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Requests for reprints should be addressed to Alan H. Daniels, MD, Department of Orthopedic Surgery, Alpert Medical School of Brown University, 2 Dudley St, Providence, RI 02905.
Differentiating the cause of pain and dysfunction due to cervical spine and shoulder pathology presents a difficult clinical challenge in many patients. Furthermore, the anatomic region reported to be painful may mislead the practitioner. Successfully treating these patients requires a careful and complete history and physical examination with appropriate provocative maneuvers. An evidence-based selection of clinical testing also is essential and should be tailored to the most likely underlying cause. When advanced imaging does not reveal a conclusive source of pathology, electromyography and selective injections have been shown to be useful adjuncts, although the sensitivity, specificity, and risk–reward ratio of each test must be considered. This review provides an evidence-based review of common causes of shoulder and neck pain and guidelines for assistance in determining the pain generator in ambiguous cases.
Differentiating the true cause of shoulder and cervical pain may represent a difficult clinical challenge, with approximately one fourth of patients experiencing both problems.
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Successfully treating these patients requires an evidence-based and systematic approach to the history and physical examination.
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Follow-up imaging should be selected on the basis of the history and physical examination to prevent false-positives.
Determining the cause of symptoms in patients experiencing a combination of neck and shoulder pain and dysfunction often presents a diagnostic challenge. It is reported that painful shoulder impingement may occur in up to 24% of patients with cervical radiculopathy.
In addition, pain reported in the neck may represent referred pain from the shoulder girdle and vice versa, because selective injections into the cervical facet joints have been found to manifest as shoulder pain.
Although challenging, determining the true source of pain and dysfunction in patients with cervical and shoulder syndromes is essential to providing appropriate treatment recommendations. The success of these treatments is highly dependent on an accurate diagnosis, which can be achieved with careful examination and selective diagnostic testing. This review describes both common and uncommon sources of shoulder and cervical pain and provides an evidence-based, systematic guide to evaluation and diagnosis.
Relevant Anatomy
The shoulder represents a complex structure consisting of bony, muscular, and ligamentous structures.
It consists of a number of joints including the acromioclavicular, glenohumeral, sternoclavicular, and scapulothoracic joints. The shoulder is highly dependent on additional static and dynamic stabilizers.
The static stabilizers of the shoulder include the bony architecture, the capsuloligamentous complex, and the glenoid labrum, whereas the rotator cuff muscles provide the primary dynamic stabilization (Table 1).
The cervical spine is made up of 7 vertebrae and 8 sets of nerve roots, which innervate the upper extremity via the brachial plexus (Table 2). Although the C1 and C2 vertebrae are uniquely connected by a complex ligamentous complex consisting of the alar and cruciate ligaments, the remainder of the subaxial spine connects through a series of facet joints and intervertebral disks.
Pain generated within the spine occurs when the structural elements of the spine compress the nervous anatomy, as seen with a herniated nucleus pulposis or a facet joint cyst.
Table 2Motor, Reflex, and Sensory Abnormalities Associated with Specific Cervical Radiculopathies
Subsequent diagnostic testing should be directed by the examination findings, particularly for patients with an unclear presentation or a history of both neck and shoulder pathology.
Shoulder
Obtaining a complete shoulder history begins with patient demographics, including age, gender, presence of comorbid medical and psychosocial conditions, hand dominance, and mechanism of injury or onset.
The clinician should be aware of certain predispositions to shoulder pathology, such as the association of diabetes mellitus and hypothyroidism with adhesive capsulitis.
A complete characterization of the pain, including quality, progression, and aggravating and relieving factors, is determined from the history. For example, dull and aching pain is more consistent with shoulder pathology, whereas burning or electric type pain is more indicative of cervical spine or neurologic origin.
The progression of the pain also is of diagnostic value because certain symptom patterns can accompany shoulder pathology, such as the stages that commonly occur in adhesive capsulitis: pain (freezing), stiffness (frozen), and recovery (thawing).
The anatomic region reported to be painful may mislead the practitioner; however, certain characteristic distributions of pain may be helpful in diagnosing shoulder pathology. Pain directly over the lateral deltoid region suggests subacromial or intrinsic glenohumeral pathology. Pain localized directly over the acromioclavicular joint or directly over the anterior aspect of proximal arm with radiation to the biceps muscle may indicate acromioclavicular joint pathology and biceps tendinopathy, respectively (Figure 1).
