Neck Pain / Stiffness
Neck pain or stiffness is discomfort or restricted range of motion in the cervical spine region, commonly caused by muscular strain, degenerative disc disease, or cervical spondylosis, but requiring urgent evaluation when associated with meningeal signs or neurological deficits.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Mechanical neck pain / Cervical spondylosis | Gradual onset, worse with activity/posture, better with rest, no neuro deficit, age > 40 | 「頸痛係咪郁嘅時候差啲，休息好啲？」 | ~40% |
| Myofascial pain / Muscle strain | Localised tender points in trapezius/levator scapulae, a/w stress or poor posture | 「有冇成日對住電腦？膊頭有冇繃緊？」 | ~30% | |
| Serious Not To Miss | Meningitis / encephalitis [7] | Fever + headache + neck stiffness + photophobia ± confusion; Kernig/Brudzinski +ve | 「有冇發燒、頭痛、怕光、意識模糊？」Check meningism | < 1% |
| Subarachnoid haemorrhage | Thunderclap "worst headache of my life" + neck stiffness ± LOC [7] | 「有冇突然爆炸咁頭痛？係咪一世人最痛？」 | < 1% | |
| Cervical myelopathy [3] | UMN signs in LL (hyperreflexia, spasticity, gait disturbance), Hoffmann sign +ve, Lhermitte's sign | 「行路有冇唔穩？隻手有冇唔靈活？」Check Hoffmann sign | ~2% | |
| C-spine fracture | Trauma, focal bony tenderness, neurological signs | 「有冇跌倒或者撞親？」 | ~1% | |
| Malignancy / Metastasis | Constant pain, night pain, weight loss, PMH of cancer | 「半夜會唔會痛醒？有冇輕咗磅？」 | < 1% | |
| Spinal infection (epidural abscess, TB) | Fever, focal bony tenderness, IVDU/immunocompromised — not meningism | 「有冇發燒？頸有冇一個位特別痛？」 | < 1% | |
| Giant cell arteritis (GCA) [4][5] | Age > 50, new headache, jaw claudication, visual symptoms, ↑ESR | 「食嘢咀嚼有冇痛？有冇睇嘢矇咗？」 | < 1% | |
| Pitfalls | Cervical radiculopathy | Dermatomal arm pain/numbness, Spurling test +ve | 「邊隻手指痺？（Check Spurling test）」 | ~10% |
| Torticollis | Acute onset, head tilted, SCM spasm, often younger patient | 「瞓醒之後頸係咪歪咗？」 | ~5% | |
| Polymyalgia rheumatica (PMR) [5] | Age > 50, bilateral shoulder + hip girdle stiffness, ↑ESR, dramatic response to steroids | 「兩邊膊頭同大腿有冇僵硬？朝早有冇好差？」 | ~2% | |
| Referred pain (cardiac, diaphragm) | Exertional, a/w chest pain/SOB | 「頸痛嗰陣有冇胸口唔舒服？」 | ~1% | |
| Masquerades | Psychosocial stress / Anxiety about serious disease | Fear of paralysis, stroke, cancer; work stress; medicolegal (whiplash claim) | 「你最擔心係咩？係咪驚有大問題？」 | ~15% |
| Depression | Poor sleep, fatigue, diffuse pain, loss of interest | 「心情點？有冇開心唔到？」 | ~10% | |
| Ankylosing spondylitis (cervical) [1][2] | Young male, insidious onset, morning stiffness > 30 min, ↓ROM, HLA-B27 | 「你幾歲開始痛？朝早僵硬有冇超過半個鐘？」 | ~2% | |
| RA with cervical involvement [6] | Known RA, C1/2 subluxation → myelopathy signs | 「你有冇風濕關節炎？」Check for long tract signs | ~1% |
Neck Pain / Stiffness – Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport | 「你好，我係X醫生。今日想同你傾吓，了解吓你嘅情況，會問你啲問題，希望你唔介意。」(Hello, I'm Dr X. I'd like to chat and understand your situation today.) | Builds rapport; interpersonal marks start here |
| 0:30–1:30 | Chief complaint + HPI – SOCRATES, onset, progression, aggravating/relieving, radiation | 「你頸邊度唔舒服？幾時開始？點樣痛法？有冇傳去隻手或者膊頭？朝早起身有冇特別僵硬？」 | Core symptom analysis; determines mechanical vs inflammatory vs neurological |
| 1:30–2:30 | Red flags – trauma, fever, weight loss, neuro deficits, UMN signs | 「有冇整親過？有冇發燒？隻手有冇痺或者冇力？行路有冇唔穩？大小便有冇問題？體重有冇輕咗？」 | Must screen for cervical myelopathy, meningitis, malignancy, fracture |
| 2:30–3:30 | Systems review + PMH/DHx/FHx/SHx – inflammatory features, eye problems, occupation, posture | 「你有冇其他關節痛？有冇眼紅眼痛？做咩工作？平時用電腦多唔多？食緊咩藥？有冇藥物敏感？」 | Screens SpA, PMR/GCA, occupational cause |
| 3:30–4:30 | ICE – uncover hidden agenda | 「你自己覺得頸痛係咩原因？你最擔心啲咩？（停一停）你今日嚟睇醫生，最想我幫到你啲咩？」 | ICE is marks-bearing; pause after "concerns" – the patient may reveal fear of cancer, stroke, etc. |
| 4:30–5:15 | Functional impact + psychosocial | 「頸痛有冇影響你返工或者瞓覺？心情點呀？有冇壓力大？」 | Biopsychosocial model; captures psychological & social problems for CRF |
