What are the treatment options for a 20-year-old female with acute onset of severe neck pain on the right side after hearing a popping sensation while stretching?

Management of Acute Neck Pain Following Audible "Pop" in a Healthy 20-Year-Old Female

Immediate Recommendation

This patient requires no imaging and should be managed conservatively with NSAIDs, activity modification, and reassurance, as she has no red flags warranting further investigation. 1

Clinical Assessment and Red Flag Screening

This presentation represents acute mechanical neck pain (Grade I-II) without concerning features. The key determination is whether red flags are present that would alter management 1:

Red flags to exclude:

• Trauma (minor stretching injury does not qualify as significant trauma) 1
• Neurological deficits (radiculopathy, myelopathy) 1
• Constitutional symptoms (fever, weight loss, night sweats) 1
• History suggesting malignancy, infection, or inflammatory arthritis 1
• Severe or progressive symptoms despite appropriate therapy 1
• Age >50 years with vascular disease concerns 1

This patient has none of these red flags - she is young, healthy, experienced a benign mechanical event (stretching), and has localized pain without neurological symptoms. 1

Imaging Recommendations

No imaging is indicated. 1, 2

The ACR Appropriateness Criteria explicitly state that in the absence of red flags, therapy is rarely altered by radiographic findings in acute neck pain. 1 Most cases of acute neck pain (<6 weeks duration) resolve spontaneously, though approximately 50% may have residual symptoms up to one year. 1, 3

Why imaging is not helpful here:

• MRI has a high rate of abnormal findings in asymptomatic individuals and correlates poorly with symptoms 1
• Plain radiographs show degenerative changes in most adults over 30 that do not correlate with pain 1
• The audible "pop" likely represents benign cavitation of facet joints, not structural injury 3

Treatment Algorithm

First-line therapy (initiate immediately):

1. NSAIDs: Ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg/day) 4, 5

   • Evidence supports NSAIDs for acute neck pain 5
   • Use the lowest effective dose for shortest duration 4

2. Activity modification: Continue normal activities as tolerated, avoiding extreme neck positions 6, 7

   • Complete rest is not recommended 6

3. Consider adding muscle relaxant if muscle spasm is prominent:

   • Cyclobenzaprine 5 mg three times daily for 7-10 days maximum 8, 3
   • Evidence supports muscle relaxants in acute neck pain with muscle spasm 3, 5
   • Start with 5 mg dose to minimize sedation 8

If inadequate response at 2-4 weeks:

1. Add supervised exercise program 7

   • Range-of-motion exercises initially 7
   • Progress to strengthening exercises 7

2. Consider manual therapy: Manipulation or mobilization 7

   • Evidence supports multimodal care including manual therapy for recent-onset neck pain 7

3. Alternative: Massage therapy 5

   • Weaker evidence but may provide benefit 5

Follow-Up Strategy

Reassess at 2-4 weeks if symptoms persist 2

At that point, if no improvement:

• Re-screen for red flags 1
• Consider physical therapy referral 2, 7
• Imaging remains unnecessary unless red flags develop 1

Refer for imaging only if:

• Neurological symptoms develop (radiculopathy) 1
• Pain becomes refractory to 6 weeks of conservative treatment 3
• New red flags emerge 1

Critical Pitfalls to Avoid

Do not order imaging in this scenario - it will not change management and may lead to unnecessary interventions for incidental findings that are unrelated to her symptoms. 1 Degenerative changes are ubiquitous in adults and correlate poorly with pain. 1

Do not assume the "pop" indicates structural damage - audible sounds during neck movement are common and usually benign, representing joint cavitation rather than injury. 3

Do not prescribe prolonged muscle relaxants - limit to 7-10 days due to sedation and lack of evidence for longer courses. 8, 3

Do not recommend complete rest - early mobilization and return to normal activities as tolerated leads to better outcomes. 6, 7

Prognosis

Most acute neck pain episodes resolve with or without treatment, though nearly 50% of individuals will experience some degree of ongoing pain or recurrences. 3 Factors associated with poor prognosis include female gender, older age, and psychosocial factors, though this young healthy patient has favorable prognostic indicators. 1