CHAPTER 3 Caroline Mitchell1 and David Stanley2 1 Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK 2 BMI Thornbury Hospital, Sheffield, UK The neck and shoulder are two of the most common sources of musculoskeletal pain. Neck pain has a self‐reported point prevalence of between 10% and 20%. The majority of neck pain is acute and self‐limiting and can be attributed to a mechanical or postural cause. However, moderate or severe symptoms may persist in up to 30% of patients. Shoulder pain has a self‐reported point prevalence of between 14% and 26% in the general population. The incidence of shoulder pain increases with age, as does its functional impact. About one‐quarter of all new episodes presenting for care resolve fully within 1 month, and nearly half have resolved within 3 months of onset. However, persistence or recurrence of shoulder symptoms within a year of initial presentation is common (in up to 50% of people). By the actions of the surrounding muscles, the neck moves almost constantly during waking hours through flexion, extension and rotation at the intervertebral and facet joints of the seven cervical vertebrae. The shoulder is a series of articulations. It includes the glenohumeral joint, acromioclavicular joint and scapulothoracic articulation which allows the scapula to slide on the ribcage (Figure 3.1). Soft tissue structures – capsules, ligaments, muscles, tendons, bursae and neurovascular elements – complete the framework and allow remarkable mobility to be achieved. Instability problems involving the glenohumeral joint usually occur in young men and are most often the result of trauma. Infrequently, instability is associated with congenital laxity. With increasing age, rotator cuff disease results in shoulder pain and limited shoulder function. Figure 3.1 The shoulder ‘complex’ of joints. This includes the scapulothoracic articulation, where the scapula slides on the ribcage. Source: Adapted from Speed et al. (2000) The elbow is a compound synovial joint composed of a complex of two closely related articulations between the humerus and both the ulna and radius. It is supported by ligaments and muscles. Neck and arm pain have a wide differential diagnosis, making it hard at times to distinguish between pain arising from the neck or the shoulder (Figure 3.2). Pain proximal to the shoulder, in the shoulder girdle or over the scapula indicates referred pain from the neck. Figure 3.2 Sites and radiation of pain in the shoulder, arm and neck. Source: Adapted from Speed et al. (2000) It is always important when taking a history to assess the patient’s concerns, expectations, functional disability and any psychosocial and occupational issues. Details of hand dominance, trauma, hobbies, sporting activities and previous similar symptoms should be noted together with all treatments that have been undertaken. Significant past and current medical history – including prescribed drugs and adverse reactions – should be recorded. The history must also elicit the presence of any clinical features that indicate potentially serious systemic and musculoskeletal pathology. The clinician should determine the mode of onset and duration of the pain, its nature, site, radiation, temporal characteristics, exacerbating and relieving features, and associated symptoms. Disturbed sleep is common with both neck and shoulder pain. However, nocturnal pain should raise suspicion of nerve root pain, bony pathology or underlying malignancy, particularly if there is a history of cancer and/or systemic symptoms. Radiation of pain distally from the upper arm or elbow suggests referred pain from the neck or peripheral neurological lesions (see Figure 3.2). Neurological symptoms should be sought and their distribution ascertained (Figure 3.3). Figure 3.3 Features of cervical nerve root lesions Joint swelling around the shoulder or elbow can occur in relation to arthropathy, infection or trauma. Other notable symptoms of arthropathy include stiffness, clicking, clunking or locking. It is important to enquire about proximal muscle pain and weakness in the upper and lower limbs as this may represent a neurological disorder. Systemic symptoms, such as fevers, night sweats, weight loss, generalized joint pains, new ‘lumps’ (lympadenopathy, mass lesions) and new respiratory symptoms, should be specifically sought and recorded. A structured examination must define the source of the pain and the degree of functional deficit and co‐existing pathologies. It includes careful inspection, palpation, movement, special clinical tests and a neurological assessment. Depending on the findings, appropriate further investigations should then be undertaken. Pain in the neck usually occurs due to poorly defined mechanical influences but may result from pathology within the spine or be referred from elsewhere. A list of the differential diagnoses of neck pain is shown in Box 3.1. When considering the diagnosis, it is important to look for specific ‘red flags’ as these