| 5:15–6:00 | Summarise, signpost, close | 「等我總結吓：你頸痛咗X個禮拜，主要係…… 我理解嘅啱唔啱？如果我幫你做個簡單檢查，再商量點處理，好唔好？多謝你今日嚟。」 | Summarising + checking understanding + closing = high interpersonal marks |
Uncovering the hidden agenda: The symptom is neck pain, but the reason for consultation today may be fear (e.g., worried about stroke, cancer, paralysis), functional impact (can't work/sleep), or a triggering event (numbness started, friend diagnosed with something). Always ask: 「點解你揀今日嚟睇？係咪最近有啲嘢令你特別擔心？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & Duration | When did it start? Sudden or gradual? | 「幾時開始？突然定慢慢嚟？」 | Acute → trauma/disc; insidious → spondylosis/inflammatory | Acute: disc herniation, whiplash; Gradual: OA, SpA |
| Character | Dull ache, sharp, burning, stiff? | 「係痠痛、刺痛、定係僵硬？」 | Stiffness → inflammatory vs mechanical | Morning stiffness > 30 min → SpA/RA [1][2] |
| Radiation | Does pain travel to shoulder, arm, fingers? | 「有冇傳去膊頭、手臂或者手指？」 | Dermatomal radiation → radiculopathy | C5–C7 radiculopathy, cervical disc herniation |
| Morning stiffness | How long does morning stiffness last? | 「朝早僵硬維持幾耐？郁吓會唔會好啲？」 | > 30 min + improves with exercise = inflammatory back/neck pain [1][2] | AS, SpA, RA, PMR |
| Neuro – Upper limb | Any numbness, tingling, weakness in arms/hands? | 「隻手有冇痺、冇力、或者好似觸電咁？」 | UL neuro deficit → radiculopathy or myelopathy [3] | Cervical radiculopathy, myelopathy |
| Neuro – Lower limb / gait | Any leg weakness, unsteady walking? | 「行路有冇唔穩？對腳有冇冇力？」 | LL UMN signs → cervical myelopathy (spinal cord compression) [3] | Cervical myelopathy – urgent referral |
| Bladder/bowel | Any difficulty with urination or bowel control? | 「大小便有冇控制唔到？」 | Sphincter dysfunction = cauda equina / myelopathy red flag | Myelopathy, cord compression |
| Trauma | Any recent injury, fall, or whiplash? | 「有冇整親、跌倒、或者撞車？」 | Fracture, ligamentous injury | C-spine fracture, whiplash |
| Fever / weight loss | Any fever, night sweats, weight loss? | 「有冇發燒、出夜汗、或者體重輕咗？」 | Red flags for infection/malignancy | Spinal infection, metastatic disease, TB spine |
| Eye symptoms | Any red eyes, blurred vision? | 「有冇眼紅、眼痛、視力模糊？」 | Anterior uveitis → SpA; visual loss → GCA [4] | Ankylosing spondylitis, GCA |
| Headache | Any new headache, especially temporal? | 「有冇頭痛？邊度痛？」 | Temporal headache + neck stiffness in elderly → GCA/PMR [4][5] | GCA, PMR, meningitis |
| Jaw claudication | Pain when chewing? | 「食嘢咀嚼嗰陣有冇痛？」 | Jaw claudication is specific for GCA [4][5] | Giant cell arteritis |
| Other joints | Any other joint pain or swelling? | 「其他關節有冇痛或者腫？」 | Polyarthritis → RA; peripheral + axial → SpA | RA, SpA, PMR |
| PMH | Any DM, cancer, RA, osteoporosis? | 「有冇長期病？糖尿、風濕、骨質疏鬆？」 | DM → frozen shoulder; RA → C1/2 subluxation [6]; cancer → mets | RA cervical subluxation, pathological fracture |
| Drug Hx | Any medications, especially steroids? | 「食緊咩藥？有冇食類固醇？」 | Steroids → osteoporosis; anticoagulants → epidural haematoma | Drug-related causes |
| Occupation | What work do you do? Computer/manual? | 「做咩工作？成日對住電腦？」 | Prolonged posture → mechanical neck pain | Myofascial pain, postural strain |
| Psychosocial | Any stress, mood changes, sleep problems? | 「最近壓力大唔大？心情點？瞓得好唔好？」 | Depression/anxiety → muscular tension; secondary gain | Depression masquerade, fibromyalgia |
| Functional impact | Can you drive, turn your head, work? | 「頸痛影唔影響你返工、揸車、或者瞓覺？」 | Determines severity and social problem for CRF | — |
Case Report Form Answer Builder
- CC: Neck pain / stiffness × [duration]
- HPI high-yield points: Onset (acute/insidious), duration, location (posterior/lateral), radiation (arm/hand – which dermatome), character, severity (VAS), aggravating factors (movement/posture), relieving factors (rest/NSAID), morning stiffness duration, associated symptoms (numbness, weakness, headache, fever, visual symptoms), trauma history, functional impact
