constant; and aching, throbbing, or cramping (Lee et al., 2017). Lee et al. (2017) present a case study of a patient who suffered a cervical spinal cord injury due to fracture and dislocation of C5 and C6 during a car crash. He underwent subsequent posterior cervical laminectomy and posterolateral fusion at C3–C7. Two Screening for vascular/cardiovascular causes of neck pain Vascular pain patterns originate from two possible main sources: Cardiac (heart) and peripheral vasculature (blood vessels). The most common referred pain patterns seen in physical therapy are angina, myocardial infarction, and aneurysm (Carvallaro Good- man et al., 2018). Pain from cardiac sources is referred to different areas based on multisegmental innervation. The heart is inner- vated by C3 to T4 spinal nerves. Therefore, patients with a heart attack can experience jaw, neck, shoulder, arm, upper back, or chest pain (Carvallaro Goodman et al., 2018). Angina Angina can appear as neck pain (Mathers, 2012). There is typically a three- to five-minute lag time between an increase in activity and the onset of neck pain caused by angina (Carvallaro Good- man et al., 2018). Other possible symptoms of angina include diz- ziness, fatigue, nausea, shortness of breath, and sweating (Angina - Symptoms and Causes, 2022). Mathers (2012) presents a case study of a 64-year-old male who was referred to physical therapy by a neurosurgeon. This patient has an eight-week history of anterior and posterior neck pain with onset related to running. His past medical history included hy- pertension, depression, anxiety, dyslipidemia, hypothyroidism, gastroesophageal reflux disease, peptic ulcer disorder, erectile dysfunction, allergic rhinitis, and thyroidectomy. The patient had seen a primary care physician, an otolaryngologist, and a neuro- surgeon. The therapist was unable to reproduce the client’s neck pain with clinical examination. Since the pain came with exertion, the therapist attempted to reproduce the symptoms by having the client exercise. Within four minutes of cardiovascular exercise, the patient reported neck. Upon stopping, his neck pain went away in five minutes. The therapist referred the patient to his primary care physician for cardiac testing. He underwent cardiac bypass for atherosclerosis shortly thereafter. Self-Assessment Quiz Question #25 Angina can present as neck pain. A tell-tale sign of neck pain related to angina is: a. A three- to five-minute lag between an increase in activ- ity and the onset of neck pain. b. Blood pressure that drops sharply with exertion. c. A sharp increase in blood pressure with exertion. d. A drop in oxygen saturation with exertion. Myocardial infarction Heart disease and myocardial infarction (MI) can refer pain to the anterior neck. Age and past medical history are important when screening for angina or MI, and vital signs are key in clinical as- sessment. There are usually some associated symptoms with an - gina and MI, including diaphoresis, nausea, vomiting, pallor, diz- ziness, and/or extreme anxiety (Carvallo Goodman et al., 2018). Case Study: Mr. George Goodmanson Mr. Goodmanson is a 68-year-old client who is obese and who presents to physical therapy for treatment of his anterior neck pain. He states that he could not get in to see his doctor for over a week, so he made a physical therapy appointment instead be- cause he could get in the next day. The onset of pain began yes- terday while he was playing golf. Mr. Goodmanson states that the pain began at about the 10th hole and got worse by the time he
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