Patient:

a 34 year old female, came to the clinic with right-sided neck and shoulder pain for 10+ years and hand numbness and pain for 1 month.

Assessment and examination:

● Neck stiffness and lack of curvature
● Subjective neck and shoulder pain VAS=8 points
● Cervical forward flexion, backward extension, and turning the head from side to side moderately aggravated by nerve compression
● Right lateral upper trapezius and scapular tibialis muscle tenderness(+), right dorsal supraspinal muscle group tenderness diagonal muscle tenderness(+), rhomboid muscle tenderness(+)

Diagnostic imaging:

● MRI cervical C3-4, C4-5, C5-6 disc herniation, dural sac compression
● DR cervical curvature straight

● Cervical shoulder fasciitis.

Treatment plan: Comprehensive diagnosis and treatment standards for cervical disc herniation combined with cervical shoulder fasciitis are given, and manual release of the neck muscles is combined with physical high-energy laser treatment, 1-2 times a week, 15 minutes each time for 4 consecutive weeks, and at the same time, functional exercises and overall exercises of the cervical spine are combined to improve the mobility of the cervical spine and relieve discomfort.
Treatment effect: After 2 weeks of treatment, neck pain was relieved, and after 4 weeks, the pain level was relieved by 50%, the frequency of pain was reduced, and the mobility was improved.