General Considerations

The classic cervical pathology related to trauma is “whiplash.” It is the most common sequela of nonfatal car injuries and provides significant clinical challenges. The severity of the trauma is often not correlated with the seriousness of the clinical problems, and the exact underlying cause of whiplash’s symptomatology is rarely identified. One of the current theories regarding whiplash is facet joint strain leading to a myriad of other secondary symptoms. A more detailed discussion of whiplash is discussed elsewhere in this issue. Many other cervical disorders have insidious onset in the absence of trauma.

Defining the exact onset of pain with primary shoulder pathology can be difficult, particularly with overuse injuries. At risk are athletes who endure repetitive overhead motions and individuals who put repetitive strain on the shoulder during activities of daily living (ADL) or work-related tasks. Specifically, rotator cuff injuries are commonly associated with overuse in overhead athletes or workers such as mechanics who put daily strain on their rotator cuff. Labral tears with or without glenohumeral instability may be traumatic or insidious from repetitive microtrauma. Snyder and colleagues reported that a compressive force or traction injury to the affected extremity was the most common mechanism of injury in patients suffering a superior labral tear, anterior to posterior (SLAP lesion); however, 21% of their patients had insidious onset of injury. Moreover, most throwing athletes examined by Andrews and colleagues did not report any distinct traumatic event.

Glenohumeral (GH) instability can occur as a result of trauma or insidiously. GH instability is the result of imbalance between the surrounding muscular and capsular structures of the glenohumeral joint. When associated with trauma, GH instability commonly occurs after a fall on the outstretched hand (FOOSH). This injury forces the arm into abduction and external rotation, levering the humeral head out of the glenoid cavity. Activities associated with this injury include contact sports, falls from heights, and motor vehicle accidents. Atraumatic instability can present as a sense of subluxation or looseness with ADL, and should provoke further inquiry and evaluation for a multidirectional pattern of laxity, particularly if bilateral or posterior. AC joint pathology most commonly involves a fall directly onto the acromium, with the arm adducted against the body. Multiple indirect forces can result in AC joint injury. FOOSH and trauma involving downward force on the upper extremity have also been implicated in AC joint injuries.

Primary neuropathic causes of neck and shoulder pain can also present with either acute or insidious onset. Trauma is a common cause of an acute presentation of neuropathic pain. Specifically, falls are implicated in cervical myelopathy (fall with exaggerated cervical extension), traumatic brachial neuritis (cervical extension, rotation, lateral bending, and depression or hyperabduction of the shoulder), or cervical radiculopathy due to disc herniation (cervical extension with associated lateral bending, rotation, or axial loading). The rare exception of nontraumatic acute onset of neuropathic pain is brachial neuritis. These patients present with acute onset of severe pain that may follow recent illness, surgery, immunization, or even trauma. Up to two-thirds of cases begin at night. In 25% to 50% of patients, history reveals a prior viral illness or vaccination. Some patients may report recent trauma, severe exercise, surgery, infection, or immunization. Overhead athletes such as baseball pitchers, volleyball players, archers, and swimmers can develop insidious traction-related neuropathies including neuropathies of the long thoracic, suprascapular, and spinal accessory nerves.

Myofascial neck pain can occur in the setting of almost any pathology involving the cervical spine or shoulder. There is no classic presentation, as patients may present with a history of acute trauma associated with persistent muscular pain, or without a clear antecedent accident or injury. Patients may also present with symptoms in the setting of poor posture or poor ergonomic set-ups in the workplace.

If patients present with pain after relatively minor trauma that includes some degree of cervical distortion, one must always consider the diagnosis of vertebral artery dissection (VAD) as it can be fatal. Of greatest relevance is those patients presenting after manual spinal manipulation, as this has been proved to be a risk factor for developing VAD.

Location

Pain location and radiation patterns may be helpful in formulating a differential diagnosis. Primary cervical pathology without neurologic involvement will most commonly present with axial neck pain extending into the upper trapezius muscles, without any dermatomal distribution. Patients with facet arthropathy will classically report radiation of pain into the occiput, shoulder, scapula, and proximal upper arm. Similarly, provocative cervical discography has been shown to cause referral of pain into the neck, occiput, face, shoulder, interscapular region, and upper limb.

Pain from acute inflammatory shoulder pathology may be difficult for patients to define, as opposed to subacute or chronic pathology, which may present more often with classic pain patterns. Patients with glenohumeral arthritis or labral tears will usually initially complain of a diffuse pain and note that the pain is actually “deep” within the shoulder. By contrast, patients with rotator cuff pathology often complain of pain in the anterolateral shoulder, radiating laterally along the deltoid and upper arm. AC joint arthropathy may present as anterior shoulder pain centralized to the area over the joint itself.

