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Background: Similar upper extremity symptoms can present with varied physiologic etiologies. However, due to the multifaceted nature of musculoskeletal conditions, a definitive diagnosis using physical examination and advanced testing is not always possible. This report discusses the diagnosis and case management of a patient with two episodes of similar upper extremity symptoms of different etiologies. Case Presentation: On two separate occasions a forty-four year old female patient presented to a chiropractic office with a chief complaint of insidious right-sided upper extremity symptoms. During each episode she reported similar pain and parasthesias from her neck and shoulder to her lateral forearm and hand. During the first episode the patient was diagnosed with a cervical radiculopathy. Conservative treatment, including manual cervical traction, spinal manipulation and neuromobilization, was initiated and resolved the symptoms. Approximately eighteen months later the patient again experienced a severe acute flare-up of the upper extremity symptoms. Although the subjective complaint was similar, it was determined that the pain generator of this episode was an active trigger point of the infraspinatus muscle. A diagnosis of myofascial referred pain was made and a protocol of manual trigger point therapy and functional postural rehabilitative exercises improved the condition. Conclusion: In this case a thorough physical evaluation was able to differentiate between radicular and referred pain. By accurately identifying the pain generating structures, the appropriate rehabilitative protocol was prescribed and led to a successful outcome for each condition. Conservative manual therapy and rehabilitative exercises may be an effective treatment for certain cases of cervical radiculopathy and myofascial referred pain. Background Among the general population, musculoskeletal pain and injury rank second only to upper respiratory conditions as the most common reasons for visiting a physician[1]. About 23% of patient visits to the family physician and 20% of visits to the emergency department are for musculoskeletal pain and injury [2-4]. Kahl reported that osteoarthritis is the single most common musculoskeletal problem, followed by isolated Published: 19 July 2007 Chiropractic & Osteopathy 2007, 15:10 doi:10.1186/1746-1340-15-10 Received: 15 February 2007 Accepted: 19 July 2007 This article is available from: http://www.chiroandosteo.com/content/15/1/10 © 2007 Daub; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.