- Examples: "Worsening neck pain affecting work" / "New onset arm numbness with neck pain" / "Worried neck pain may be a serious disease" / "Came because unable to turn head while driving"
- Choose the single most important reason the patient came today — often the trigger or the fear, not the symptom itself
| Likely Content | Example Wording | |
|---|---|---|
| Ideas | "I think it might be from my posture" / "Maybe a slipped disc" / "Could it be arthritis?" | Patient thinks neck pain is from prolonged computer use |
| Concerns | "I'm worried it could be something serious like cancer/stroke/paralysis" / "Worried about not being able to work" | Patient is concerned about nerve damage or paralysis |
| Expectations | "I want an X-ray/MRI" / "I want painkillers" / "I want a referral to a specialist" | Patient expects imaging or specialist referral |
- In primary care, middle-aged/elderly patient with insidious neck pain, no red flags → Mechanical neck pain / Cervical spondylosis
- Minimum supporting evidence: gradual onset, worse with movement, better with rest, no neurological deficit, limited C-spine ROM, tenderness over paraspinal muscles, no fever/weight loss
- If young patient with morning stiffness > 30 min improving with exercise → consider axial spondyloarthropathy [1][2]
| DDx | One Key Discriminator |
|---|---|
| Cervical radiculopathy | Dermatomal arm pain + numbness, Spurling test +ve |
| Myofascial pain syndrome | Localised trigger points in trapezius, a/w stress/posture, no neuro signs |
| Cervical myelopathy [3] | UMN signs (hyperreflexia, Hoffmann +ve, gait disturbance) |
(Adjust based on stem: if elderly + temporal headache → include GCA/PMR [4][5]; if young male → include AS [1][2])
| Domain | Problem |
|---|---|
| Biological | Chronic neck pain with limited ROM affecting daily activities |
| Psychological | Anxiety about serious underlying disease (e.g., fear of paralysis/cancer); or co-existing depressed mood |
| Social | Occupational impairment (unable to work at computer/drive); or strained relationships due to chronic pain |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Cervical spondylosis (most likely) | Reduced cervical ROM (flexion, extension, rotation, lateral flexion) + paravertebral tenderness | Ask patient to actively flex/extend/rotate neck; palpate paraspinal muscles | Limitation in multiple planes with local tenderness without neuro deficit supports degenerative mechanical cause |
| Cervical radiculopathy | Spurling test +ve | Extend + laterally flex neck to affected side, apply axial compression → reproduces arm pain/numbness | Foraminal narrowing compresses nerve root; dermatomal reproduction is specific |
| Cervical myelopathy [3] | Hoffmann sign +ve (or hyperreflexia, inverted supinator reflex, Lhermitte's sign) | Flick distal phalanx of middle finger; +ve = involuntary flexion of thumb and index finger | UMN sign indicating cord compression; warrants urgent MRI and referral |
| GCA [4][5] | Thickened, tender, non-pulsatile temporal artery | Palpate temporal artery bilaterally | Arteritic inflammation; a/w ↑ESR; sight-threatening – needs urgent steroids |
| Ankylosing spondylitis [1][2] | ↓Cervical ROM + occiput-to-wall distance > 0 cm | Patient stands against wall; measure distance from occiput to wall | Loss of cervical lordosis in advanced AS; confirm with SI joint XR/MRI |
| Meningitis | Neck stiffness (meningism) + Kernig/Brudzinski sign [7] | Passively flex neck → resistance and pain; knee extension with flexed hip → hamstring spasm | Meningeal irritation from infection or SAH |
| Myofascial pain | Trigger point tenderness in trapezius/levator scapulae | Palpate upper trapezius; firm pressure reproduces referred pain | Localised taut band without neuro signs confirms muscular origin |
Must Not Miss Red Flags – Urgent Referral
