Objective: To discuss the case of a patient with unilateral vertebral artery tortuosity and dilatation resulting in vertebral body and transverse foramen erosion. An emphasis is placed on diagnostic imaging.Clinical features: A 45-year-old man had a frozen shoulder and headaches. Previous arm pain, numbness, and a cold extremity were the result of occlusion of the subclavian artery and had been treated with a subclavian-carotid bypass procedure.Intervention and outcome: As a result of the angiographic detection of the left vertebral artery dilatation and tortuosity and the concomitant hypoplastic right vertebral artery, high-velocity, low-amplitude manipulation of the cervical spine was contraindicated. However, the patient's symptoms were not related to these findings. Alternatively, low-force manipulation of the cervical spine, shoulder range of motion and muscle techniques were used, and the patient's symptoms diminished significantly with improved shoulder range of motion.Conclusion: Clinicians need to be alert to clinical presentations and appropriate imaging protocols in cases of suggested vertebral artery anomaly.