Case Report 14.05.07

Case Report

I reviewed a 49 year old gentleman who had a previous history of neck pain including pain and paraesthesia, particularly in the left arm, with pins and needles in the left hand. 

These symptoms had dramatically improved since his treatment with anti-inflammatories and physiotherapy, and had settled down well.  However, he was left with a persistent pain in the left shoulder and on examination in the clinic, he had some reduction in the range of movement in his neck.  He had some tenderness, particularly cervical facet joints.  However, the most notable examination finding was a left trigger point which was particularly tender in the left shoulder and very tender on palpation. 

The gentleman had a local trigger point injection with local anaesthetic and Cortisone performed in the clinic.  He was reviewed 2 months later and I was very pleased to see that he had had over 80% improvement.  He said he occasionally got flare ups with the pain but this was generally easily manageable.  He was getting on with his work and life without any great impairment and was extremely happy about this.  He was discharged from the clinic.

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