In addition to these characteristic pain distributions, nighttime aching and sleep disturbance are extremely common in shoulder pathology, with up to 90% of patients with rotator cuff tears showing sleep disturbance.
For example, suprascapular nerve entrapment may cause weakness and eventual atrophy of the supraspinatus or infraspinatus muscles, and may result from direct trauma to the shoulder or from a ganglion cyst, as is commonly observed with comorbid labral pathology.
Cervical radiculopathy commonly produces pain around the lateral portion of the shoulder girdle. Classically, patients with cervical radiculopathy report a combination of strength and sensory disturbances starting in the neck and radiating to the upper extremity, although the presentation may differ on the basis of myotome and dermatome variation (Figure 2).
More than 90% of patients with cervical radiculopathy present with arm pain, and thus symptoms of arm pain (especially atraumatic) should trigger an evaluation of the cervical spine.
Certain pathognomonic findings are highly indicative of cervical pathology. The shoulder abduction sign, in which the patient raises his or her arm above the head to relieve pain via reducing tension on a cervical nerve root, indicates a likely cervical cause for pain. Likewise, the patient also may tilt his or her head away from the painful side to relieve radiculopathic pain.
History of trauma also may be useful in differentiating shoulder versus cervical pathology. In a population-based study from Rochester, Minnesota, Radhakrishnan et al
found that cervical radiculopathy was infrequently associated with trauma (only 14.8% of cases). Finally, neck and shoulder pain in the setting of painless loss of hand dexterity or an increasingly unstable gait or lack of bladder or bowel control should alert the clinician to the possibility of cervical myelopathy or myeloradiculopathy.
A complete physical examination of the shoulder and cervical spine includes inspection, palpation, range of motion testing, strength testing, and a variety of signs and tests used to elicit findings that suggest specific diagnoses.
Shoulder Examination
The examination begins with careful observation, noting any shoulder girdle muscle atrophy, scapular protraction, retraction, or winging (medial or lateral).
Although cuff degeneration may result from a chronic tear, the presence of atrophy in a younger patient must raise concerns for an underlying neurogenic cause, such as a suprascapular nerve compression or idiopathic brachial plexus neuritis. Presence of a biceps deformity indicative of a long head of the biceps rupture should raise concern for degeneration of other tendons, including the rotator cuff.
After observation, the shoulder girdle is palpated to identify specific areas of tenderness, including the sternoclavicular and acromioclavicular joints, clavicle shaft, biceps tendon, greater tuberosity, and anterior and posterior joint lines.
The shoulder is then moved through both passive and active range of motion, with certain examination findings highly indicative of shoulder pathology compared with cervical pathology. For example, limited active and passive range of motion may indicate adhesive capsulitis or glenohumeral osteoarthritis and is an unlikely finding in the setting of cervical radiculopathy.
In addition, it is not uncommon to see a mild loss of internal rotation motion due to posterior capsular tightness in the setting of rotator cuff syndromes (subacromial bursitis, rotator cuff tendonitis, and impingement).
During range of motion testing, a positive drop arm sign occurs when the patient is unable to hold the affected arm at 90 degrees of abduction. This sign is highly specific (97.2%) for subacromial or rotator cuff pathology.
In addition to range of motion testing, a full assessment of shoulder girdle strength is performed to identify any isolated muscle weakness or patterns of weakness (Table 1).
A variety of provocative maneuvers may be used to assess the shoulder depending on the underlying pathology. Moreover, the reproduction of pain with these specific maneuvers must be localized to a specific shoulder distribution (Figure 1) and greatly increases the likelihood of underlying shoulder pathology. There have been hundreds of provocative maneuvers described, and a full description of all is beyond the scope of this review. Of the most commonly used, the lateral Jobe test (empty can) (downward force directed on a 90-degree abducted and internally rotated arm) was shown to have consistently high sensitivities and specificities for supraspinatus tears.
Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.
A positive O'Brien's test occurs when pain is caused by internal rotation while flexing the arm to 90 degrees with slight adduction. O'Brien's test has been shown to have a sensitivity of 83% and positive predictive value of 90%.
Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.
The position of the head and neck is first noted. Specifically, if the patient sits with his or her head tilted away from the affected side or is unable to achieve rotation greater than 60 degrees, cervical radiculopathy is more likely.
Cervical lordosis or kyphosis also should be noted. The neck, including the vertebral spine, paraspinal muscles, interscalene groove, and nape of the neck, including the upper trapezius and levator scapulae muscles, is palpated to elicit tenderness.
