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JariArokoski

Neck and Shoulder Pain

Essentials

  • As the prognosis of patients with neck pain is usually relatively good, symptoms can be treated without a specific diagnosis as long as diseases that are serious or require immediate treatment have been excluded.
  • The prognosis of acute neck pain is usually good and recovery spontaneous. Any strain that may provoke the pain should be addressed.
  • In the treatment of localized neck pain, continuation of normal activities and safe analgesic medication are the primary measures.
  • In the treatment of chronic neck pain, neck and shoulder exercise improving muscular strength or endurance may be beneficial.
  • Progressive muscle weakness or myelopathy warrants referral for urgent or immediate assessment for surgical treatment.

Prevalence

  • The area from the highest nuchal line of the occipital bone to the inner margin of the scapular spine and from the lower margin of the mandible to the upper margin of the clavicle and the jugular notch of the sternum is called the neck. The anatomically defined area covers the back and front of the neck and the shoulder region; therefore, the ‘neck-shoulder' concept sometimes also used describes the typical area with symptoms quite well.
  • Neck pain is a common symptom. Two out of three people experience neck pain at some time in their life.
    • Globally, age-standardized prevalence rate was 27 per 1 000 population in 2019, with significant variation between countries http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04957-4.
    • According to the FinHealth 2017 study, 37% of Finnish men and 51% of Finnish women aged over 18 years had experienced neck pain during the past month and 5.3% of men and 7% of women had a chronic neck syndrome diagnosed by a physician.
    • In Finland, neck symptoms are the cause of 3-4% of visits to health centre physicians.

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).

Aetiopathogenesis of neck pain

  • There are many possible sources of pain in the neck, such as intervertebral discs, facet joints, dura mater, ligaments, muscles and nerves.
    • In many cases, no single reason for neck pain can be found and it is not possible to make an exact tissue pathophysiological diagnosis. Indeed, unspecific localized pain is the most common form of neck pain.
  • Changes seen in imaging of the cervical spine increase with age and commonly also occur in patients without neck symptoms.
    • Degenerative changes can be seen in most people over 65 on plain cervical x-ray.
    • MRI scans show multiple findings even in those with no neck symptoms, particularly degenerative changes increasing with age but also disc protrusion and herniation.
  • Neck diseases have risk factors associated with living habits, psychosocial and physical factors.
    • Habits
      • Smoking probably increases the risk of neck pain slightly.
      • Overweight probably increases the risk of neck diseases.
      • Leisure time physical exercise probably reduces the risk of unspecific (localized) neck pain and improves the prognosis of neck pain.
    • Psychosocial factors
      • Doing a lot of work, getting insufficient social support from colleagues, having little chance to influence things and poor job satisfaction may increase the risk of neck pain.
      • Obesity is associated with an increased risk of herniated lumbar disc and severe pain syndromes.
    • Physical factors
      • Sitting for most of the working day, working for prolonged periods with the neck bent forward, work requiring repetition and precision, rotation or forward bent position of the torso, working with raised arms, and raised position of the upper arm probably increase the risk of neck pain.
    • Hereditary factors explain most cases of intervertebral disc degeneration.

Examination of a patient with neck and shoulder pain

  • 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.

Serious or specific diseases causing neck pain

DiseaseHistory or finding, investigations
Intervertebral disc prolapseRadiating neck pain or numbness of the fingers with a rapid onset. Central prolapse may cause symptoms of spinal cord compression. Intensive follow-up. If there are progressive motor deficit symptoms, consult a specialist.
Myelopathy (spinal cord compression)Symptoms in the lower extremities (to be remembered in association with walking difficulties in an elderly person), spasticity, bladder and bowel symptoms when advanced. Examine sensations and reflexes, including vibration sense and Babinski's sign. If the symptoms are progressive, consult a neurosurgeon.
MalignancyDeteriorated general condition, loss of weight, fatigue, fever, intractable pain not associated with strain. Basic investigations, MRI of the cervical spine.
Inflammatory rheumatic diseaseRheumatoid arthritis: changes in the cervical spine usually appear later. Bending of the neck should be avoided because of the risk of atlantoaxial subluxation. Ankylosing spondylitis may stiffen the neck. Progression is periodic, to be remembered in episodic neck pain.
Bacterial spondylitisPossible underlying factors include e.g. intravenous drug abuse or immunosuppression. MRI of the cervical spine is the basic investigation.
Arterial dissectionDissection of the carotid or vertebral artery may, in addition to posterior or anterior neck pain, cause symptoms typical of a cerebrovascular disturbance (visual disturbances, lateralized neurological deficits, cognitive symptoms), Horner's syndrome, pulsating tinnitus or symptoms from the lower cranial nerves.

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.

Treatment and rehabilitation

General principles

  • As the prognosis of patients with neck pain is usually quite good, symptoms can be treated without a specific diagnosis as long as diseases that are serious or require immediate treatment have been excluded (see Tables T1 and T2).
    • Any mechanical or psychological strain provoking pain (see Aetiopathogenesis of neck pain) should be addressed early but straining of the neck should not be forbidden.
    • The patient should be encouraged to stay active and to maintain normal daily activities even in the acute phase.
    • As soon as any serious causes have been excluded, the patient should be informed that neck symptoms are quite common and benign and have a good prognosis.
    • A follow-up appointment should be scheduled for about 2-3 weeks later if severe neck pain persists.
    • Imaging findings in unspecific, benign neck pain should be interpreted "in positive light" because abnormal findings do not necessarily predict subsequent neck pain.
    • Patients should also be asked to present for a follow-up visit if they develop clearly radiating pain or any symptoms suggestive of serious disease.
    • The need for sick leave for neck problems should be assessed case by case, considering the patient's functional and work ability and the workload involved.
      • If sick leave is necessary, 1-3 days is usually sufficient.
      • If incapacity for work continues for more than 2 weeks, the case should be assessed primarily in occupational health care.