Peripheral neurologic processes are commonly associated with clearly defined pain patterns, but this is not always the case. In the first few days to weeks of any acute cervical radiculopathy, pain can be centralized to the medial scapula border or shoulder, and may be initially worked up as shoulder pathology. The radicular symptoms may then progress along the sensory distribution of the nerve root that is involved. With higher cervical root involvement (C4–C5), the patient may only present with shoulder pain, making diagnosis even more challenging. Similarly, patients with acute brachial neuritis (traumatic or atraumatic) may complain of shoulder pain before the onset of distal neurologic symptoms. Patients suffering from neurogenic thoracic outlet syndrome, long thoracic neuropathy, suprascapular neuropathy, and spinal accessory neuropathy may also complain of medial periscapular pain.

If pain is diffuse and widespread in the absence of recent trauma, one should consider systemic connective tissue disorders. Patients with fibromyalgia may initially complain of pain at a tender point of a single muscle where their worst pain is localized, but further history reveals that the individual’s pain may be more global in its distribution. Similarly, patients with polymyalgia rheumatica may first mention shoulder pain, but further questioning may reveal bilateral hip or neck pain as well. Further discussion of these entities can be found in an article elsewhere in this issue.

Exacerbating and Alleviating Factors

Identification of movements and positions that exacerbate or alleviate pain can be helpful in guiding diagnosis and treatment.

When considering primary cervical pathology, pain exacerbated with cervical extension activities implies facet pathology. Conversely, in patients reporting alleviation of neck pain while lying supine with the neck extended, one should consider a discogenic source. Activities that that increase intradiscal pressure (lifting and Valsalva maneuver) or are associated with vibrational stress (riding in a car or train) have been associated with degenerative disease as well.

Overhead movements or overuse may exacerbate shoulder pathologies and rest may help alleviate symptoms, but further targeted questioning can be helpful in establishing a differential diagnosis. Difficulty falling asleep in a side-lying position is classically associated with rotator cuff tendonitis/impingement or AC joint arthrophy. Inquiring about distinct arm positions that exacerbate or alleviate pain may help identify underlying shoulder instability. Patients with instability report improvement with the affected arm supported and exacerbation with the affected arm in a dependent position.

Patients with cervical radiculopathy may complain of increased pain with cervical extension, lateral bending, or rotation toward the symptomatic side, all of which are theorized to narrow the foramen. Conversely, radicular symptoms may be alleviated by abducting the shoulder and placing the hand behind the head. This maneuver is thought to relieve symptoms by decreasing tension at the nerve root. Neuropathic diagnoses believed to be due to traction neuropathies are difficult to differentiate from primary cervical pathologies, as all are exacerbated by overhead movements. These conditions include neurogenic thoracic outlet syndrome, suprascapular neuropathy, long thoracic neuropathy, and spinal accessory neuropathy.

Neurologic Symptoms

Whenever seeing a patient with musculoskeletal complaints, it is imperative to inquire about signs of neurologic involvement such as sensory loss, paresthesias, or weakness. Proximal neck or shoulder pain with upper limb sensory deficits can be the presenting symptoms in cervical radiculopathy, particularly if symptoms occur in nerve root distributions. Other neurogenic and nonneurologic processes can also be associated with upper extremity sensory symptoms. These conditions include thoracic outlet syndrome that can present with vague shoulder girdle numbness or paresthesias, cervical myelopathy that can present with deficits anywhere in upper or lower extremities, and cervical myofascial pain that may be associated with referred sensory symptoms throughout the upper limbs. Facial numbness and dysesthesias should be taken seriously, as they are common presenting symptoms of VAD.

Weakness associated with neck or shoulder pain can be differentiated into proximal (shoulder girdle) or distal (intrinsic hand) weakness. Painless proximal weakness may be a sign of suprascapular, long thoracic, spinal accessory, or traction mononeuropathies. Suprascapular neuropathy may result in decreased shoulder abduction and external rotation strength, long thoracic neuropathy in reduction of overhead strength, and spinal accessory neuropathy in weakened shoulder shrug and abduction. Atraumatic onset of pain in the shoulder followed by progressive proximal weakness is suggestive of brachial neuritis. Weakness due to brachial neuritis manifests within about 2 weeks of pain onset and progresses over 1 or more weeks. Several muscles can be affected, particularly those innervated by the upper trunk of the brachial plexus. The supraspinatus, infraspinatus, serratus anterior, and deltoid muscles are particularly susceptible, but many different combinations of muscle involvement, including a pure distal form, have been reported.

