SUBCLAVICULAR & NECK PAIN MANAGED BY
MANIPULATION AND TRIGGER POINT DRY NEEDLING
Background
A myriad of disorders can give rise
to anterior neck and chest wall pain.
Musculoskeletal causes of these
pain patterns are often overlooked
or misdiagnosed. A potential pain
generator is the subclavius muscle
which is innervated by the nerve to
the subclavius (C5, 6).
Pur pose
The purpose of this case study is to
describe the diagnosis, management,
and outcomes of an individual with
chronic subclavicular pain.
Subject Histor y
A 39 year-old female with insidious
onset of unrelenting left anterior
neck pain and subclavicular pain
following a sinus infection was
referred to physical therapy 4 weeks
post onset of symptoms.
Physical Therapist ( PT ) 1
Treatment :
Sitting manipulation to the
posterior aspect of T1; supine
st
manipulation of the 1 rib; trigger
point dry needling (TPDN) to upper
trapezius (UT) and levatorscapula
(LS), and taping to elevate the
shoulder girdle. No change in pain
after 4 sessions (2 weeks).
Referral to a Physiatrist :
MRI of the cervical spine, upper
thoracic spine, and brachial plexus;
trigger point injections (Lidocaine)
to the UT, LS, anterior scalene (AS)
and sternocleidomastoid (SCM).
Tim Flynn PT , PhD and Laura LaPorta Krum PT , PhD
Regis University School of Physical Therapy
Email: tflynn@regis.edu and lkrum@regis.edu
Medical Exam Findings
•MRIs revealed an os odontoideum, moderate
to severe degenerative change at C7-T1
costovertebral joints and slight foramen
narrowing at C7-T1 left.
•Suspicious of a bright left
supraclavicular lymph node, referral was
made to a hematological oncologist to
rule out cancer. Blood work, chest x-rays
negative.
•Referral to anesthesiologist for
consultation on pain management.
•Patient sought a second opinion
from another PT ( PT 2 ).
Superior Inferior
Lateral Mobilization Cervical Traction
Ribs 1 & 2 Manipulation
Outcomes
•NPRS improved from
8/10 to 1/10
•PSFS average
improved from 1/10
to 8.7/10
PT 2 Exam Findings
•Pain with shoulder elevation/depression
Numeric Pain Rating Scale (NPRS) 8/10 .
•Patient Specific Functional Scale (PSFS)
score 1/10.
•Hypermobility in the upper cervical spine.
•Hypertonicity in the UT, LS, AS, middle
scalene, and SCM on the left .
•Hypomobility in C4-C5, C6-T1, 2nd rib, and SC
joint.
•Neuromotorsensory screen was WNL.
PT 2 Tr eatment
•Patient was seen for 5 visits over the
course of 16 calendar days.
TPDN Subclavius
Discussion
We describe a case that is
consistent with a subclavius
muscle and C5-6 dysfunction
which was successfully managed
with cervical traction
manipulation, TPDN, and patient
education on the probable
source and the musculoskeletal
behavior of the patient
presentation. Pain that is
poorly defined and presents in
a somewhat non standard
fashion frequently causes
heightened anxiety in both
patients and practitioners and
frequently leads to increased
medical intervention. A
systematic approach to
treatment followed by repeated
retesting of the most
provocative symptoms assisted
the physical therapist in
choosing treatment options
that seemed to be successful
in this instance.
Conclusion
Without a precise diagnosis
for the pain syndrome, a series
of escalating clinical
decisions were made which
delayed diagnosis and
treatment and led to increased
imaging and medical
intervention.
Refer ences
Browder, Erhard, Piva. Intermittent Cervical
Traction and Thoracic Manipulation for
Management of Mild Cervical Compressive
Myelopathy Attributed to Cervical Herniated Disc:
A Case Series. JOSPT. 2004; 34(11):701-712
Flynn , Whitman , Magel. Orthopaedic Manual
Physical Therapy Management of the Cervical-
Thoracic Spine & Ribcage.
www.evidenceinmotion.com , 2000.