By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.
Case Presentation
A 33-year-old office worker, married with one child, presented with neck and shoulder pain of approximately one year’s duration.
The neck pain initially developed in association with stress-related headaches and had gradually become persistent. Over the preceding two months, the patient also reported the onset of shoulder pain, described as a dull, aching discomfort.
The neck pain was aggravated by left lateral flexion and rotation, with no clearly identifiable relieving factors. The patient had previously been prescribed analgesics and muscle relaxants; however, these provided minimal or no sustained relief.
The patient also reported recurrent headaches associated with neck stiffness.
Clinical Examination
Examination findings included:
- Myofascial trigger points in the upper trapezius bilaterally (left > right), reproducing referred headache patterns
- Restricted joint mobility at C0–C1 and the cervicothoracic (CT) junction
- Pain reproduced with cervical flexion, extension, and left rotation/lateral flexion
Neurological and orthopaedic testing:
- No significant abnormalities detected
- Sensory, motor, and reflex (SMR) testing within normal limits
Clinical Impression
Findings were consistent with a combination of:
- Cervical spine dysfunction
- Myofascial pain syndrome
- Likely cervicogenic headache component
Cervicogenic headache is commonly associated with upper cervical joint dysfunction and muscular trigger points, particularly involving the upper trapezius and suboccipital muscles.
Treatment
A multimodal conservative treatment approach was implemented:
Cervical Spinal Manipulation (SMT)
High-velocity, low-amplitude (HVLA) adjustment was applied to the upper cervical spine (C1–C2) to restore joint mobility and reduce pain.
Myofascial Therapy
- Trigger point therapy
- Suboccipital muscle stretching
- Myofascial release
Dry Needling (Acupuncture)
Applied to active trigger points to reduce muscle tension and pain.
Postural & Ergonomic Advice
Targeted advice to reduce mechanical strain associated with prolonged desk work.
Clinical Outcome
Following approximately 3 weeks of care:
- Complete resolution of neck and shoulder pain
- Resolution of associated headaches
- Restoration of normal function
At 3-month follow-up:
- The patient remained asymptomatic
Discussion
Neck pain is a highly prevalent musculoskeletal condition, particularly among office workers, and is often associated with postural strain and myofascial dysfunction.
Cervicogenic headache has been linked to dysfunction of upper cervical joints (C0–C3) and associated musculature.
Manual therapy, including spinal manipulation and mobilisation, has been shown to be effective in the management of neck pain and cervicogenic headache. A systematic review by Eric L Hurwitz et al. (1996) demonstrated that cervical manipulation and mobilisation are effective treatment options for mechanical neck pain.
More recent evidence, including Gert Bronfort et al. (2012), supports the use of spinal manipulation combined with exercise for improved outcomes in neck pain.
Myofascial trigger points are recognised contributors to both local and referred pain patterns, including headache. Dry needling and needling therapies have demonstrated effectiveness in reducing myofascial pain and improving function (Timothy M Cummings & Adrian R White, 2001).
In addition, César Fernández-de-las-Peñas has demonstrated the role of trigger points in cervicogenic headache and neck pain syndromes.
A multimodal approach combining manual therapy, needling, and exercise is widely recommended in current clinical guidelines for mechanical neck pain.
Conclusion
This case highlights the effectiveness of a multimodal conservative approach in the management of chronic neck pain associated with myofascial dysfunction and cervicogenic headache.
The combination of cervical spinal manipulation, soft tissue therapy, dry needling, and ergonomic intervention may provide significant clinical benefit, particularly in patients who have not responded to medication alone.
References
- Eric L Hurwitz et al. (1996). Manipulation and mobilisation of the cervical spine: a systematic review. Spine.
- Gert Bronfort et al. (2012). Spinal manipulation, medication, or home exercise for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine.
- Timothy M Cummings & Adrian R White (2001). Needling therapies in the management of myofascial trigger point pain. Archives of Physical Medicine and Rehabilitation.
- César Fernández-de-las-Peñas (2010). Myofascial trigger points and their role in chronic tension-type headache.
- National Institute for Health and Care Excellence (NG59). Low back pain and sciatica / MSK pain guideline (relevant manual therapy recommendations).
