Concomitant presentation of neck and shoulder pain is a common
clinical scenario which can present a significant diagnostic
and therapeutic dilemma. Neck and shoulder pain presentations can be
separated into four different categories: Primary neck
pathology with referred pain to the shoulder, primary shoulder pathology
with referred pain to the neck, primary neck and primary
shoulder pathology, and primary neck pathology resulting in secondary
shoulder pathology. Primary neck pathology resulting in
secondary shoulder pathology is mechanically plausible but not proven.
Authors are proposing this scenario to be described as
“neck-shoulder syndrome.” For instance, C5 and/or C6 cervical
radiculopathy can result in rotator cuff, deltoid, biceps and scapular
muscle weakness as these nerve roots innervate the shoulder girdle
musculature which in turn could produce shoulder/scapular
muscle imbalance resulting in shoulder impingement signs. A patient may
present with features of both cervical radiculopathy and
shoulder impingement syndrome in this scenario. At this time there are
no agreed clinical criteria for a diagnosis of “neck-shoulder
syndrome.” As with any other syndrome, management differences can only
be well studied once the entity has been properly
defined. In this article, authors set out to summarize how to best
approach patients presenting with both neck and shoulder pain
while describing features of proposed “neck-shoulder syndrome.” It is
paramount to take a comprehensive and holistic approach
towards patients presenting with concomitant neck and shoulder pain as
the symptoms may not always represent isolated entities.
Keywords: Neck and shoulder pain; Neck-shoulder syndrome; Pain treatment; Differential diagnosis of neck and shoulder pain
Introduction
Co-existent neck and shoulder pain has been described in
limited fashion in the literature as a unique diagnosis, but the
concomitant presentation of neck and shoulder pain is a common
scenario in primary care and orthopedic offices [1,2]. Gorski et
al described “shoulder impingement syndrome” where patients
presented with neck pain secondary to rotator cuff tendinopathy
[1]. Compere et al described a “neck, shoulder, and arm syndrome”
which primarily referred to neuropathic pain in the neck, shoulder
and arm resulting from a brachial plexus lesion [2]. When patients
present with both neck and shoulder pain, it can present a significant
diagnostic dilemma[3]. “Hip spine syndrome” has recently been
described, and “neck-shoulder syndrome” likely represents an
analogous entity involving the cervical spine and upper limb [4].
It is estimated that among primary care office visits, neck pain
accounts for approximately 20-30% and shoulder pain for 10-20%
of musculoskeletal complaints. From this population, combined
neck and shoulder problems account for approximately 6-10%
[3,5,6,7].
Discussion
Concomitant neck and shoulder pain presentations can be
separated into four different categories: Primary neck pathology
with referred pain to the shoulder, primary shoulder pathology
with referred pain to the neck, primary neck and primary shoulder
pathology, and primary neck pathology resulting in secondary
shoulder pathology
Primary neck pathology with referred pain to the shoulder
An isolated C5 and/or C6 radiculopathy without shoulder
pathology could certainly present with neck and shoulder pain due
to C5 and C6 dermatomal symptoms corresponding to the shoulder
region. C5 or C6 myotomal pain can cause pain in the deltoid,
scapula and biceps, and can mimic shoulder pathology [8,9]. This
scenario is typically straightforward as the physical examination
will be absent of shoulder impingement signs. Classically, cervical
radiculopathy examination can demonstrate positive cervical root
impingement signs (Spurling’s maneuver), myotomal weakness,
dermatomal sensory abnormalities and blunted reflexes in a
specific root distribution. Several neuropathies involving brachial
plexus and its proximal branches will also refer pain to neck and
shoulder simultaneously.
Primary shoulder pathology with referred pain to the neck
Primary shoulder pathology should not directly lead to neck
pathology, and such cases are not well described in the literature.
Nevertheless, patients with shoulder pathology may develop
pain and tightness in the trapezius muscle on the ipsilateral side
and referred pain in the cervical area. Restricted motion at the
glenohumeral joint may also lead to overuse and pain in the
scapulothoracic musculature. A general concern in musculoskeletal
medicine is that symptomatic pathology in a joint may refer pain to
a joint below and/or above.
Primary neck and primary shoulder pathology
Degenerative arthritis can affect multiple joints. Thus, many
patients may have both glenohumeral arthritis and cervical
spondylosis. The radiographic incidence of glenohumeral arthritis is
reported as 32.8% in people over 60 years of age [10]. Radiographic
evidence of cervical spondylosis is present in 50% of people over
50 years of age and 75% of individuals over 65 years of age [11]. As
both conditions are common, both can present as “pain generators.”
