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Interscapular, shoulder, and thoracic pain often share a common cervical etiology -but not always. Evidence-based chiropractors must use orthopedic testing to identify if the pain is due to a local pathology versus neurologic referral. Practitioners must employ their knowledge gained from the patient history, clinical symptoms, and intuition to select the optimal physical exam components needed to identify the correct pathology.  Sometimes, these evaluations resemble more of an art than a science!

Today’s blog will highlight one maneuver that may ultimately be the difference between a satisfied patient and a negative google review.

Historically, chiropractic education advocates the Spurling and Maximal Foraminal Compression tests to evaluate the patency of the IVF. The Choi’s Test (aka Neck Tornado Test) is another simple way to assess if the intravertebral foramen is the site of nerve compression.  This relatively unknown test demonstrates high sensitivity and accuracy of revealing cervical radiculopathy. (1)Watch this video to see how to perform the Choi’s Test, then read on to understand three essential keys about why it may be invaluable to your care.

1. What Is Choi’s Test?

The practitioner applies an axial compression to the cervical spine of a seated patient. The practitioner then passively flexes the patient’s spine fully under continuous compression. The patient is then guided through end-range lateral flexion towards the painful side through 180 degrees of rotation until the patient reaches a fully extended position. A positive test reproduces radicular pain or tingling in the area of chief complaint.

2. When Should You Consider Choi’s Test?

Patients presenting with a radicular pain pattern in one or both upper extremities often suffer from compression or irritation of one or more cervical nerve roots. Radiculopathies due to disc herniation, disc degeneration, or spondylosis result from decreased neural foramen size. Choi’s test compresses the IVF across all ranges of motion, exposing sensitive nerve roots. In contrast, Spurling’s Test only compresses the cervical spine in one specific direction.

Pain in the suprascapular, interscapular, or scapular regions commonly originates from a compressed cervical nerve root. While this may be common knowledge to most musculoskeletal care providers, it is sometimes more challenging to convince patients of cervical pathology leading to their shoulder or arm pain. Selecting the correct orthopedic test (s) may be the difference between a compliant patient and a second opinion.

When the painful site was suprascapular, C5 or C6 radiculopathy was frequent.

When it was interscapular, C7 or C8 radiculopathy was frequent.

When it was scapular, C8 radiculopathy was frequent.

3. Is Choi’s Test Better Than Spurling’s Test?

The short answer is no! The Spurling test has utility with very high specificity (92%–100%); however, its sensitivity is low to moderate (30%–60%). For example, if 100 patients walk into your office with confirmed cervical radiculopathy; if you only perform Spurling’s test, 40-70 patients will likely demonstrate a negative test, leading you down the wrong differential path. However, if you also perform Choi’s Test (sensitivity of 85%), your ability to properly diagnose the patient increases exponentially.

“Choi’s test is more sensitive with superior diagnostic accuracy for cervical radiculopathy diagnosed by magnetic resonance imaging than the Spurling test.” (1)

Like most any other condition, the keys to correctly diagnosing interscapular pain include performing the cluster of tests that will lead you to the most appropriate diagnosis and subsequent management.

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  1. Park J, Park WY, Hong S, An J, Koh JC, Lee YW, Kim YC, Choi JB. Diagnostic accuracy of the neck tornado test as a new screening test in cervical radiculopathy. International journal of medical sciences. 2017;14(7):662.
  2. Tanaka, Yasuhisa MD; Kokubun, Shoichi MD; Sato, Tetsuro MD; Ozawa, Hiroshi MD Cervical Roots as Origin of Pain in the Neck or Scapular Regions, Spine: August 1, 2006 – Volume 31 – Issue 17 – p E568-E573 

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