Physio Referrer Online-
Are you SURE it’s your Shoulder?
Shoulder and upper arm pain is a common clinical presentation with a number of potential diagnoses, including subacromial bursitis, rotator cuff tear and frozen shoulder (adhesive capsulitis). Most patients with shoulder pain get better with physiotherapy, injection or surgery, but what about the patient who doesn’t improve?
Is the Neck Involved?
Most GP’s and physiotherapists are familiar with the clinical presentation of cervical radiculopathy – pain and parasthesia in the arm arising from a compressed or irritated nerve root in the cervical spine. Moving the neck has a clear effect on the patient’s symptoms and with some education, they grasp the concept that their arm pain is coming from their neck.
But what about patients with shoulder pain only? Can any of these patients have referred pain that looks and behaves like shoulder pain, but is in fact coming from their neck?
Clues the neck is involved:
When patients present with isolated extremity pain, and there is no clear trauma or cause, one of our first questions should be “Are we sure this is an extremity problem and not being referred from the spine?”. There are several clues in your patient’s history that indicate your patient’s shoulder or arm pain may be referred from their neck.
There are several clues in your patient’s history that indicate your patient’s shoulder or arm pain may be referred from their neck. These are listed in Table 1 below and provide a reference for you when interviewing patients with shoulder pain. If your patient has several of these features, you should begin your physical examination by looking at their cervical spine.
Perform a basic movement screen of your patient’s neck – flexion, extension, rotation, side flexion and ask them if any of these movements reproduce their shoulder or arm pain. If so, then their neck is relevant.
Clinician Tip: when screening the neck, it is a good idea to use gentle overpressure to test your patient’s movements, as often patients DON’T use their full range of movement when asked to look up, down or to the side. Gentle overpressure tests their full range of movement.
Relevant, non- relevant or secondary?
If a simple movement screen clearly reproduces your patients symptoms, then their neck is relevant and they need treatment targeting their cervical spine. Alternatively, if your patient moves their neck freely, with no restriction or symptoms in any direction (including with overpressure) then their neck is NOT relevant.
A third option is where your patient has some symptoms or restriction when moving their neck, but their shoulder assessment shows more definitive features of shoulder dysfunction. In this case their neck pain is secondary to their shoulder problem.