Primary neck pathology resulting in secondary shoulder pathology
Primary neck pathology resulting in secondary shoulder
pathology is mechanically plausible although not proven. For
instance, C5 and/or C6 cervical radiculopathy can result in rotator
cuff, deltoid, biceps and scapular muscle weakness as these nerve
roots innervate the shoulder girdle musculature. This could
produce muscle imbalance and poor shoulder/scapular mechanics.
A patient may present with features of both cervical radiculopathy
and shoulder impingement syndrome in this scenario. In clinical
practice, it is not uncommon to see a patient with chronic neck
pain presenting with insidious onset of shoulder pain later in the
course. Authors are proposing this unique presentation be referred
to as “neck-shoulder syndrome.” Although most clinicians would
treat this as separate neck and shoulder pain, they may be related
diagnoses.
Literature Search
We conducted a comprehensive search in the PubMed database
in order to identify relevant studies on “neck-shoulder syndrome.”
Based on the review of the available literature, there are no agreed
upon clinical criteria for a diagnosis of “neck-shoulder syndrome”
despite its common clinical presentation nor is there a well
described “neck-shoulder syndrome.” As with any other syndrome,
management differences cannot actually be studied until the
entity has been appropriately defined. This article will concentrate
on how to best approach patients presenting with both neck
and shoulder pain while describing features of proposed “neckshoulder
syndrome.”
Presentation
In patients presenting with neck and shoulder pain, a thorough
history is paramount in identifying the etiology of the patient’s pain.
Location: Patients with primary neck pathology can experience
pain extending beyond the neck based on the etiology. Disorders
that affect the lower cervical nerve roots will often result in pain
distal to the shoulder which can be characterized by radiation into
the arm in a clear dermatomal or myotomal distribution [12]. In
addition, Dwyer et al described reproducible pain patterns that
can refer into the shoulder, trapezius and occiput from cervical
zygapophyseal joint pathology [13-15]. Pain from a primary
shoulder problem can also refer pain to the neck, periscapular
region and distally into the arm although not typically extending
below the elbow [16]. Associated paresthesias are not classically
associated with a primary shoulder problem.
Onset: Onset of symptoms is also a key component of the
history. Degenerative cervical pathology can have insidious onset
although acute disc herniations can have a sudden onset that may be
precipitated by trauma. Whiplash injuries are known to precipitate
neck pain which can be of myofascial and/or cervical facet in origin.
Shoulder disorders can also be of insidious (overuse injuries) or
acute onset (trauma). Sudden onset of shoulder pain with restricted
motion can be associated with acute calcific tendinitis or adhesive
capsulitis. Neuralgic amyotrophy (Parsonage Turner syndrome/
brachial neuritis) has a unique presentation where patients usually
experience severe, acute pain following exercise, recent illness,
immunization, surgery or trauma [17]. As the initial severe pain
starts to resolve, neurological deficits will become apparent, which
is in contrast to most presentations of cervical radiculopathy where
pain will continue with associated neurological symptoms. Onset
of symptoms plays a key role in proper identification of proposed
“neck-shoulder syndrome.” Development of shoulder pain
(especially in the absence of injury) after onset of neck/radicular
pain can be considered primary neck pathology with secondary shoulder pathology and can be referred to as “neck-shoulder
syndrome.” Shoulder pain in this scenario is likely secondary to
rotator cuff and periscapular muscle weakness/imbalance caused
by C5 and/or C6 cervical radiculopathy. This clinical scenario is not
well studied in the literature, hence prevalence and incidence is not
known. Among patients with cervical radiculopathy, studies report
a frequency of C5 nerve root involvement at 5-10%, C6 at 20-25%,
and C7 at 45-60% [12,18].
Exacerbating factors: Pain with overhead arm movements
generally suggests primary shoulder pathology. However same
pattern can also be present in peripheral neuropathies like thoracic
outlet syndrome and spinal accessory, suprascapular, or axillary
neuropathy. Shoulder pain with side lying on the affected upper
limb tends to be associated with shoulder impingement and
acromioclavicular joint arthropathy.
Features of systemic diseases: In patients who present with
neck and shoulder pain in the absence of trauma, the history
will need to include an assessment for widespread involvement
that may suggest systemic disease processes like fibromyalgia,
polymyalgia rheumatica, myofascial pain syndrome and myopathy.
