Degenerative arthritis of the upper thoracic spine, thoracic spine sprains, rib sprains, cervical spine radiculopathy, Myofascial Pain Syndrome.

Physical Exam Findings:

Weight: 195, Height: 6’2”

Thoracic spine examination revealed extremely rigid and tight upper trapezius, pectoralis, and coracobrachialis muscles bilaterally. Rib sprains were evident in the upper rib cage from ribs 1 – 5 bilaterally.

Cervical spine examination demonstrated some mild sprains at the lower cervical spine. Cervical spine muscles were spastic at the lower cervical spine. This includes the bilateral levator scapulae. Scalenes and SCMs were unremarkable. This patient did not goose-neck.

There was extensive bilateral shoulder rounding. Scapulae were protracted and laterally displaced with the left scapula riding higher than the right. There is a slight lateral curvature of the upper thoracic spine to the left. Both findings can be attributed to how this patient holds his guitar.

Question: What is your working Diagnosis at this point?