Your Shoulder Pain may be caused by a Cervical (Neck) Problem

[mtomaino]

Although shoulder pain is commonly attributed to rotator cuff tears,with an estimated 4.5 million US physician visits in 2002 for cuff problem, it's important to remember that shoulder pain can also be produced by an extrinsic cause such as cervical radiculopathy or degenerative disc disease. Indeed, neck arthritis and/or degenerative disc disease can both coexist with a rotator cuff disease and cause shoulder pain in the absence of a problem like bursitis, impingement, or a rotator cuff tear.

It is not infrequent that I see patients who are referred by their Spine Doctor after neck surgery, or by their Internist---for either shoulder pain or trapezial discomfort. The 4th and 5th cervical nerve roots can become pinched by cervical spodylosis--osteophytes in the facet joints or the uncovertebral joints (joints of Luschka). Spondylosis can result in axial neck pain, as well as cervical radiculopathy. ‘‘Radiculopathy’’refers to the presence of pain, sensory changes,or motor deficits in a dermatomal distribution and can existwith or without neck pain. Radiculopathy is generally produced by 1 of 2 mechanisms.Most commonly, disk herniation occursthrough an annular fissure, typically through the posteriorlateral disk. Alternatively, foraminal stenosis due to thedegenerative changes can impinge on the nerve root.

The localization of the arm pain is related to the level of root compression. A C4 radiculopathy can produce pain radiating from the neck to the superior aspect of the shoulder and posteriorly to the scapula. Motor findings can be difficult to detect with this level of a lesion. Rotator cuff disease is more commonly mimicked by a C5 radiculopathy. Pain in this situation is commonly localized to the shoulder and weakness found in abduction and external rotation of the shoulder.Weakness from cervical radiculopathy is usually incomplete; profound weakness and atrophy are uncommon except in chronic neglected cases. The diagnosis of a radiculopathy can be made with well defined symptoms and neurologic examination with a corresponding
structural lesion on an imaging study, generally a magnetic resonance imaging study. Electrophysiologic studies can be useful to confirm the diagnosis and to exclude other neurologic conditions.

Cervical radiculopathy is commonly treated nonoperatively, at least initially, with measures such as analgesics, anti-inflammatory medication, muscle relaxants, corticosteroids, injections, and physical modalities including traction.Surgical treatment for cervical radiculopathy is typically
indicated for persistent, disabling radicular pain, progressive motor deficit, or disabling motor loss. My general approach includes conservative treatment of most cases of cervical radiculopathy---when also accompanied by a rotator cuff problem. Most patients who seek relief from their shoulder pain prefer to address the shoulder first, when surgical treatment is necesssary. Thereafter, if incomplete pain relief is still problematic, neck surgery may be needed. However, prior to any recommendation for shoulder surgery, I will typically have you see a "neck surgeon" first if physical therapy has not been helpful.

I have attached neck xrays which reveal disc space narrowing on the lateral view as well as nerve root foraminal stenosis from arthritic spurs. Most of the time physical therapy is helpful, and surgery is not required for relief. This patient's shoulder xray is attached, as well. Impingement was also a cause of shoulder pain.