Red flags: The history should also include an evaluation for
findings to suggest a disease process that requires more urgent
evaluation. Red-flag symptoms to assess for include gait imbalance,
hand clumsiness, bowel/bladder dysfunction (cervical myelopathy),
pain after high impact trauma (fractures), unintentional weight
loss (Pancoast tumor), chest pain (cardiac ischemia), blurry
vision, nausea/vomiting and vertigo (vertebral artery dissection/
insufficiency).
Physical Examination
In addition to a detailed history, a thorough physical
examination is key for proper diagnosis and identification of the
pain generator(s). A thorough neurological exam plays an essential
role in distinguishing neck from shoulder pathology. Sensory,
motor and reflex changes in a specific nerve root distribution
are characteristic of cervical radiculopathy. C5 and C6 cervical
radiculopathies may result in periscapular and shoulder/rotator
cuff muscle weakness while C7 radiculopathy is unlikely to cause
shoulder weakness. Rotator cuff pathology may result in shoulder
weakness with preserved elbow flexion while a C5 radiculopathy
can result in weakness of both. Testing deltoid strength with
the arms at the sides instead of in shoulder abduction can aid in
differentiating pain inhibition versus true weakness.
Provocative Testing
Provocative testing can assist in the diagnosis of cervical
and shoulder disorders [9, 19]. Among them, provocative tests
for shoulder impingement may help distinguish primary versus
secondary shoulder pathology in proposed “neck-shoulder
syndrome”(Table 1) [18-30].
In patients with neck and shoulder pain, one test by itself may
not have enough sensitivity and specificity to make a diagnosis
and most physical exam maneuvers are not pathognomonic. A
combination of multiple exam components and a thorough history
are necessary to accurately identify the etiology of symptoms.
Table 1: Provocative tests for common cervical and shoulder problems and reported validity.
Diagnostic Testing
When presented with both neck and shoulder pain, history
and physical exam should dictate appropriate use of diagnostic
tests. Although imaging studies such as radiography, CT and MRI
can reveal many pathologies, further testing should be done to
identify the true pain generator. When suspecting pain mediated
by a cervical zygapophyseal joint, cervical diagnostic medial branch
blocks can be considered. A shoulder injection of lidocaine with
or without corticosteroid can be done for diagnostic and perhaps
therapeutic reasons. In cases of secondary shoulder pathology,
this may give the patient partial benefit, but a primary cervical
pathology should still be investigated [9]. Electrodiagnostic testing
with electromyography (EMG) and nerve conduction studies (NCS)
can be employed when suspecting myopathy, brachial plexopathy,
peripheral neuropathy or radiculopathy. When evaluating neck and
shoulder pain, scientific evidence suggests using a combination
of history, physical examination, imaging modalities, diagnostic
injections and electrodiagnostic study to make the appropriate
diagnosis.
Treatment
Success of any proposed treatment algorithms will depend on
an accurate diagnosis. There is scant evidence on how to approach
the concomitant presentation of neck and shoulder pain. Treatment
should be geared toward the primary site of pathology whether it
be the cervical spine or the shoulder [3]. Lack of current literature
evidence underscores the importance of describing a “neckshoulder
syndrome,” as it can lead to studies looking at management
differences. It can be hypothesized that in patients with cervical
radiculopathy with secondary rotator cuff impingement, treatment
of the primary lesion will likely yield eventual improvement at the
secondary site although no studies have been done on this topic.
Conclusion
The concomitant presentation of shoulder and neck pain is a
common scenario in primary care and orthopedic offices and can
present a diagnostic and therapeutic dilemma. A careful history
and thorough physical examination along with ancillary studies
can often yield the correct diagnosis and successful treatment.
Primary neck pathology resulting in secondary shoulder pathology
is mechanically plausible but not proven. Authors are proposing
this scenario to be described as “neck-shoulder syndrome.”
Appropriately describing a “neck-shoulder syndrome” can lead to
further studies looking at management differences. A prospective
study looking at incidence of shoulder impingement signs in chronic
C5 and/or C6 radiculopathy patients could be helpful in delineating
diagnostic criteria for “neck-shoulder syndrome.” Above all, it is
paramount to take a comprehensive and holistic approach towards
patients presenting with concomitant neck and shoulder pain as
the symptoms may not always represent isolated entities.
Acknowledgements
The authors would like to thank Dr. David Janerich for his help
with the development of the article.
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