A 34-year-old male walks in your clinic with pain in the right shoulder and shoulder blade. He was helping a friend move heavy boxes over the weekend. His pain is made worse with neck extension and ipsilateral rotation. He also has difficulty with shoulder abduction and flexion. There is no radiation of pain or paresthesia into the hand, however, his lateral arm feels like it is “burning”. Symptoms are alleviated with recumbency.
Is the pain coming from the shoulder or cervical spine?
This is a common presentation in our offices. There are many overlapping symptoms that make differentiating shoulder versus neck pain difficult. Evidence-based chiropractic treatment is dependent on making the proper diagnosis. This blog will cover three potential questions to help you arrive at the correct diagnosis and direct an effective treatment pathway.
Are there any red or yellow flags?
For the sake of simplicity, assume there are no red or yellow flags. Most of us recognize red flags: unexplained weight loss, history of cancer, corticosteroid use, trauma, night pain, fever, or drug/alcohol abuse. Yellow flags are potential bio-psychosocial complaints, and general fear avoidance behaviors that limit your ability to treat the patient.
Another key attribute is the position of relief. If the patient does not have a position of relief it may indicate a chemical-mediated or pathologic origin. These pains are inflammatory in nature and will not subside with a change in body position. Chemical pain is constant, unrelenting, and may result in nighttime pain. For more information on chemical mediated pain see this past blog.
Is the pain coming from the neck or shoulder?
Shoulder and cervical anatomy share many of the same components; resulting in overlapping symptoms that can make differentiation of cervical radiculitis versus shoulder pathology challenging. Fortunately, clinical prediction rules can be used to help differentiate a shoulder condition from cervical radiculopathy. A recent paper published in Spine (1) provides such a clinical prediction rule. The authors use the combination of Spurling’s Test, Arm Squeeze Test, and Axial Distraction Test to diagnose cervical radiculopathy. Specifically, the Arm Squeeze Test can be used to differentiate between a shoulder and neck complaint. In short, compressing the affected arm will exacerbate symptoms via compression of hypersensitized nerves. Compression of the arm will not reproduce pain that originates from shoulder dysfunction, i.e. rotator cuff impingement. For pain of cervical origin, Spurling’s Test will reproduce the pain extending from the neck to the right shoulder, while axial distraction will alleviate symptoms.
What is the tissue of origin?
The cervical foramen is only so big. If extension and rotation exacerbate radicular pain, we can assume the source of injury is near or within the neuroforamen. Radiculopathies in patients over 50 are more likely from degenerative stenosis while younger patients are more likely to experience symptoms from disc lesions. While degenerative changes limit range of motion and decrease the capacity of tissue, we can assume the arthritic changes are not the direct cause of pain for our patient.
Ninety percent of cervical disc lesions are at C5/6 or C6/7. Performing nerve-tensioning maneuvers for the ulnar, median, and radial nerves may further delineate the location and severity of the injury. Disc problems are often a slowly progressing disorder exacerbated by repetitive stress. Lifting heavy boxes, especially with poor form, can overload the cervicothoracic junction leading to injury. Teaching this patient about proper lifting from the hips, retracting his chin, and keeping his elbows close to his body will limit re-exacerbation of symptoms.
Answering these three questions will lead you in the right direction even before entering the exam room. Then ChiroUp’s exam forms can help guide you to the most useful tests to confirm your diagnosis.
Prescribing a ChiroUp condition report will allow you to relay the best exercises, chiropractic patient education, and ADL advice to help your patient heal quickly. ChiroUp will automatically harvest a Google review, send his MD an initial report, and allow you to spend time treating your patient with the most effective techniques in your toolbox.
When people seek chiropractic care they are often looking for a solution that requires a different thought process. The difference in treatment lies within the mindset and training of the practitioner. Understanding diagnosis, prognosis, standards of care, patient education, and achieving excellent outcomes is our area of excellence. Together we can show a greater percentage of the population HOW and WHY we are the best choice for non-surgical musculoskeletal care.
- Thoomes EJ, et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2017.
About the Author
Dr. Brandon Steele
Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.
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