Shoulder pain:

1. 
   

   Common complaint; patients may have difficulty localizing exact location of pain and describe more broad upper extremity shoulder and neck pain

   
   
2. 
   

   May result from glenohumeral, acromioclavicular, and/or biceps tendon pathology

   
   
3. 
   

   Can be related to degenerative cervical spine disease and radiculopathy, as roughly a quarter of patients with cervical radiculopathy have symptomatic shoulder impingement: ¹

   
   
   
   
   1. 
      

      May also be referred to as cervical facetogenic pain. ² , ³

   
   
4. 
   

   Often difficult to differentiate referred cervical radiculopathy from glenohumeral or subacromial shoulder pain secondary to complexity of pain patterns and interactions between joint articulations ⁴

   
   
5. 
   

   In addition, there may be an association between spinal kyphosis and scapular impingement syndrome, ⁵ and increased thoracic kyphosis and spinal inclination angles have been shown to be risk factors for limitations in active shoulder motion ⁶ and development of scapular dyskinesis:

   
   
   
   
   1. 
      

      It is not known how many shoulder surgeries are performed for mis or undiagnosed cervical pathology as a result of inadequate evaluation and workup of cervical spine pathology as possible primary pain generator

      
      
   2. 
      

      It is not known how cervical and shoulder surgeries may affect shoulder alignment and mechanics

      
      
   3. 
      

      There is no standard algorithm for clinicians, shoulder and spine specialists specifically, to evaluate and differentiate overlapping causes and presentations of “shoulder pain.”

   
   
6. 
   

   The interaction between the cervical spine and the shoulder is similar to those described in Hip Spine Syndrome. ⁷ , ⁸ The goal of this review chapter is to review the basic approach to the shoulder-spine patient including an algorithm for the evaluation and diagnostic workup for the complaint of “shoulder pain.”

History:

1. 
   

   Common sources of shoulder pain (▶ Fig 4.1a, b ):

   
   
   
   
   1. 
      

      Often increased pain with arm abduction ⁹

      
      
   2. 
      

      Pain over acromioclavicular joint (ACJ) and adjacent to lateral acromion

      
      
   3. 
      

      Rotator cuff tears (RTC):

      
      
      
      
      • 
        

        i. Increased incidence of both symptomatic and asymptomatic tears with age

        
        
      • 
        

        ii. Numbness and tingling past the elbow, even into palm, can be seen in patients with RTC tears/tendonitis and subacromial bursitis. Pain that extends into the finger tips is more commonly from cervical pathology.

      
      
   4. 
      

      Biceps/superior labral anterior to posterior (SLAP), anterior and deep shoulder pain

      
      
   5. 
      

      Glenohumeral osteoarthritis (OA)—global pain, typically increased with movement

      
      
   6. 
      

      Shoulder instability

      
      
   7. 
      

      Scapular dyskinesis/trapezial pain—typically posterior and periscapular pain.

   
   
2. 
   

   Common cervical radiculopathy complaints:

   
   
   
   
   1. 
      

      Often pain relief with arm abduction ⁹

      
      
   2. 
      

      Numbness/tingling in arm, forearm, and hand

      
      
   3. 
      

      Review of dermatomes/myotomes, exiting nerve root anatomy:

      
      
      
      
      • 
        

        i. C4: Base of neck/upper shoulder

        
        
      • 
        

        ii. C5: Shoulder/deltoid, lateral arm

        
        
      • 
        

        iii. C6: Shoulder, lateral arm, radial forearm, thumb/IF.

   

Physical examination:

1. 
   

   Shoulder:

   
   
   
   
   1. 
      

      Impingement tests—Neer/Hawkins, cross-arm test, and ACJ tenderness to palpation

      
      
   2. 
      

      Biceps/SLAP—Speed/Yergason’s test, O’brien’s test, dynamic load and shear

      
      
   3. 
      

      RTC—Strength testing, Jobe’s test, empty can test:

      
      
      
      
      • 
        

        i. Drop arm, painful arc.

      
      
   4. 
      

      Instability:

      
      
      
      
      • 
        

        i. Anterior and posterior translation

        
        
      • 
        

        ii. Apprehension, Jerk test.

      
      
   5. 
      

      Range of motion.

   
   
2. 
   

   Cervical spine:

   
   
   
   
   1. 
      

      Paraspinal/trapezius tenderness and pain

      
      
   2. 
      

      Motor examination

      
      
   3. 
      

      Spurling’s sign: High specificity for radiculopathy, but only 30–50% sensitivity and often performed incorrectly. ¹⁰ , ¹¹

      
      
   4. 
      

      Squeeze arm test: First described in 2013, the test involves compression of the upper third of the symptomatic arm, ACJ, and anterolateral-subacromial area: ¹²

      
      
      
      
      • 
        

        i. The test is considered positive if visual analog scale (VAS) pain level reached or exceeded 3/10

        
        
      • 
        

        ii. As described, the test has a sensitivity of 96% and specificity ranging from 91 to 100% for cervical nerve root pathology.