What are the differential diagnoses for a male patient presenting with left neck pain that worsens with flexion and lateral rotation to the left, given his physically demanding job as a roller derby referee?

Differential Diagnoses for Left Neck Pain with Flexion and Lateral Movement

The most likely diagnosis in this male roller derby referee is acute cervical myofascial strain, given the mechanical nature of pain with specific movements and his physically demanding occupation involving repetitive neck movements and potential awkward positioning. 1

Primary Differential Diagnoses

Acute Cervical Myofascial Strain (Most Likely)

• This is the leading diagnosis for sudden onset neck pain with localized stiffness and reduced range of motion, particularly in the absence of neurological symptoms 1
• The pattern of pain with flexion (moving head down) and ipsilateral lateral rotation is classic for muscle and fascial involvement 1
• His occupation as a roller derby referee involves repetitive neck movements, sudden directional changes, and maintaining awkward positions while tracking fast-moving athletes—all risk factors for myofascial strain 1
• This condition typically presents with localized pain, muscle spasm, and stiffness without radiation to the arms 1

Cervical Facet Joint Syndrome

• Facet joints are major stabilizing structures and a common source of mechanical neck pain 2
• Pain from facet joint irritation characteristically worsens with extension and ipsilateral rotation, though flexion can also provoke symptoms 3
• The physically demanding nature of refereeing could cause repetitive microtrauma to facet joints 3

Cervical Spondylosis with Facet Arthropathy

• Degenerative changes are common in adults over 30 years and can cause mechanical neck pain 3
• However, spondylotic changes correlate poorly with symptoms, as they're frequently found in asymptomatic individuals 3
• This becomes more relevant if symptoms persist beyond 6 weeks 3

Cervical Disc Pathology (Less Likely Without Radiculopathy)

• Disc herniation or degenerative disc disease could cause neck pain 4
• However, the absence of arm radiation, tingling, or neurological symptoms makes this less likely 4
• Cervical radiculopathy has distinct features including arm pain and sensory/motor deficits that distinguish it from simple mechanical neck pain 4

Whiplash-Associated Disorder (WAD)

• If there was any acute trauma during refereeing (collision, sudden acceleration-deceleration), this should be considered 5
• WAD involves multiple soft-tissue structures including paraspinal muscles, facets, disks, and craniocervical ligaments 5
• Diagnosis is primarily clinical, as imaging has limited usefulness in diagnosing WAD 5

Cervical Ligamentous Injury/Instability

• Capsular ligament laxity can cause chronic neck pain and cervical instability 2
• In the lower cervical spine (C3-C7), this causes muscle spasms and chronic neck pain 2
• More relevant if there's a history of previous neck trauma or if symptoms become chronic 2

Red Flags to Exclude Serious Pathology

Immediate evaluation is required if any of the following are present:

• Constitutional symptoms (fever, weight loss, night sweats) suggesting infection or malignancy 1, 4
• History of significant trauma requiring assessment for fracture or ligamentous injury 1
• Progressive motor weakness or neurological deficits 4
• Bilateral symptoms suggesting myelopathy 4
• New bladder or bowel dysfunction 4
• Symptoms affecting both upper and lower extremities 4
• Severe pain unresponsive to conservative measures 1

Clinical Evaluation Approach

Key History Elements

• Mechanism of injury: sudden movement, awkward positioning, or cumulative trauma from refereeing 1
• Pain characteristics: localized vs radiating, constant vs movement-related 1, 4
• Presence or absence of arm symptoms (tingling, numbness, weakness) to distinguish radiculopathy 4
• Any recent trauma or collision during roller derby activities 5

Physical Examination Findings

• Localized tenderness over cervical paraspinal muscles suggests myofascial strain 1
• Muscle spasm and guarding are typical of myofascial involvement 1
• Limited range of motion due to pain rather than mechanical block 1
• Absence of neurological deficits (normal strength, sensation, reflexes) makes radiculopathy unlikely 4
• Pain reproduction with palpation of specific structures helps localize pathology 1

Imaging Recommendations

Initial Management (No Red Flags Present)

• Imaging is generally NOT indicated for acute mechanical neck pain in the absence of red flags 5, 1
• Radiographs are often not needed in the acute setting and do not influence management or improve clinical outcomes 5
• The diagnosis of acute cervical myofascial strain is clinical 1

When to Consider Imaging

• Persistent symptoms beyond 4-6 weeks warrant further evaluation 1, 3
• MRI cervical spine without contrast may be considered if symptoms persist or worsen beyond 6 weeks 3, 4
• If radicular symptoms develop (arm pain, tingling), MRI becomes the appropriate initial imaging study 4
• Plain radiographs may be useful to diagnose spondylosis but rarely alter therapy in the absence of red flags 3

Management Approach

Conservative Treatment (First-Line)

Most cases of acute cervical myofascial strain resolve with conservative management: 1

• Rest and activity modification (may need temporary break from refereeing) 1
• Over-the-counter anti-inflammatory medications (NSAIDs) 1, 3
• Gentle stretching exercises 1
• Heat or ice application 1
• Physical therapy for persistent cases 1

Expected Timeline

• Symptoms are usually self-limiting, with many cases resolving within days to weeks 1
• Seek further evaluation if symptoms persist beyond 4-6 weeks 1
• Development of neurological symptoms requires urgent reassessment 1, 4

Common Pitfalls to Avoid

• Do not order imaging for simple mechanical neck pain without red flags—this leads to unnecessary radiation exposure and often identifies incidental findings that don't correlate with symptoms 5, 1, 3
• Do not miss cervical radiculopathy—always assess for arm symptoms, as this changes the diagnostic approach and may require MRI 4
• Do not overlook trauma history—even seemingly minor collisions during roller derby could cause ligamentous injury requiring different management 5
• Do not assume all neck pain is benign—always screen for red flags that require urgent evaluation 1, 4