indicate that there might be a serious underlying cause of the complaint (Table 3.1). Table 3.1 “Red flags” or clinical features indicative of potentially serious pathology in the neck and/or shoulder Restricted cervical movements and local tenderness help to confirm the local origin of neck pain. Risk factors include manual jobs, heavy workload, increasing age and depression. Chronicity is weakly predicted by the presence of concomitant low back pain, older age and previous episodes of neck pain. Simple mechanical neck pain describes a common, usually self‐limiting, clinical presentation of pain with or without restricted movement, but without neurological or ‘red flag’ features. Onset may be acute (acute torticollis, or ‘wry neck’) or gradual, and, like low back pain, tends to be recurrent. It usually responds to conservative treatment with analgesics and simple exercise regimes. Patients should be instructed to return for further assessment if symptoms persist or change in quality. Neck pain may be accompanied by myofascial or diffuse regional pain often involving the shoulder girdle and reproduced by palpation of trigger points (‘knots’ within muscle). Radicular pain, due to compression of a nerve root from herniation of a cervical disc, or as a result of local infection or tumour, refers to neck pain that radiates into the shoulder girdle and/or arm with paraesthesia or numbness in a root distribution. Subjective weakness is less common. Examination may not reveal the nerve root level because of the extensive overlap of dermatomes (Table 3.2). Motor involvement and/or objective sensory loss warrant urgent referral for specialist assessment. In general, 40–80% of people with compressive cervical radiculopathy will have complete resolution of their symptoms over time with conservative treatment. Patients should, however, be specifically advised about ‘red flag’ symptoms and told to return if there are concerning changes or persistence of symptoms. Table 3.2 Arm dermatomes NA = not applicable Cervical myelopathy (compression of the spinal cord), which may arise due to midline disc herniation, is suggested by a history of difficulty in walking and bladder and bowel dysfunction. Signs of myelopathy below the level of spinal cord involvement may include motor weakness with increased reflexes and tone (upper motor neurone signs), decreased pinprick sensation and loss of position and/or vibration sense. These symptoms warrant urgent referral for specialist assessment. Whiplash injury, an abrupt flexion/extension movement of the cervical spine as a result of sudden acceleration‐deceleration, may occur in road traffic or sporting accidents. It is characterized by neck and arm pain with muscle spasm, and limited neck movements. Symptoms may be persistent, although 50% of patients recover within 3 months and 80% within 12 months. Risk factors for chronicity after whiplash include the severity of the initial symptoms and psychological disturbance. Neurological sensory and/or motor deficit warrants immobilization of the cervical spine and urgent specialist assessment. Neck pain is common in inflammatory arthritis, and atlantoaxial and subaxial subluxation may develop, particularly in rheumatoid arthritis. Consequently, special care is needed when rheumatoid patients with cervical spine involvement require a general anaesthetic. Osteophytic linking of vertebrae may be seen in ankylosing spondylitis, resulting in reduced or absent cervical spine movement. For most patients with acute neck pain and no ‘red flags’, further investigation (radiographs, blood tests) is not necessary. Due to the high prevalence of asymptomatic degenerative changes in the cervical spine, plain radiographs are rarely diagnostic, and pain severity correlates poorly with radiographic abnormalities. Magnetic resonance imaging (MRI) is highly sensitive in detecting disc and cord abnormalities if these are suspected, whereas computed tomography is better for evaluation of bone. Patients should be informed of the generally favourable prognosis of neck pain and the fact that serious underlying conditions are very unlikely. Pertinent psychosocial and occupational issues may need to be explored in order to tailor the management plan. Neck pain usually responds to simple analgesia and advice on self‐care, including simple mobilization and exercises. High‐quality evidence for the effectiveness of many treatment modalities is limited and often contradictory. Advise to stay active – Encourage patients to persist with their normal activities. There is no evidence that collars reduce pain or improve function, nor is there evidence about special pillows. In general, patients are advised to sleep on their side with a single pillow supporting the neck. Early mobilization and return to normal activity may reduce pain in people with acute whiplash injury more than immobilization or rest with a collar. Drug therapy – There is limited evidence about the relative benefits of paracetamol, opioid