Version June 2024
| Condition | Symptoms | Physical findings | Provocative maneuvers* | Supportive findings on diagnostic tests¶ |
| Musculoskeletal | ||||
| Cervical strain | Pain and/or stiffness on neck movement | Tenderness on palpation of neck and trapezius muscles | Negative | None (clinical diagnosis) |
| "Whiplash" injury | Pain and/or stiffness on neck movement following an abrupt extension–flexion type injury (may present immediately or may be delayed for several days); other symptoms may include headache, shoulder or back pain, dizziness, paresthesias, fatigue, and sleep disturbances | Decreased range of motion associated with neck spasm | Negative | None (clinical diagnosis) |
| Cervical discogenic pain | Pain and/or stiffness on neck movement; cervical radicular symptoms are sometimes present (refer to cervical radiculopathy below) | Decreased range of motion with associated pain | Variable | Degenerative changes of the discs may be noted on imaging |
| Cervical facet osteoarthritis | Pain and/or stiffness on neck movement; symptoms can be somatically referred to the shoulders, periscapular region, occiput, or proximal limb | Decreased range of motion associated with neck spasm | Negative | Degenerative changes of the zygapophyseal (facet) joint may be noted on imaging |
| Cervical myofascial pain | Focal pain and pressure sensitivity; often involves right side of neck and shoulder; pain typically has a deep aching quality, occasionally accompanied by a sensation of burning or stinging | Localized tenderness ("trigger points") on palpation | Negative | None (clinical diagnosis) |
| Diffuse skeletal hyperostosis (DISH) | May also have thoracic spine, low back, and/or extremity pain; spinal morning stiffness is common; some affected patients may complain of dysphagia | Decreased range of motion may be present | Negative | Evidence of bone deposition at ligament and tendon insertion sites may be noted on plain radiographs or CT |
| Radiculopathy/myelopathy | ||||
| Cervical radiculopathy | Pain, numbness, and/or tingling in a dermatomal distribution, and/or weakness in upper extremity | Decreased or altered sensation, diminished deep tendon reflexes, and/or decreased strength in upper extremity | Positive | Spine MRI or CT myelogram demonstrates cervical nerve root compression |
| Cervical spondylotic myelopathy | Lower extremity weakness, gait or coordination difficulties, and bowel or bladder dysfunction | Focal neurologic signs in upper and/or lower extremities may be present | Lhermitte's signΔ | Spine MRI or CT myelogram demonstrates cord compression |
| Ossification of the posterior longitudinal ligament | Typically present in the fifth to sixth decades of life with neck pain, stiffness, and progressive radiculopathy/myelopathy symptoms | Focal neurologic signs in upper and/or lower extremities may be present | Variable | Flowing calcifications along posterior surface of the vertebra on spine radiography or CT |
| Nonspinal causes | ||||
| Coronary artery disease (angina pectoris, MI) | Chest pain with radiation to neck; pain that worsens with exertion | Normal neck exam | Negative | Evidence of myocardial ischemia on ECG and/or stress testing |
| Infection (osteomyelitis, discitis, pharyngeal abscess, meningitis) | Fever; other signs vary depending on nature of infection | Vary depending on nature of infection | Negative | Evidence of bony or soft tissue infection on spine MRI or CT (osteomyelitis, discitis, pharyngeal abscess); elevated WBC count and other inflammatory markers (ESR, CRP); CSF pleocytosis on lumbar puncture (meningitis) |
| Malignancy (metastatic disease) | Unexplained weight loss or prior history of cancer | Localized tenderness on palpation of spine | Negative | Focal enhancing mass involving marrow on spine MRI or CT Lytic or blastic focal cortical lesion on spine CT |
| Neurologic conditions | ||||
| Tension headache | Bilateral dull headache, which may be associated with neck pain; no other neurologic symptoms | Localized tenderness on palpation of scalp and/or neck; no neurologic abnormalities | Negative | None (clinical diagnosis) |
| Cervical dystonia | Sustained or intermittent muscle spasms of neck | Muscle contractions causing abnormal, often repetitive, movements and/or postures | Negative | None (clinical diagnosis) |
| Chiari malformation (CM-1) | Neck pain or headache from meningeal irritation is the most common presentation | Variable focal central nervous system signs | Negative | Head and/or cervical spine MRI demonstrates displacement of one or both cerebellar tonsils 5 mm or more below the foramen magnum |
| Referred shoulder pain (eg, impingement, adhesive capsulitis, rotator cuff tear) | Shoulder pain with radiation to neck | Localized tenderness on shoulder exam with or without decreased range of motion | Negative | |
| Rheumatologic conditions | ||||
| Polymyalgia rheumatica | Aching and morning stiffness in shoulders, hip girdle, neck, and torso | Decreased range of motion of joints in affected areas; normal muscle strength | Negative | Increased inflammatory markers (ESR, CRP) |
| Giant cell arteritis | Constitutional symptoms, headache, and visual loss | Prominent and/or tender temporal artery; absent temporal artery pulse | Negative | Increased inflammatory markers (ESR, CRP); temporal artery biopsy may be used to confirm diagnosis |
| Fibromyalgia | Diffuse musculoskeletal pain with fatigue | Multiple soft tissue "tender points"; no evidence of joint or muscle inflammation | Negative | Normal inflammatory markers (ESR, CRP) |
| Thoracic outlet syndrome | Upper extremity neurologic and/or vascular symptoms (eg, numbness, paresthesias, weakness, swelling, pain, pallor, and/or coldness in the hand) | Focal neurologic signs in upper extremities and/or signs of venous or arterial compression (eg, sensory deficits, swelling, cyanosis or pallor) | Variable | EMG/NCS may demonstrate denervation in ulnar and median innervated muscles; cervical ribs may be seen on plain radiographs; additional imaging (neck and chest ultrasound with Doppler, CTA or MRA) can help confirm the diagnosis |
| Vascular conditions (vertebral or carotid artery dissection) | Symptoms of cerebral ischemia (eg, sudden onset of focal motor and/or sensory deficits) | Variable focal central nervous system signs | Negative | Head and neck MRI/MRA or CTA demonstrate characteristic findings |
| Visceral etiologies | ||||
| Esophageal obstruction | Dysphagia, which may be associated with throat or neck pain | Normal neck exam | Negative | Fluoroscopic contrast esophagram and/or upper endoscopy show evidence of obstruction |
| Biliary tract disease | Right upper quadrant abdominal pain with radiation to shoulder and/or neck | Normal neck exam; jaundice and/or right upper quadrant abdominal tenderness may be present | Negative | Abdominal ultrasound, CT, MRI or MRCP shows evidence of biliary tract disease |
| Apical lung tumor | Cough, hemoptysis, dyspnea, and/or chest pain with radiation to neck may be present | Normal neck exam; pulmonary exam may show focal abnormalities (eg, rales, rhonchi) | Negative | Chest radiograph or CT shows a lung mass |
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