Referred pain

This week, a patient with sharp pain behind her left eye. This patient had a history of cervicogenic headaches that had responded well to physio treatments. This presentation was without neck pain or pain on the sides or over the back of the skull, just behind the eye. Slightly limited AROM into R SF and R rotation otherwise NAD. PPIVMS detected hypomobility at C4 on both sides and PAIVMS were P2 limited at C2, C3, C4 some unilaterals as well. Palpation was ++ tight upper traps, LS, scalenes and SCM. No active or passive testing so far had reproduced symptoms. I had a student with me who asked to palpated SCM, doing TPs along the muscle produced intense pain however not until approaching the bottom third did the pain in the eye start. Here we are a trigger point reproducing the exact pain the patient is complaining of.

So off we went to report the objective, soft tissue the main concern, tick, what will we treat, the soft tissue – but not SCM!! The reason being it is in the anterior triangle where all the vessels and nerves are. Indirect treatment by loosening the U.T.s, LS and posterior structures will help? Ahhh but the SCM reproduces the pain! So off I went treated the posterior structures, yes improved ROM, pt felt better, I bid her farewell with some SCM and Cx stretches feeling horrible as I am sure she will again suffer her eye pain.

So here is a dilemma, well not really, I have learnt that SCM can refer to behind the eye, there are indirect ways to treat it, hold relax, stretches, posture repositioning and if I am asked in the PCR to treat the anterior of the neck I will say no that is contraindicated or at least an area of high caution which should be avoided.

You can turn the patient’s head to the side in supine, support their head with one hand and with the other pick up SCM between your thumb and fingers to perform TPs without fear of compromising the neurovascular structures I believe.