Summary

Keywords: Shoulder, cervical, pain, radiculopathy

 

Introduction

Shoulder pain:

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

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

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

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

Often difficult to differentiate referred cervical radiculopathy from glenohumeral or subacromial shoulder pain secondary to complexity of pain patterns and interactions between joint articulations4

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 motion6 and development of scapulardyskinesis:

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

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

alignment and mechanics

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

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.”

Diagnosis‌

History:

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

Often increased pain with arm abduction9

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

Rotator cuff tears (RTC):

Increased incidence of both symptomatic and asymptomatic tears with age

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.

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

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

Shoulder instability

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

Common cervical radiculopathy complaints:

Often pain relief with arm abduction9

Numbness/tingling in arm, forearm, and hand

Review of dermatomes/myotomes, exiting nerve root anatomy:

C4: Base of neck/upper shoulder

C5: Shoulder/deltoid, lateral arm

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

 

Fig. 4.1 (a, b) Common shoulder complaints.

 

 

 

Physical examination:

Shoulder:

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

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

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

Drop arm, painful arc.

Instability:

Anterior and posterior translation

Apprehension, Jerk test.

Range of motion.

Cervical spine:

Paraspinal/trapezius tenderness and pain

Motor examination

Spurling’s sign: High specificity for radiculopathy, but only 30–50%

sensitivity and often performed incorrectly.10,11

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

The test is considered positive if visual analog scale (VAS) pain level

reached or exceeded 3/10

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

 

Diagnostic tests

Plain radiography:

Shoulder:

Indicated in patients whose physical examination findings suggest the

shoulder as the primary source4

Anteroposterior (AP), Grashey AP, scapular “Y,” and axial views.

Cervical spine:

AP, lateral, and flexion/extension:

Osteophytosis, disk collapse, static or dynamic spondylolisthesis

Indicated in patients with shoulder complaints who also complain of axial neck pain, and/or radicular symptoms or who have peripheral weakness in strength testing.

Advanced imaging:

Shoulder:

Magnetic resonance imaging (MRI) to evaluate for RTC tears, labral tears, biceps abnormality, cartilage injury, and/or arthritic joint changes.

 

Cervical:‌

MRI:

Evaluate for central versus foraminal stenosis, myelomalacia, and perineural or facet cysts

Computed tomography (CT) myelogram if unable to obtain MRI.

Diagnostic/therapeutic injections:

Shoulder: Only in rare instances are injections performed prior to obtaining an MRI as this can potentially guide treatment:

Subacromial injections: In patients with impingement findings or evidence of subacromial bursitis or partial RTC tears

Glenohumeral injections: To address any potential intra-articular sources of pain including biceps, labrum, and RTC

ACJ injections: Can be done in isolation in patients with isolated ACJ symptoms.

Cervical:

Selective nerve root block (SNRB), interlaminar epidural steroid injection:

Dangers associated with injections in C-spine

Cervical SNRB pain relief may correlate with symptom relief after surgical intervention, but patients experiencing no effect after injection still may have pain relief with surgery:13

Questionable diagnostic utility.

Electrodiagnostics:

Used if diagnosis remains unclear but cervical is suspected to be the main etiology4

Often negative in purely sensory radiculopathy.

 

Differential diagnosis

Also consider: Peripheral vascular disease, diabetic neuropathy, and acute cardiac pathology

Neuralgic amyotrophy (Parsonage-Turner syndrome)

Uncommon shoulder conditions: avascular necrosis, metastases, fractures, and cysts

Thoracic outlet syndrome:

Cervical ribs (▶Fig. 4.2).

 

Management

Surgical management is only considered after a trial of conservative measures, regardless of the etiology, in the absence of progressive neurologic deficits. In patients with concurrent pathology, the predominant complaint should guide treatment.

 

Fig. 4.2 Treatment algorithm.

 

 

 

Shoulder:

RTC repair in symptomatic patients with full- or nearly full-thickness tear

Shoulder arthroscopy with biceps tenodesis in patients with degeneration or tearing of superior labrum/biceps complex

Labral repair in patients with recurrent glenohumeral instability.

Cervical:

Anterior cervical discectomy and fusion (ACDF)/cervical disk arthroplasty (CDA)

Keyhole foraminotomy.

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