Most therapists see disc bulges in the clinic from time to time. We often see them get better or worse, but we rarely see them progress in front of our eyes. The evolution of a disc bulge is extremely interesting to observe, but the very acute phases of this condition are difficult to help due to their irritable nature.

The history of a disc bulge is usually one of initial pain that might not be severe on the day it occurs, but is significantly worse the next day. This is thought to be due to chemical irritation and swelling that occurs after the injury, as well as the injury itself. The initial injury may be a disorder of the disc internally.

If this is the second or third episode with this type of pain, the disc disorder will probably involve the nucleus and the annulus. If the outer annulus is involved, the result will be a disc bulge with referred pain. Once the symptoms extend further from the neck, the outer annulus of the disc is considered to be herniated. The most common disc disorders in the cervical spine are at the C5/6 and C6/7 level.

Understanding Referred Pain

Cloward found that the cervical intradiscal disorders refer pain to the scapular area. This feature of medial scapular pain caused by cervical disc disorders is still frequently misdiagnosed by therapists and physicians alike. It is commonly mistaken for thoracic spine pain or rhomboid spasm, whereas the true diagnosis can be referred cervical disc pain.

Dermatomal pain is referred pain found in most patients when they present with nerve root involvement. The pain-sensitive structures such as the nerve-root sleeve and the posterior fibers of the annulus fibrosis become involved in the pain mechanism.

I recently evaluated a 37-year-old athletically active patient who had just injured his neck and right shoulder while carrying his son in a backpack for 8 miles. The patient had had many years of periodic neck pain that had usually resolved without intervention. This episode was much more severe and had lasted for two weeks without improvement.

The patient complained of stiffness in his right neck, right medial shoulder blade, and entire right shoulder in a wraparound fashion. The neck and shoulder pain began at the same time, though he felt the pain was separate in nature. The patient denied any abnormal symptoms, such as nausea, double vision and passing out. Sleeping on the right shoulder was not an aggravating factor, indicating the neck as a probable cause of his pain. (In general, side-of-neck pain can be slept on, but shoulder pain usually cannot.)

Aggravating factors included biking, lifting his right arm greater than 90 degrees, right rotation, improving his posture, sitting and computer work. (The patient was a professor, which required extensive computer work.)

Easing factors were ice, anti-inflammatory medication and self massage. The 24-hour pain pattern was severe stiffness in the neck and shoulder in the morning; the neck pain improved after 30 minutes, but the shoulder pain increased with activity. The patient's neck and shoulder pain woke him up one to three times a night.

Evaluation

Shoulder evaluation was as follows: The patient tested positive for impingement tests, painful arc of the right shoulder, and an abnormal scapulothoracic rhythm in the right shoulder. End-range internal and external rotation of the right shoulder was decreased slightly. The patient also had a tight capsule on the right shoulder with posterior and inferior glide. All rotator cuff muscles were 5/5 with manual muscle testing.

Neck evaluation was as follows: Dermatomal pain was in a C5-6 pattern, though pain did not radiate past the clavicle. Myotomal testing was deferred at the initial evaluation due to the lack of distal symptoms.

Reflexes and sensation were normal for the bilateral upper extremities. The neck was positive for a right shift at end-range extension, and right rotation was decreased by 25 percent. Neck flexion was decreased by 50 percent. Right-side bending, right rotation and neck flexion all reproduced the patient's familiar pain.

Passive accessory mobilization to C7 reproduced familiar symptoms and was notably stiff. Grade II to III mobilization was performed to C7, which resulted in improved cervical rotation, and neck extension shift resolved. Cervical traction did not affect the patient's symptoms.

My initial impression was lower cervical dysfunction with right shoulder impingement. Symptoms continued to progress during treatment, and a disc bulge began to evolve. Initially I had been convinced that there was both neck and shoulder involvement, and the acuteness of the patient's symptoms continued to cloud the true diagnosis. At this time the patient's symptoms were unstable, irritable and acute.