Distal upper extremity weakness in the setting of neck or shoulder pain is often assumed to be secondary to cervical radiculopathy; however, one must always consider additional diagnoses. Patients with cervical myelopathy, lower trunk plexopathy, Pancoast tumor, or thoracic outlet syndrome may also complain of focal hand weakness or loss of dexterity.

Associated Symptoms

If considering a primary cervical pathology, headaches, dizziness, vertigo, or nausea should be considered. Cervicogenic headaches are prevalent in patients with multiple types of primary cervical pathologies, especially facet arthropathy and cervical strain. However, vision changes, vertigo, numbness, nausea, and vomiting are usually only associated with vertebrobasilar artery insufficiency secondary to atlantoaxial instability. Failure to diagnose atlantoaxial instability can be fatal for any individual, therefore these symptoms should not be overlooked.

The sensations of shoulder popping, clicking, or catching are classically seen in patients with shoulder instability, whether unidirectional or multidirectional. In these patients, associated labral pathology may be present, including tear extension into the anterior ligament and labrum (Bankart lesion).

When considering possible neurologic involvement involving the cervical spine, one should screen for symptoms of myelopathy. Gait imbalance, lower extremity stiffness or jerkiness, and urinary or fecal urgency or incontinence may indicate a myelopathy and should be further evaluated.

In patients with diffuse musculoskeletal shoulder and neck pain and in whom fibromyalgia is being considered, inquiring about other systemic complaints is important. Fatigue is the second most common complaint in fibromyalgia and patients may report frequent nightly awakening and nonrestorative sleep. Also, sensations of swollen tissues and symptoms of irritable bowel are present in more than 40% of patients with this disorder.

Symptoms of venous obstruction (extremity swelling, venous distention) or arterial obstruction (color changes of the extremity, claudication) may be associated with vascular thoracic outlet syndrome. Further details about thoracic outlet syndrome are discussed in another article elsewhere in this issue.

Sports and Work Activity

An athletic and work history may be contributory to the diagnosis and management of neck and shoulder pain. In athletes, competition level, positions, and frequency of play should be considered. Similarly, a patient’s profession may entail significant overhead activities thus increasing risk for shoulder overuse, or poor ergonomics and extended time at computers may be associated with cervical myofascial pain. This history is also important in managing patient expectations and recommending alterations or adjustments in sport or work participation.

Prior Diagnostic Testing

Inquiring about prior diagnostic testing will limit duplicate testing and delay eventual treatment. Original images with reports are always preferred over reports alone. Physicians should be comfortable reviewing their own diagnostic images.

Prior Treatments

It is important to review all previous treatments a patient has trialed including physical and occupational therapy, medications trialed, previous injections, chiropractic manipulation, acupuncture, and any surgical interventions.

The quality of physical therapy and compliance with treatments can be variable; therefore, further inquiry regarding length of therapy, modalities, and therapeutic exercises done in therapy sessions, and compliance with home exercise programs should be ascertained. When reviewing prior medications, effectiveness, side effects, and reason for discontinuation should be considered. A similar review should be performed for prior procedures or injections. Actual procedure or operative notes are preferable. However, if unavailable, descriptors of anatomic areas, medications, guidance, and benefits of the intervention are important in managing future treatment.

Inspection

Patients with cervical radiculopathy will commonly tilt their head opposite to their affected side, potentially opening the neuroforamina and relieving pain. A forward head position can increase strain on the cervical musculature while also limiting cervical motion. Patients with cervical facetogenic pain develop this posture to offload the posterior elements. This forward head posture is commonly accompanied by rounded shoulders (humeral internal rotation and scapular protraction). This positioning may cause narrowing of the subacromial space and predispose patients to rotator cuff impingement, or contribute to the susceptibility for thoracic outlet syndrome.

Inspection of the shoulder girdle and scapula is best done from behind the patient, and side-to-side comparisons should be made. Diffuse shoulder girdle atrophy may be seen in brachial neuritis, whereas more selective atrophy of girdle muscles may be seen with large rotator cuff tears or suprascapular and spinal accessory nerve palsies. Evaluation of scapular winging should be done with the patient at rest and during active ROM. Exaggerated scapular winging in the presence of long thoracic neuropathy (medial winging) or spinal accessory neuropathy (lateral winging) may be obvious at rest; however, subtle winging may only be seen with active shoulder forward elevation or wall push-ups.

Palpation

Tenderness to the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus is commonly implicated in cervical myofascial pain. However, diffuse tenderness throughout the paracervical musculature should not be considered diagnostic for fibromyalgia, as many cervical pain syndromes can present with similar findings. The diagnosis of fibromyalgia should only be made after a comprehensive history is completed, and the physical examination is consistent with that defined by the American College of Rheumatology.

