Good to know. What are your thoughts on imaging on a weight lifter who injured his neck while lifting 2 years ago and has had chronic neck and trap pain since? Normal neuro exam and no myelopathic or radicular symptoms. Guessing imaging still unnecessary. Also what’s the tire fire with steroids and NSAIDs. Are you talking about the potential or theoretical inhibitory effects on healing?
Unless there is some sort of weakness pointing to a fully ruptured muscle, or some sort of progressive myotomal weakness, then nah... What would it show? Also this is a small snap shot of a much larger picture.
(Assuming imaging is looking for a bulging disc or the like, Nakashima 2015 is worth a glance and is just one of a library on imaging and absent correlates to pain specific to cervical spine, Baretto 2019 for shoulder, etc etc etc)
A few things I would want to consider:
What have other providers told this patient to create kinesiophobia, catastrophizing, and maladaptive pain beliefs? (Darlow 2012, Gardner 2017, etc)
What does sleep look like?
Anxiety?
Depression?
Diet?
Pain beliefs?
Daily activity levels? Aggravating and easing factors? Irritability? Severity?
With trap pain is it R or L and is there any possibility of referral from a systemic/visceral issue?
And if its trap pain, where? I dont know if I have ever seen true trap pain, with neck issues I would generally assume thats our primary culprit causing some referrals.
Also consider healing timelines - a muscle is generally going to heal up pretty quick as they are highly vascular, 2 years in what would I expect imaging to show? Maybe looking for calcific tendonitis?
With the neck itself what will I find looking at lateralization, pain pressure threshold algometry, 2 point discimination, etc... Is there any pain anywhere else? Is this just an issue of central sensitization? Or peripheral neuropathic pain involved? Unlikely nociceptive at this point.
What there failure with conservative treatment (PT)? If so did the PT understand managing chronic pain or did they just load the hell out of peripheral tissues hoping for the best?
NSAIDS - yeah, generally the growing data pool supporting both inhibitory effects on long term outcomes and potential increased risk of transitioning from acute to subacute and chronic.
Steroids.. Oh boy. Thats a long one. Same as above, but more than that its capacity to degrade tendons and ligaments just isnt worth it. I cant rattle the studies off the top of the dome like the ones above, but its pretty clear that we have a total, not relative, risk increase of 9.7% increased likelihood of a TKA with every steroid injection to the knee, increased chances of full thickness traumatic RTC tears with each injection, etc etc etc... 0 effect on non specific or mechanical low back pain (in absence of clear dermatomal pain indicating what is likely a herniated disc they arent well evidenced to do anything more than placebo ((But hey, placebo 100% has an effect))), similar with neck pain. Only sort of evidenced reason to stick them in the shoulder is early stage adhesive capsulitis alongside lidocaine, but thats still dubious.
If its a last resort, its a last resort, but other options should have been exhausted first.