Strength and reflex testing are imperative in the diagnosis of cervical radiculopathy (Table 2). The distribution of strength, sensory, and reflex impairment depends on the level of cervical radiculopathy, with C5/6 overlapping most commonly with shoulder pathology (Figure 2). As with the shoulder, the underlying cause may be unclear at this stage of assessment. It is important to note that restricted cervical motion (<60 degrees), improvement of pain with movement away from the affected sign, and biceps weakness have the highest positive likelihood ratios in predicting cervical radiculopathy.
Therefore, the presence of 1 or more of these findings should necessitate provocative radiculopathy testing.
The Spurling maneuver is frequently cited as the diagnostic maneuver of choice for provoking cervical radiculopathy. To perform the maneuver, the head is extended to the ipsilateral side of the pain and a compressive force is directed downward to compress the neural foramen.
The maneuver is positive when the axial load reproduces the patient's pain. Recent investigations have found sensitivities as low as 30% to 50% and a specificity of 93% for the Spurling test.
This low sensitivity coupled with a consistently high specificity make the test more valuable in confirming radiculopathy when suspicion is high based on history and examination.
To differentiate cervical and shoulder pain generators on examination, Gumina et al
recently proposed the “arm squeeze test,” in which pain reproduced from squeezing the middle third of the humerus represents a positive test for radiculopathy. Impressively, 96.7% of patients with a positive test result were found to have radiculopathy on imaging, whereas only 3.8% of patients with rotator cuff pathology had a positive test result.
Although the reliability of this test has not been proven yet, it theoretically represents a provocative maneuver with high positive and negative predictive values.
Diagnostic Testing and Treatment Principles
After a guided history and physical examination, the majority of patients will have a clear diagnosis, although some may present an ongoing diagnostic challenge. On the basis of the specific history and physical examination, further testing may be considered, as is outlined next.
Patients with Positive Provocative Shoulder Testing
In the common scenario of a patient experiencing shoulder pain with positive provocative shoulder testing, imaging of the shoulder is indicated. Plain radiographs are appropriate initial tests.
For the shoulder, a standard set of radiographs, including an anteroposterior (AP), true AP (Grashey view), axillary, and scapular “Y” views may provide valuable information for diagnosing pain due to a variety of shoulder disorders, including glenohumeral osteoarthritis, rotator cuff impingement and tears, and calcific tendinitis.
Although plain radiographs often are nonspecific for many shoulder conditions, there are findings associated with rotator cuff pathology, including coracoclavicular ligament ossification, anterior and lateral acromial spurring, and greater tuberosity cystic and sclerotic changes.
When plain radiography is nondiagnostic, further testing is based on the presumed diagnosis. For example, if an underlying rotator cuff tear is suspected, magnetic resonance imaging (MRI) and ultrasound have been shown to be highly accurate for the identification of full-thickness rotator cuff tears.
Regardless of the test chosen, images always must be interpreted carefully and correlated with the history and physical examination, because false-positives are common.
In more diagnostically complex cases, patients with cervical pain may have positive provocative shoulder test results. Although there is limited evidence for the diagnostic workup of these patients, small case series may provide insight. In 2003, Gorski and Schwartz
described a series of 34 patients primarily experiencing neck pain but with positive provocative impingement testing and radiographic evidence of impingement. They subsequently named this phenomenon “referred shoulder impingement syndrome” and hypothesized that protective trapezial muscle spasms were the ultimate pain generator complicating the clinical picture. Accordingly, for patients with provocative impingement testing and primary cervical pain, it is reasonable to consider a diagnostic subacromial injection to diagnose a “referred impingement syndrome,” because the majority of patients in the series by Gorski and Schwartz
responded to this treatment (only 5 underwent ultimate subacromial decompression).
Patients with Positive Provocative Cervical Spine Testing
For patients presenting with classic radiculopathy pain with a positive Spurling test, the diagnostic workup includes standard AP and lateral cervical radiographs with the addition of lateral flexion/extension views as an appropriate starting point to assess spondylosis, facet arthrosis, and degenerative disc pathology.
In addition, oblique radiographs may be useful for assessing foraminal stenosis, particularly with the addition of flexion and extension views, which mimic the underlying mechanism of radiculopathy.
When radiculopathy is suspected, MRI is the appropriate test.
MRI is noninvasive, imparts no ionizing radiation to patients, and has a sensitivity of more than 90%, and thus has eclipsed computed tomography (CT) myelography as the imaging modality of choice.