Flow chart for the examination and treatment of localized neck pain or pain radiating from the neck to the upper limb. Source: Niskakipu (aikuiset) [Neck pain (adults)] - Current Care Guideline 2017 (referenced on 28.2.2022).

Duration of painLocalized neck painRadiating pain
1 If there are warning signs suggestive of serious disease, the required further investigations should be performed (e.g. ESR, basic blood count, CRP, plain x-ray) or the patient referred for further investigations.
2 If no emergency assessment by a specialist is required, basic investigations (e.g. ESR, basic blood count, CRP, plain x-ray or MRI) are recommended before assessment by the specialist.
AcuteBasic investigations and measures
  • Symptoms and basic clinical examination
  • Warning signs suggesting serious disease or injury1
  • Addressing the causes and any aggravating factors
  • Required analgesia
Basic investigations and measures
Required analgesia
Emergency assessment by a specialist if there are progressive or significant motor deficit symptoms or if there is intolerable pain resistant to treatment
1 week-Basic investigations and measures
Assessment by a specialist if there are progressive or significant motor deficit symptoms or if there is intolerable pain resistant to treatment2
2-3 weeksBasic investigations and measuresBasic investigations and measures
Assessment by a specialist if there are progressive or significant motor deficit symptoms or if there is intolerable pain resistant to treatment
4-6 weeks-Basic investigations and measures, as necessary
Assessment by a specialist if there is pain causing significant harm or if there are progressive motor deficit symptoms
8-12 weeksBasic investigations and measures
Multiprofessional workup, as necessary		Basic investigations and measures
Assessment by a specialist if there is pain causing significant harm or if there are progressive motor deficit symptoms
3-6 monthsPhysiotherapy increasing muscle strength or endurance, multiprofessional rehabilitationMultiprofessional rehabilitation

Treatment of unspecific localized neck pain Electrotherapy for Neck Disorders, Manipulation or Mobilisation for Neck Pain, Massage for Neck Pain, Mechanical Traction for Neck Pain, Workplace Interventions for Neck Pain in Workers

  • Acute pain
    • Paracetamol and NSAIDs can be used.
      • If these are not sufficiently effective, a weak opioid may be added to the regimen.
      • A muscle relaxant may be an option if the patient cannot tolerate paracetamol or NSAIDs.
    • Cryotherapy or thermal therapy may provide short-term relief for neck pain.
    • Aerobic training is recommended.
  • Chronic pain
    • Analgesics can be used periodically, as necessary, depending on the intensity and occurrence of pain. Paracetamol and NSAIDs can be used. If these are not sufficiently effective, a weak opioid may be added to the regimen.
      • Antidepressants (e.g. tricyclic antidepressants) may be beneficial particularly in patients whose pain involves an element of mental strain or disturbed sleep at night or whose neck pain is associated with chronic headache.
    • The patient should be referred to a physiotherapist for guidance of self-care and therapeutic exercises.
      • Exercises specifically for neck and shoulder muscles and improving muscle strength, endurance, flexibility or coordination may reduce chronic neck pain Exercises for Mechanical Neck Disorders. The individual exercise programme and type of exercise should be chosen according to the patient's preferences.
      • Aerobic training is recommended.
      • Mobilization therapy may provide short-term benefit in association with other treatment for chronic neck pain.
      • Manipulation of the cervical spine is not recommended for the treatment of neck pain.
      • Acupuncture and transcutaneous electrical nerve stimulation (TENS) may provide short-term relief for neck pain.
      • Cryotherapy or thermal therapy may provide short-term relief for neck pain.
    • Intramuscular injections of local anaesthesics may be helpful in the treatment of chronic myofascial pain.
    • Multiprofessional assessment and measures should be started when symptoms causing significant functional limitation have continued for no more than 2 months.

Treatment of radiating neck pain

  • The patient should be informed about the possibility of motor symptoms in the upper extremities or myelopathic symptoms. Should these occur the patient should immediately seek medical treatment.
  • The guidelines for pharmacotherapy of acute localized neck pain can also be applied for acute radiating pain.
  • If a patient presents with prolonged motor weakness or excruciating pain despite medication, they should be referred for assessment by a physiatrist, neurosurgeon or other specialist with appropriate expertise; if there is significant limb weakness or progressive motor symptoms, emergency referral is warranted.
    • Pain radiating to the upper limb, causing significant harm and continuing for 6 weeks also requires assessment by a specialist.
    • Indications for surgery should be examined before radicular symptoms, and motor deficit symptoms, in particular, turn chronic.
  • The general guidelines for the treatment of neck pain and recommendations for the treatment of chronic localized pain can also be applied for chronic radiating pain.
  • Drugs used for neuropathic pain (tricyclic antidepressants, gabapentinoids [gabapentin and pregabalin] and SNRI antidepressant analgesics [duloxetine and venlafaxine]) may be helpful in the treatment of chronic radiating neck pain Antidepressants for Neuropathic Pain.