Differentiating the Cause of Shoulder and Cervical Spine Pain – An Evidence-Based Approach

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An interesting review 1 in the ‘American Journal of Medicine’ focused on the challenge when it came to differentiating between the cause of cervical spine and shoulder pain. It presented an evidence-based approach to address such a clinical situation.


Why Was Such a Review Conducted?

Trying to differentiate the origin of pain as well as dysfunction because of cervical pain and shoulder pathology has presented itself as a tough clinical challenge when dealing with numerous patients. A practitioner might be misled due to what the patient reports as the anatomic region where the pain is being experienced.

For such patients to be successfully treated, there needs to be a complete history and physical examination as well as the administration of the appropriate provocative maneuvers. 

Furthermore, it’s essential to have an evidence-based selection of clinical testing, which should be customized to the most likely underlying cause. The current study set out to present an evidence-based review of the common reasons behind neck and shoulder pain. Another objective was to offer guidelines to help identify the pain generator in challenging cases.

Patient Evaluation – Shoulder

According to the review, a thorough history and physical examination are a must for beginning patient evaluations. Diagnostic testing should be done depending on the examination findings.

Talking about the shoulder, recording history includes patient demographics to cover factors such as age, gender, presence of any psychosocial and medical condition, mechanism of injury, hand dominance, and such. By using a patient’s history, pain can be characterized to learn about the pain’s quality, relieving as well as aggravating factors, and progression.

Take note; dull and aching pain is seen more in shoulder pathology, while a burning or electric type pain is usually a determining factor for cervical spine or neurologic origin.

Also, shoulder pathology is commonly related to painful arm abduction. However, patients with cervical radiculopathy might experience symptom relief due to arm abduction.

The review shared that pain experienced directly over the lateral deltoid region could indicate subacromial or intrinsic glenohumeral pathology. Similarly, pain that’s localized directly over the acromioclavicular joint may indicate acromioclavicular joint pathology.

Also, shoulder pathology is commonly related to nighttime aching and sleep disturbance. According to data, patients with rotator cuff tears exhibited sleep disturbance in up to 90% of cases. 

Other than that, weakness of the shoulder while in the absence of pain should raise concern for nerve impingement.

Patient Evaluation – Cervical Spine

According to the review, pain is commonly produced (by cervical radiculopathy) around the shoulder girdle’s later portion. Patients with such a condition do report a disturbance in their sensory and strength levels starting in their neck and moving to the upper extremity.

Arm pain is reported by more than 90% of cervical radiculopathy cases.

Furthermore, data has stated that cervical radiculopathy has an infrequent association with trauma.

Clinicians could suspect cervical myelopathy or myeloradiculopathy because of shoulder or neck pain with painless loss of hand dexterity or an uncomfortable gait or even a lack of bowel or bladder control.

Cases with Positive Provocative Shoulder Testing

In a typical case of a patient with shoulder pain with positive provocative shoulder testing, plain radiographs can be used as an initial test.

If pain radiography ends up being non-diagnostic, further testing can be done based on the presumed diagnosis. MRI and ultrasound can be used if an underlying rotator cuff tear has been suspected.

In complex cases, positive provocative shoulder testing results might be demonstrated by patients having cervical pain. A diagnostic subacromial injection can be used for provocative impingement testing as well as primary cervical pain.

Cases with Positive Provocative Cervical Spine Testing

Coming to cases with classic radiculopathy pain along with a positive Spurling test, a standard AP and lateral cervical radiographs can be used. If radiculopathy has been suspected, MRI is deemed an appropriate test. If an MRI isn’t feasible, CT myelography may be used.

EMG or electromyography has also been used when the MRI or CT are considered inconclusive. However, EMG is controversial when used as a follow-up test for radiculopathy. Selective nerve root injections are also an option.

Positive Provocative Shoulder and Cervical Spine Testing

In cases having evidence of both cervical spine and shoulder pathology on advanced imaging, focusing on the shoulder first has been considered effective.

Negative Provocative Shoulder and Cervical Spine Testing

False-positives and useless treatment strategies might be produced in cases showing an absence of specific provocative findings in the cervical spine or shoulder. In such instances, it’s recommended to opt for nonsurgical management along with physical therapy meant to address periscapular and neck pain.

What Was Concluded?

The current review concluded that in cases with a complex clinical history or displaying a complex mix of shoulder and neck pain, differentiating between a cervical spine vs. shoulder cause is challenging.

The first step is to rely on data from a thorough physical and history examination along with the necessary provocative maneuvers. Appropriate follow-up imaging should be selected. EMG and selective injections are deemed useful when advanced imaging is inconclusive. 

The health provider needs to understand the intricacies and overlapping of pain and dysfunction resulting from shoulder and cervical spine disorders. Both should be considered when evaluating a patient to help come up with a suitable treatment plan.

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