Systematic approaches to neck and shoulder palpation are crucial to maintain consistency. Palpable step-offs of the clavicle may suggest occult fracture whereas point tenderness over the acromioclavicular joint is more suggestive of arthropathy. Point tenderness subacromially or along the greater humeral tuberosity may indicate rotator cuff impingement or tear. Glenohumeral crepitus suggests glenohumeral pathology. In addition, palpation of cervical, supraclavicular, and axillary nodes may reveal masses or enlarged lymph nodes.

Range of Motion

In the cervical spine, flexion and extension movements are greatest at the C5/6 and C6/7 interspaces, lateral bending at the C3/4 and C4/5 levels, and rotation at the atlantoaxial joint.

Because the complex series of articulations of the shoulder allows a wide ROM, the affected extremity should be compared with the unaffected side as a normal reference. Active ROM should be performed first to establish end range of pain-free ROM prior to the potentially painful passive manipulation of the shoulder by the examiner. Patients with primary rotator cuff pathology may have limitations in both active and passive ROM. Pain may limit passive shoulder internal rotation and active abduction as the rotator cuff tendons become compressed under the anterior acromium arch and coracoacromial arch. Alteration of glenohumeral-scapulothoracic motion can be observed, with glenohumeral motion decreasing and scapulothoracic motion increasing to compensate. Unlike individuals with rotator cuff pathology, those suffering from glenohumeral arthropathy may have restrictions in all planes. If restriction in passive shoulder external rotation is greater than internal rotation, the diagnosis of frozen shoulder should be considered.

Neurologic Examination

A thorough neuromusculoskeletal examination should include, at least, cranial nerve testing, motor and sensory examinations, reflex evaluation in the upper and lower extremities, and gait analysis.

Testing of a patient’s cranial nerves should not be overlooked in the evaluation of neck and shoulder pain. Asymmetric strength of the sternocleidomastoid or trapezius may be evidence of a spinal accessory neuropathy. This test is particularly important to consider in overhead athletes or those with recent neck dissection as they are predisposed to spinal accessory neuropathy. Similarly, nystagmus noted during extraocular muscle testing may be evidence of an underlying VAD.

Motor examination can include testing of all key (C5–T1) myotomes along with thorough testing of shoulder girdle and rotator cuff muscles. If motor weakness is detected, it is important to consider less common causes. For example, true shoulder girdle weakness may be due to rotator cuff pathology or C5 radiculopathy, but possible underlying suprascapular, spinal accessory, or long thoracic neuropathy should not be overlooked. This is especially true for those with relatively normal cervical spine and shoulder imaging. Similarly, weakness in the intrinsic hand muscles in the setting of neck or shoulder pain is commonly associated with C8-T1 radiculopathy; however, clinicians can also consider the less common diagnoses of thoracic outlet syndrome, Pancoast tumor, or cervical myelopathy. Muscle spasticity can be a sign of upper motor neuron involvement and should prompt evaluation for cervical myelopathy.

Similar to motor examination, sensory examination of the upper limb may include testing of key cervical and thoracic dermatomes (C4–T1). Individuals with a clear-cut radiculopathy affecting the dorsal root ganglion should demonstrate sensory changes (sensory loss or hyperesthesia) in a dermatomal distribution. On the other hand, patients with cervical myelopathy, brachial neuritis, or thoracic outlet syndrome may present with more diffuse sensory changes.

Reflex testing can include standard screening of the upper and lower limbs along with an evaluation for upper motor neuron signs with Hoffman reflex, Babinski testing, and testing for the presence of clonus. Reflexes should be tested bilaterally to ensure symmetry. The presence of ataxia with gait evaluation is a potential sign of upper motor neuron involvement.

Special Testing

There is a myriad of provocative maneuvers for disorders of the cervical spine and shoulder. Unfortunately, few alone have adequate specificity and sensitivity to be relied on to make a diagnosis. However, multiple provocative tests used in conjunction for a suspected clinical pathology increase the predictive value of the physical examination. Provocative maneuvers listed in Table 1 are some used in the authors’ practice to screen patients presenting with neck and shoulder pain. Findings on provocative testing should be noted in the context of the other parts of the history and physical examination.

Table 1

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History, Physical Examination, and Differential Diagnosis of Neck Pain The Anatomy and Pathophysiology of Neck Pain Cervical Radiculopathy Conservative Treatment for Neck Pain: Medications, Physical Therapy, and Exercise Thoracic Outlet Syndrome Neck Pain from a Spine Surgeon’s Perspective

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