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 5 common misunderstandings in neck driven shoulder pain.

I've had a day in clinic, I've been asked to review three different patients who've had symptoms for several years.

And there's been a really common theme. Let me tell you about one guy who's got a three-year history of shoulder pain, very much posterior lateral, gets some radiation into the medial board of the scapula. Very static job. Loves going to the gym, but really struggling to get back to the things that matter to him.

He's done every shoulder exercise that I know of. Sounds like he's been really motivated, done everything he's been asked to do, but he's still having issues with driving, when he's been sitting for long periods and he goes to the gym really gets into a lot of problems.

Now, the referrals for all the patients I saw today said that the neck had been cleared, that there was full range of movements, and no indication that perhaps that was involved.

And I thought, right. That's what we're going to talk about.

So five common misunderstandings.

1. With neck driven shoulder pain, you do not have to have the presence of neck pain. So none of these patients reported pain in the upper fibers of trapezius, any lateral cervical spine pain.

They both vary.

They all very much had posterior lateral or medial border shoulder pain. Now what's really interesting is when you look at the location of pain, scapular pain is more pathognomonic of neck driven shoulder pain, than local cervical spine pain. So remember, you don't have to have neck pain to have neck driven shoulder pain.

Now, of course, referral of pain, so referrals certainly below the elbow with any associated symptoms immediately might make us more suspicious of neck driven shoulder pain. However, that brings me nicely to number two.

2. Just because you've got referred symptoms doesn't mean it's the neck. So if we look at pain mapping studies, they aren't without their limitations,

because sometimes we have to ask ourselves, did they actually fully screen the neck? However, those that seem to have good methodology show us, certainly when we look at patients with frozen shoulder, that populations with high levels of psychosocial factors measured on scoring have a wider distribution of pain, which can be across the chest wall as well as the whole arm.

Similarly, we can see patients with osteoarthritis of the glenohumoral joints. Again, it can have referral of symptoms into the forearm. We have studies showing a third of patients with rotator cuff pathology that then needs intervention also seem to have some referred symptoms. Now, of course we have to be cautious because remember 40% of people who've had shoulder problems for six months or longer are likely to have some cervical spine involvement.

So again, it's making sense of that subjective examination, which remember is up to 80% of our clinical decision making. But just because you got referred symptoms, that's pain predominant rather than anything neurological. It doesn't mean that it's definitely the neck. So that brings me nicely to number three.

So remember, all these letters I received said I've cleared the neck. And generally that seemed to mean they hadn't suspected it in the history. And there wasn't any neck pain and, they'd looked at their range of movement in the neck. So they'd said they'd got full range of rotation, left side flexion, flexion, extension movements, and so they were fine.

So I'm sure you've seen this in clinic. You can get somebody to move their neck. It looks okay. It looks pretty symmetrical, but when you over press it, they've actually got significantly more range. And the other thing, when we look at expert consensus, studies by people specialising in the cervical spine.

It's absolutely clear, that just looking at range of movement and over pressure is not sufficient to rule out the cervical spine.

Palpation has to be in there as well. So one, if we're going to look at range of movement, we have to over press it. Remember, stiffness to the same side is highly pathognomonic of neck driven shoulder pain.

And actually, interestingly, if you look at sporting populations, again, with over pressure, if they have stiffness, particularly on their throwing arm side compared to the other, there's an increased risk of injury. Similarly, if we look at people who've had repeated shoulder injuries, often if they have stiffness to that side and we measure their strength in range and change their neck rotation again, that can have a big impact actually on strength in the upper limb.

So range of movement, looking at it actively isn't enough, and we wouldn't just do that in the shoulder. So why would it be any different in the neck? Now I mentioned palpation. That brings me really nicely to number four.

4. So I mentioned palpation, and again, one of these letters that I got, they said, "oh, I palpated the neck".

It was a little bit sore, but it didn't reproduce their symptoms and therefore I ruled out a cervical spine component."

Now again, when we look at well controlled studies by researchers that are really prevalent in cervical spine pathology, they say very clearly, you don't have to reproduce those peripheral symptoms for it to be relevant.