After the first visit, the patient's pain was worse, and he hadn't slept in two days. Symptoms worsened with any type of mobilization to the lower cervical spine, and were therefore avoided. The patient appeared to have irritable symptoms and treatment was decreased to focus on the shoulder only. Cross-friction massage and iontophoresis of the shoulder were performed and the patient was educated on computer setup for work to decrease any stress on his neck.

The third visit revealed increased referred pain down the patient's arm, and relief by placing his arm overhead. Patients with C5 nerve irritation will find relief by holding their arm above their head in this fashion, while shoulder pain is usually aggravated with this position. C4 to T1 myotomes were normal, except grip strength on the right was weak at 20 kg, compared to 40 kg on the left. (The patient was right-handed.)

Reflexes were still normal in bilateral upper extremities. Sensation was now decreased in the patient's little finger (C8 dermatome). The patient had adverse neural tension in the right upper extremity with median nerve testing. At this time, the patient appeared to have symptoms correlating to an irritable C7 disc bulge. It was recommended by the therapist that the patient obtain a steroid pack from his physician.

Seeing Results

By the fourth visit, the patient had obtained a steroid pack. The primary care physician insisted on the patient obtaining a cervical MRI and seeing a neurosurgeon. On this day, joint work to the C6 area gave the patient relief and allowed for increased cervical extension. Mechanical traction was helpful and performed for 15 continuous minutes. Reassessment of the patient's sensory awareness revealed decreased sensation in his left thumb (C6 dermatome), but his pinky numbness had resolved. Right grip strength had improved to 23 kg.

At the fifth visit, the patient complained of right arm pain and right forearm pain, and his thumb still tingled. The symptoms were finally a match for a C5-6 dermatomal pattern and were finally becoming consistent with a probable disc bulge causing referred pain. The patient's computer work was now an aggravating factor. Traction was still helpful, as was joint mobilization work to the C6-7 level. The patient was able to exercise in the gym, performing scapulothoracic stabilization exercises with a ball and exercising on the elliptical machine.

At the sixth visit, the patient had his MRI and the results were reviewed. The MRI revealed a mild C4-5 disc protrusion and a C5-6 mild DDD with a moderate-to-large protrusion or herniation in the right lateral recess and foraminal region, likely affecting the right C6 and C7 nerve roots.

Although the patient was visibly upset over the results of the MRI, the symptoms matched the diagnosis. Sensory changes were beginning to improve, with decreased sensory loss in the right thumb and slight improvement in the patient's right grip strength of 25 kg. The patient was told that the disc would scar over if he avoided continuously aggravating it through work and athletic activity (running aggravated the patient's neck.)

At this point, the patient began to take his symptoms seriously, and managed them on an improved level, avoiding aggravating activities and exercising appropriately. Manual therapy and traction was unhelpful at this time.

By the seventh visit, the patient's right grip had improved to 30 kg and his symptoms were slowly resolving. It had been about two months since his initial evaluation. Exercise and postural education continued. On the eighth and final visit, the patient reported he had seen the neurosurgeon, who stated that no intervention was necessary and that he would heal independently (i.e., let the disc scar over). At this time, the patient was discharged to a home exercise and postural re-education program.

I saw the patient about six months later, and he reported complete resolution of his symptoms. Although I often felt that I was chasing his pain during our time in physical therapy, he felt that therapy had helped him and was successful. Manual therapy was not appropriate for this patient, due to the evolving nature of his disc bulge.

The patient's diagnosis was both irritable and acute; therefore he required constant monitoring and re-evaluation throughout treatment. It appeared that the education and recommendations were the most helpful part of therapy. Time, exercise and changing habits appeared to have the greatest impact. Watching disc symptoms evolve was very interesting and educational for me, but were quite painful for the patient.

Melissa Felder is a physical therapist at Flagstaff Medical Center Outpatient Physical Therapy, Flagstaff, AZ.