If the pain is centrally located and is provoked by bilateral elevation of the arm, traction fracture of the spinous process of C7 and/or T1 is most likely. This presents as a stress fracture of one of the lower cervical spinous processes. The lesion should be suspected when bilateral limitation of about 90° on active elevation of the arm is found. Active elevation of both shoulders is also painful, as is resisted shoulder elevation. Passive elevation is painless. Movements of the neck are only slightly painful (see p. 237). A stress fracture of the first rib is another possible cause. It gives rise to unilateral pain at the base of the neck not preceded by trauma. Active elevation of the arm cannot progress beyond the horizontal and is painful but passive elevation is normal. Pain is increased by active and resisted shoulder elevation and by active and passive side flexion of the neck to the opposite side. Resisted side flexion to the painful side is also painful (see p. 236). Pain is felt unilaterally in the upper scapular area, mostly of the dominant shoulder.1 It is activity-related: neck movements as well as shoulder girdle or arm movements may be of influence. So are prolonged postures such as sitting with the head in slight flexion as happens during computer work. A muscular lesion in the trapezius is as uncommon as pain in the trapezius is common. Usually pain in that area is referred from the cervical spine: it is the most common localization of cervical dural pain (see p. 123). Because this phenomenon is often accompanied by extrasegmental tenderness, examination based on palpation will easily result in the wrong diagnosis of ‘trapezius syndrome’. Proper functional testing, however, usually turns out to be negative, showing that no focal lesion is present. The lesion responds to local infiltration of a local anaesthetic or to deep friction. When the pain is felt anteriorly, this suggests that the lesion lies in the pectoralis minor or major muscle. Active protraction usually also elicits pain. When the pectoralis minor is at fault, resisted scapular depression is painful. If the lesion lies in the pectoralis major, resisted adduction and medial rotation of the arm is positive. Both lesions can be treated by procaine infiltrations or deep friction (see p. 260). If the pain is located in the scapular area a lesion of the serratus anterior is probable.
Disorders of the contractile structures
Pain on resisted elevation
Lesion of the levator scapulae muscle
Lesion of the trapezius muscle
Pain on resisted protraction
of the contractile structures