If you have a relevant subjective history, a relevant distribution of pain and pain behavior, which we'll talk about in just a moment, and you palpate and there is comparable tenderness on the side of symptoms that is sufficient. You don't have to reproduce somebody's pain with your palpation. So remember that subjective is

absolutely clear.

Comparable tenderness, particularly with movement restriction to the same side, starts to weigh up that increased likelihood of what you are already suspecting from your subjective is there might be a cervical spine component, or it could be primarily neck driven shoulder pain.

And then the last thing where I think there is a real misunderstanding.

5. Sometimes we put too much store on it, is using neck movements to change symptoms. Now Jo, I know I'm known as somebody who advocates symptom modification as a way of empowering patients and getting them on board, but what about neck movements? We have really nice evidence that if we do repeated movements of the neck, that it can modulate shoulder pain.

But in people without any evidence whatsoever of any cervical spine involvement. In fact a really lovely study done by David Van Der Putt many, many moons ago, showed that in patients with no evidence of any cervical spine involvement, full range of movement on over pressure, no palpation findings, et cetera, but with positive local shoulder pain on things like Hawkins and Kennedy and Neer impingement tests, which don't really figure in my assessment much anymore.

But in that particular study, they were used to help rule in local shoulder pain. Even in that cohort doing repeated neck movements, essentially reduced pain on that testing in 40% of patients.

So it really shows you we can use the neck to modulate shoulder pain. What I'm interested in the history is are there sustained positions?

Particularly static postures or if they're doing a task maybe on the phone or something about their lifting and the neck position at the time. So of course that helped weigh my suspicions. Again, if you think about things like sleep, I had a guy the other day, and he says "If I sleep with my arm under the pillow, I'm fine.

If my head supported on pillows, I'm not supported. If it's like this" and he thinks it's its shoulder, and I'm thinking. I'm pretty sure that helps rule in your neck, which I was already suspecting from the subjective history.

So guys, five common misunderstandings.

1. You don't have to have neck pain, to have neck-driven shoulder pain. That scapular pain and posterior-lateral shoulder pain are most pathognomonic.

2. Referred symptoms beyond the elbow does not mean it's the neck. So listen to that subjective and that pain behavior very clearly.

3. Clearing the neck is not about just looking at active range of movement.

Remember, passive range of movement, over pressure and palpation are important parts of your assessment. And then we can use upper limb tension tests to rule in, but not necessarily rule out.

4. I mentioned palpation, so remember that's our number four. When you palpate, comparable tenderness on the side of symptoms is sufficient.

We don't have to reproduce the symptoms.

5 Finally, whilst using neck movements, if the patient reports particular neck movements make their peripheral symptoms worse, then of course that's useful in weighing up our clinical reasoning, but from our perspective, if we do specific repeated movements and assess the effect on the shoulder,

just remember that in 40% of people with no evidence of cervical spine involvement, it will have some effect. So as ever, our subjective is absolutely key.

So, our "Super 6": our age, our mechanism, our pain location, our pain behavior, how it impacts somebody's sleep, and of course, important patient factors are absolutely paramount in making a decision.

Just listen out. Obviously, in our older patients, often they will have stiffness in their cervical spine, and that's been shown to increase local pain sensitivity. People working in very static jobs or doing a lot of driving as part of their job, or very sustained postures, again, that seems to be a potential risk factor.

But also in terms of mechanism.

Sport, if we've had a whiplash, a concussion, or we've had a fall, our older patients who've had a fall, sometimes we underestimate the impact.

They've banged their head or they've had a mini whiplash, and certainly patients with high levels of pain after that trauma. Just search out that cervical spine effectively.

And most of all, when you're listening to pain behavior, if somebody tells you they relieve their pain by putting their hand on the top of their head or on the opposite shoulder, or supporting it in abduction, again strongly suspect the neck, because that's just taking load off some of those neural structures.

So guys, I just wanted to talk about 5 common misunderstandings in neck driven shoulder pain. I hope it's given something to reflect on and I'll look forward to seeing you next week where we might do a diagnostic conundrum or some rehab tips. Who knows? Sign in and don't miss out on some more shoulder content.