- Cervical myelopathy signs (UMN in limbs, gait disturbance, Hoffmann +ve, bladder dysfunction) → urgent MRI + ortho/neurosurgery referral [3]
- Suspected GCA (age > 50, new headache, jaw claudication, visual symptoms, ↑ESR) → same-day high-dose prednisolone before biopsy [4][5]
- Fever + severe neck stiffness + altered consciousness → meningitis → A&E immediately [7]
- Post-trauma with bony tenderness/neuro signs → immobilise + imaging → A&E
- Progressive weight loss + constant night pain → malignancy / infection until proven otherwise
Top traps that lose marks:
- ❌ Forgetting to ask about neurological symptoms (arm numbness, leg weakness, bladder) — misses myelopathy/radiculopathy
- ❌ Not asking morning stiffness duration — misses inflammatory cause (SpA, RA, PMR) [1][2]
- ❌ In elderly patient: not screening for GCA (headache, jaw claudication, visual symptoms) [4][5]
- ❌ Writing "neck pain" as the reason for consultation instead of the patient's actual concern/trigger
- ❌ Listing only musculoskeletal DDx — forgetting referred pain (cardiac), meningitis, or depression masquerade
- ❌ Not eliciting ICE — loses guaranteed marks on the CRF
Shortest safe management/safety-net line for closing: 「如果你頸痛突然嚴重咗，或者隻手腳開始冇力、大小便控制唔到，要即刻去急症室。」 (If your neck pain suddenly worsens, or you develop arm/leg weakness or bladder problems, go to A&E immediately.)
GC Lecture High Yield: Inflammatory neck/back pain features (insidious onset < 40–45 yo, > 3 months, morning stiffness > 30 min, improves with exercise, NOT relieved by rest) are directly tested in AS/SpA questions. [1][2] PMR/GCA: neck + shoulder girdle stiffness in elderly with ↑ESR — don't miss jaw claudication and visual symptoms. [4][5]
High Yield Summary
What to ASK: SOCRATES + radiation to arm + morning stiffness duration + neuro symptoms (arm numbness/weakness, gait, bladder) + red flags (trauma, fever, weight loss, night pain) + eye/headache/jaw claudication in elderly + ICE + occupation + psych screen
What to WRITE on CRF: CC with duration → HPI with red flag screen → RFC = patient's actual trigger/concern → ICE with specific wording → Most likely Dx with supporting evidence → 3 DDx with discriminators → 3 biopsychosocial problems → 1 physical sign (reduced cervical ROM for spondylosis; Spurling for radiculopathy; Hoffmann for myelopathy)
What NOT to MISS: Cervical myelopathy (Hoffmann, gait, UMN), GCA in elderly (temporal headache, jaw claudication, visual loss), meningitis (fever + meningism), inflammatory SpA in young (morning stiffness > 30 min)
Active Recall - Family Medicine Clinical Test
[1] GC 074. Multiple joint pain.pdf (Modified New York criteria for AS; inflammatory back pain features) [2] MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1700–1706: Ankylosing spondylitis clinical manifestation, inflammatory vs mechanical back pain) [3] Maksim Surgery Notes.pdf (p.223–224: Cervical myelopathy, clinical features, UMN signs, spinal stenosis) [4] GC_Interactive tutorial (Rheum case 1) student copy.pdf (PMR/GCA case scenario, jaw claudication, visual involvement) [5] Block A - Rheumatology Interactive Tutorial.pdf (PMR/GCA case, focused questioning for temporal pain, jaw claudication, visual loss) [6] MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1676–1678: RA cervical spine involvement, C1/2 subluxation) [7] Ryan Ho Neurology.pdf (p.6) / Ryan Ho Fundamentals.pdf (p.84): Neck stiffness testing, meningeal signs, Kernig and Brudzinski signs
Ear Pain
Ear pain (otalgia) is discomfort in or around the ear that may arise from primary ear pathology or be referred from adjacent structures such as the temporomandibular joint, pharynx, or cervical spine.
Sleep Disturbance
Sleep disturbance is a broad term encompassing any alteration in normal sleep patterns, including difficulty initiating or maintaining sleep, excessive sleepiness, or abnormal behaviors during sleep, that impairs daytime functioning.