In the absence of a definitive cause or level of compression on MRI or CT, the appropriate follow-up test for radiculopathy is controversial. Although electromyography (EMG) is not as sensitive as MRI, several studies have shown specificities equal or greater than MRI, especially in the presence of provocative shoulder testing.
Therefore, EMG may be seen as a useful adjunct when suspicion for radiculopathy is high. Likewise, selective nerve root injections may be used as a diagnostic adjunct to MRI, although the risk to the surrounding neurovascular structures always must be considered.
Patients with Positive Provocative Shoulder and Cervical Spine Testing
In the setting of prolonged moderate to severe pain with positive provocative shoulder and cervical spine maneuvers, advanced imaging of both the shoulder and the cervical spine may be indicated, which raises the question of which test to acquire first. When patients are ultimately found to have evidence of both shoulder and cervical spine pathology on advanced imaging, a limited number of case series inform the clinician. In their study of 8 patients with comorbid radiculopathy and shoulder girdle pathology, Hawkins et al
found that the 6 patients who underwent shoulder surgery first ultimately experienced complete pain resolution, whereas the 2 patients who underwent cervical decompression first required shoulder surgery to relieve pain. Likewise, in a study of 23 shoulders with comorbid rotator cuff pathology and cervical radiculopathy, Manifold and McCann
showed that addressing the shoulder pathology first resulted in resolution of neck pain in 20 of the 23. Therefore, in the absence of a progressive neurologic deficit, it may be reasonable to pursue strengthening therapy or a diagnostic/therapeutic injection of the shoulder first in patients with comorbid disease.
Patients with Negative Provocative Shoulder and Cervical Spine Testing
In the absence of specific provocative findings in the shoulder or cervical spine, advanced imaging may produce unwanted false-positives and ineffective treatment strategies. For example, in their meta-analysis of nonspecific neck pain, Borghouts et al
found that approximately half of all cases improved with conservative therapy and that neither radiation to the arm nor degenerative disease on cervical radiography was predictive of a poorer prognosis. Therefore, in the absence of positive provocative testing, it is reasonable to pursue a course of nonsurgical management with physical therapy for neck and periscapular pain, because approximately half will improve without treatment.
Furthermore, a complete and longitudinal characterization of nonspecific neck and shoulder pain is warranted before making a diagnosis, with consideration of peripheral nerve disorders that mimic pain originating from the shoulder girdle and cervical spine. For example, the diffuse peripheral nerve pain occasionally encountered in Parsonage-Turner syndrome may resemble that of cervical radiculopathy.
If an underlying uncommon disorder such as Parsonage-Turner syndrome, suprasacular neuropathy, or thoracic outlet syndrome is suspected, EMG may be a useful and adjunct adequate and should be considered the first diagnostic test of choice.
In patients with a complex clinical history or a mixed picture of neck and shoulder pain, differentiating a shoulder versus cervical spine cause is clinically challenging. First and foremost, the clinician must rely on a complete history and physical examination with appropriate provocative maneuvers. Follow-up imaging should be selected accordingly. When advanced imaging does not reveal a conclusive source of pathology, EMG and selective injections have been shown to be useful adjuncts. The evaluating provider needs to be aware of the potential overlapping presentation of pain and dysfunction that can result from cervical spine and shoulder disorders and always consider both when evaluating and treating a patient.
References
Date E.S.
Gray L.A.
Electrodiagnostic evidence for cervical radiculopathy and suprascapular neuropathy in shoulder pain.
Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.
Conflict of Interest: JMD receives educational materials from Stryker. ESP receives educational materials from Tornier/Wright Medical and research support from Smith and Nephew, and Arthrex. AG is a consultant and receives royalties and research support from Tornier/Wright, and receives educational recourses from Smith and Nephew, and Arthrex. AHD is a consultant for Stryker, Globus, Orthofix, and Depuy and receives research and fellowship support from Orthofix.
Authorship: All authors had access to the data and played a role in writing this manuscript.
We read with particular interest the narrative review study by Bokshan et al,1 entitled “An evidence-based approach to differentiating the etiology of shoulder and cervical spine pain.” It is true that, in dealing with a patient suffering from shoulder pain, differentiating cervical from shoulder origin can be clinically challenging. However, the authors should have warned readers about the limitations of neck and shoulder examinations, based on published evidence. Reliability and accuracy with such disorders have been studied extensively, with a low value for physical examination.
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