Diagnosing neck versus shoulder pain can be very confusing and difficult to figure out. Patients may come in and be frustrated because of previous misdiagnoses and ineffective treatments, so finding the right diagnosis and getting you into the right treatment plan is key. The earlier you do that, the sooner you can get back to your life and your activities.
Neck and Shoulder Anatomy
The neck, or cervical spine, is made up of seven vertebrae and eight nerves that come out on the sides. Inside is a canal that protects your spinal cord. Each joint is made of 3 parts: one disc in the front and two facet joints. The disc and facet joints provide for motion and protect the nerves and spinal cord. Each of the nerves have a slightly different function. Unfortunately, like anything else, degenerative changes can happen in the neck. If a degenerative change such as a disc herniation, bone spur, or facet cyst touches a nerve, it can cause severe pain. Patients typically have radiating pain shooting down the arm.
The shoulder is a ball and socket joint, like a golf ball on a tee. It’s an unconstrained joint, so the golf ball can fall off. As a result, your body has created ways to create a high range of motion while keeping stability. (Your hip is also a ball and socket joint but has a low range of motion.) The stability comes from deepening the socket, or the tee in the golf ball analogy, by adding the labrum like a rim around it. Your dynamic stabilizers are your muscles. The rotator cuff is a group of four muscles that go around the ball and suck the ball onto the tee to prevent dislocations or abnormal motion. Over time, especially with above-head activities, aging and degeneration, the tendons can have tendonitis, inflammation, or tearing, which can cause pain in the shoulder.
Most people who have a pinched nerve have pain starting from the back of the neck and going into the shoulder blade area. Typically, the pain does not go to the front of the neck. Each different nerve radiates pain into a different place in the body. The C3 nerve comes to the top of the ear and the back of the neck. The C4 nerve goes to where you would have a shawl on the sides of your neck and into the shoulder blade. The C5 nerve, which is a common one to have pain in, goes to the outside of the shoulder, and can often cause the neck versus shoulder pain confusion. The C6 nerve comes to the shoulder blade, down to the bicep and to the index finger and the thumb. The C7 nerve, another one commonly pinched, is lower on the shoulder blade, down the triceps with some potential triceps weakness, and it goes to the middle finger. If the pain goes to your ring finger and little finger, it’s either a C8 nerve or a problem with the ulnar nerve from the elbow.
Shoulder pain presents typically with pain more in front of the shoulder. Most of the time pain in the back of the shoulder is from a pinched nerve and pain in the front of the shoulder is from a biceps tendon issue, a problem with your rotator cuff, or adhesive capsulitis (frozen shoulder).
Diagnosing a Patient
The first step in diagnosing a patient is to ask what their symptom history is. When did the symptoms start? Where is the pain or numbness going? How painful is it? What treatments have you tried and how did the symptoms respond?
In general, a person who has shoulder problems doesn’t like doing things above their head. If the patient says that it really hurts when they move their arm above their head—they can’t put the dishes away in the cupboards or can’t do above head activities—that’s usually a shoulder problem.
A person with a pinched nerve, on the other hand, will frequently relax with an arm lifted up so their hand is above their head: they talk, drive, and sleep with their arm raised. It’s called the shoulder abduction sign and patients feel a lot better when they do above head activities.
If someone can’t move their arm, we figure out if they can’t move it because of weakness, because of pain, or because something is blocking their motion. I watch how they hold their arms and how they move when I ask them to move. Watching for symmetry of how they’re moving their arms can give signs of where the problem is coming from.
We ask about sleeping conditions at home. People with pinched nerves like to bring their neck forward to reduce pressure on the nerve, so they add extra pillows or sleep on a recliner. Hyperextension of the neck exasperates it and rotating to the side where the nerve is pinched makes it worse. Patients with rotator cuff issues don’t like to lay on that side, and rotating in bed wakes them up.
We look at the neck range of motion, moving the neck and arm in specific ways and squeezing certain muscles to see if there is pain and where the pain is. Depending on how they react, we may be able to see if they have a pinched nerve, a frozen shoulder, a rotator cuff tear, tendonitis, bursitis, and so on.
If the diagnosis isn’t clear after a physical exam, we look at x-rays. If the x-rays can’t give enough detail, we’ll have an MRI done. MRIs are very inclusive for diagnostic modality, as they show all of the soft tissue, the disc, the bone spurs, the nerves in the spinal cord, and so on, so you have a much better understanding. However, if you get an MRI of the neck of anybody above age 50 or 60, you’ll probably see some degenerative changes. Are the degenerative changes that I’m seeing on the MRI consistent with your exam? Matching up imaging and exam to find a diagnosis is one of the most difficult parts.
If an MRI of the neck doesn’t give enough detail, an ultrasound or MIR of the shoulder may be helpful, or an EMG or nerve conduction test. The EMG isolates which nerves, if any, are angry. Finally, injections are a diagnostic modality as well as a treatment modality. If an injection takes care of your pain, we’ve been able to find out the source of your pain, which may not be where you feel the pain. For example, people may have neck pain from the trapezius muscle working overtime because their rotator cuff muscle doesn’t work very well.
If non-surgical treatments don’t work, surgical treatments are available. Disc replacement and fusion both have their pros and cons, but both are great treatments. If the pain is coming from the shoulder, I work with my shoulder colleagues here to make sure the patient is taken care of. If a patient has a problem with both their neck and their shoulder, we’ll coordinate our treatments.
Neck and shoulder pathology can be very hard to figure out. Oftentimes, if it’s in the front of the shoulder and it hurts with above head activities, that’s more the shoulder. If it’s in the back of the neck and radiates all the way down with numbness and tingling down your hands, it’s typically the neck. And neck pain can come from the shoulder and the shoulder pain can come from the neck. Finding that appropriate cause of it and finding it early so you can get in the proper treatment options is key to making sure that you’re not having prolonged pain.
Frequently asked questions
Does age play a factor in making a diagnosis?
Yes, age is a factor. When someone is 20 years old and they come in with symptoms, it’s more likely to be a soft tissue disc herniation in the neck, while an older person with the same set of symptoms is probably having some arthritis that’s causing the pinching of the nerves. However, both may have problems with their rotator cuff.
Is pain starting in the arm and moving toward the shoulder a pinched nerve?
It can be, depending on where it starts and how it travels. In patients who feel the sensation moving up, we worry more about a peripheral nerve being compressed, like carpal tunnel syndrome from the wrist up or cubital tunnel syndrome from the elbow up. Or we worry about biceps pathology or other muscle and tendons issues. So it does change how we think about it, but certainly a pinched nerve can present as traveling up versus down.
For these issues, what are some of the treatments?
For the neck pathology and pinched nerves that we’re talking about, I would say probably 75 to 85% of people get better with conservative care. Conservative care includes waiting and letting nature settle things down; taking anti-inflammatories such as Advil, Aleve, Motrin or a steroid pack; physical therapy; or cortisone shots. If none of those treatments work, there are surgical options to help.