analgesics, non‐steroidal anti‐inflammatory drugs (NSAIDs) and antidepressants. Potential benefits versus the risks of NSAIDs should be considered, particularly in high‐risk patients (consider potential drug interactions, the elderly, co‐existing asthma, past history of peptic ulceration, renal impairment and whether co‐prescription of a gastroprotective drug is required). All patients on regular analgesia should be reviewed for both efficacy and potential adverse effects. If there is significant nocturnal pain, a tricyclic drug at night may be helpful (e.g. amitriptyline 10–50 mg orally). Exercises – Gentle neck exercises may be a useful and effective treatment for acute neck pain. The best type and mix of exercise have not been defined, but include stretching and strengthening exercises. Proprioceptive retraining exercises are usually prescribed by a physiotherapist. Patients should either be provided with exercise self‐care leaflets or directed to an appropriate online resource (www.arthritisresearchuk.org/). Exercises for cervical radiculopathy are unproven. Exercise therapy is contraindicated in the presence of myelopathy. Mobilization or manipulative techniques – However, unproven mobilization or manipulative techniques for both acute and chronic pain (typically performed by physiotherapists, chiropractors or osteopaths), either alone or in combination with other physical interventions, may have only a modest effect. Multidisciplinary biopsychosocial rehabilitation – The principle underlying multidisciplinary rehabilitation for chronic neck pain is to simultaneously address all components (physical, psychological and social) of the patient’s pain experience. Cognitive behavioural therapy has been shown to decrease time off work and other behavioural manifestations of pain but not to change the degree of pain. Other non‐operative treatments – The efficacy of most passive non‐manipulative therapies (heat, massage, transcutaneous electrical nerve stimulation, pulsed electromagnetic field treatment) is not supported by evidence. Acupuncture may provide short‐term pain relief in people with chronic neck pain, but evidence is limited. There is also limited evidence about the effectiveness of massage for neck pain. Similarly, myofascial trigger‐point injections using local anaesthetic into tender points have not been shown to be beneficial in reducing chronic neck pain. There is inconclusive evidence about the effectiveness of traction for neck pain which in any case should not be performed before imaging to exclude spinal cord compression or a large disc protrusion. A short course of oral glucocorticoids prescribed by a specialist, and after appropriate investigation, may be of benefit for cervical radiculopathy but is unproven. Facet joint injections, medial branch blocks and percutaneous radiofrequency denervation are performed under the premise that pain arises from the facet joint; however, the evidence to support these procedures is very limited. Botulinum A intramuscular injections have been shown to be ineffective for neck pain with or without radiculopathy. Surgery – Surgery is not indicated for patients with neck pain in the absence of neurological symptoms of radiculopathy or myelopathy. When appropriate, an anterior cervical discectomy with or without fusion is the most commonly used procedure. The differential diagnosis of shoulder pain is summarized in Box 3.2. Pain may also arise in the scapulothoracic region, and a list of differential diagnoses is shown in Box 3.3. ‘Red flags’ or clinical features suggestive of serious underlying pathology in people who present with shoulder pain are shown in Table 3.1.
Pain in the Neck, Shoulder and Arm
Anatomy and function of the neck and shoulder joint
Clinical evaluation
Neck pain
‘Red flags’
Potential pathology
History of cancer, symptoms and signs of cancer, unexplained deformity, mass or swelling
Malignancy
Fever, systemically unwell, redness and swelling
Infection
Trauma, epileptic fit. electric shock, loss of rotation and normal shape
Unreduced shoulder dislocation
Recent trauma, acute disabling pain and significant weakness, positive ‘drop arm’ sign
Acute rotator cuff tear
Diffuse poorly localized pain and/or abnormal sensation, unexplained wasting, loss of power or altered reflexes
Neurological lesion, cervical radiculopathy, myelopathy
Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain, apical lung cancer, metastases
Pain arising from elsewhere
Bilateral shoulder pain with or without neck pain, early morning stiffness
Polymyalgia rheumatic, rheumatoid arthritis, giant cell arteritis
Rapid swelling after trauma
Haemarthrosis of the shoulder
Nerve root
Weakness
Reflex change
C5
Shoulder abduction
Biceps
C6
Wrist extension, supination, elbow flexion
Radial
C7
Elbow extension, wrist flexion
Triceps
C8
Finger flexors
NA
T1
Finger abductors
NA
Investigation of neck pain
Treatment of neck pain
Shoulder pain
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