Case Study: Neck and Shoulder Pain Diagnosis and Treatment with Ultrasound-Guided Dry Needling

Our Patient

Our patient was a 46 year-old male complaining of pain in his left shoulder and neck. During the clinical exam, it was revealed that two days prior, he had received an allergy injection in his left arm for asthma.

Initial Diagnosis

The initial diagnosis identified myofascial trigger points in the left rotator cuff and neck muscles. Diagnostic ultrasound imaging further revealed a 15mm multilocular lesion in the left suboccipital area (the posterior neck muscles below the occipital bone). The lesion included enlarged lymph nodes with entrapment of the occipital nerve, with trigger points near the site of irritation.

Further Diagnostic Recommendations

To better understand the full picture, further diagnostic steps were recommended:

  1. A fine needle aspiration biopsy of the lymph nodes was done to help determine the nature of the lesion.
  2. Further imaging studies with CT scan or MRI.
  3. Blood tests to provide more information about the patient’s overall health.

Proposed Treatment Plan

The following treatment plan was proposed:

  • Use of anti-inflammatory drugs to reduce pain and inflammation.
  • Ultrasound-guided dry needling to eliminate trigger points.
  • Physical therapy to address muscle imbalances, improve range of motion, and strengthen the affected muscles.
  • Further evaluation of affected lymph nodes.
  • Ongoing allergy management.
  • Ongoing pain management using occipital nerve blocks or other pain management strategies.
  • Followup and monitoring of patient progress.

Our Conclusion

This case emphasizes the potential association between lymph node lesions and myofascial trigger points as the underlying cause of neck and shoulder pain, and the importance of a personalized treatment plan vs generic neck pain treatment.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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