Neck and Shoulder Pain

Classification of neck pain

• Neck pain can be classified into the following groups:
  • Unspecific (diverse) localized neck symptoms not associated with signs of serious disease or nerve root dysfunction
  • Radiating neck pain (nerve root dysfunction)
  • Whiplash injury -related neck pain (see Whiplash Injury)
  • Myelopathy
  • Other neck pain: pain associated with systemic illness and tumours, sequela of cervical spine fracture
• Depending on the symptom duration the first three groups may be further classified as being either acute (duration less than 12 weeks) or chronic (duration more than 12 weeks).

• The purpose of the clinical examination and interview is to first identify patients with a potential specific cause for their symptoms, such as radicular symptoms or an inflammatory rheumatic disease, or a serious cause, such as a tumour, infection, fracture or pain referred from internal organs (see T1).
  • Signs of malignant disease include intolerable pain not relieved by rest, inappropriate aggravation of pain within a short time, poor general condition, weight loss, recurring episodes of fever, abnormal fatigue, pain waking the patient in the small hours, and a history of cancer.
• In most patients with neck pain, it is impossible to make a precise diagnosis.
• The task of primary health care is to investigate neck and shoulder problems until a decision is perhaps needed on special investigations or on assessing the need for surgery.
• It should be assessed whether the pain is due to tissue damage (nociceptive), radicular damage (neuropathic) or of a mixed type.

Patient history

• The location and severity of pain, symptom history (events associated with its onset [such as accidents, abnormal strain], continuity, episodes of pain [length and number]), radiation and concomitant symptoms (such as restricted movement or decreased muscle strength), as well as factors relieving and aggravating the symptom provide clues of the aetiology and mechanism of pain.
  • The severity of neck pain can be assessed on a pain scale (e.g. a scale from 0-10 [0 = no pain, 10 = worst possible pain]), and a pain drawing can be used as part of the assessment.
  • Pain starting gradually or as a result of postural strain is often associated with benign strain symptoms, while acute symptoms are associated with irritation of nerve roots or facet joints.
  • Pain increasing towards the evening or acute pain that wakes the patient when turning is consistent with mechanical, benign pain. Intermittent symptoms also primarily suggest a benign cause.
  • Typical symptoms of localized, unspecific neck pain include a dull ache in the neck-shoulder region, stiffness and weakness and headaches at the back of the head.
  • In contrast to myofascial referred pain, a symptom radiating from lower cervical nerve root compression to the upper limb follows the dermatomes (picture 2).
  • Pain referred from intervertebral disc prolapse to the upper limb typically begins quickly within hours or days, whereas pain due to degenerative stenosis develops more slowly over months or years.
• Examining the effectiveness of treatment and rehabilitation of any former and current neck symptoms
  • A history of medication, therapeutic exercises, manual therapy, physical therapy, injection therapy, surgical treatment, medicinal and vocational rehabilitation should be obtained.
• Known risk factors of neck pain should be discussed (see Aetiopathogenesis of neck pain).
• Coping in daily life and at work as described by the patient (what they are capable of doing and how)
  • Disability associated with neck and shoulder symptoms can be assessed with the neck disability index (NDI, see local version or e.g. http://orthotoolkit.com/ndi/)

Clinical findings

• The patient's posture, neck mobility and neck movement patterns, the strength, sensation and reflexes of the upper limbs should be assessed (picture 2).

Diagnostic tests

• Laboratory tests
  • If a serious or specific disease is suspected, it will be sufficient at first to do a basic blood count and measure CRP and ESR in primary health care.
• Imaging studies
  • Neck pain requires no immediate imaging unless there are signs of serious or specific disease (Table T1).
  • If, however, the history or clinical findings are suggestive of a serious disease or a specific disease requiring treatment, an MRI scan is the primary imaging study.
  • If neck pain significantly affecting the patient's performance persists for more than 3 months, x-ray of the cervical spine is recommended as the first imaging study.
    • An anteroposterior projection with the mouth open, and a lateral projection are usually sufficient.
  • Imaging findings must be considered in relation to the patient's age, symptoms and clinical findings, as degenerative changes can be found in asymptomatic people, too.
• Neurophysiological examinations
  • Electroneuromyography (ENMG) should be considered if the diagnosis is not clear after appropriate clinical examination and imaging and differential diagnosis is needed.
    • If nerve entrapment or injury is suspected in the shoulder region or more peripherally, ENMG may provide information about the age and prognosis of the injury.
    • If fresh nerve injury is suspected, ENMG is only justified about 1-2 months after the onset of symptoms.
  • A normal ENMG finding does not exclude radicular symptoms or neuropathic pain.

General principles