Differentiating cervical versus shoulder musculoskeletal conditions Both shoulder and cervical nerve root issues can cause arm pain. An important way to differentiate between cervical and shoulder causes of arm pain is the location of the pain. Shoulder pain does not extend below the elbow, while radicular pain does (Katsuura et al., 2020).
involvement of the cervical nerve roots C5 to T1 (Gumina et al., 2013). The following tests/symptoms increase the likelihood that the client’s symptoms are related to shoulder pathology: ● Drop arm test : The client actively abducts the shoulder, which causes impingement pain, and the patient drops their arm. This has a specificity of 0.97 for shoulder pathology. ● Acromioclavicular (AC) joint pain : Pain is localized to the anterior shoulder and lateral neck. ● Subacromial pain : Pain is localized to the lateral deltoid and upper arm. ● Shoulder impingement symptoms : Pain is localized to the deltoid and upper arm. Healthcare Consideration: Special tests play an important role in the differential diagnosis of shoulder pain. There are many special tests for the shoulder, and special tests with good sensitivity, specific, and likelihood ratios provide quality data to confirm and/or refute your diagnostic hypotheses. An appropriate diagnosis will, in turn, help you determine the best treatment options. (Vagy & Hutchins, 2018). Self-Assessment Quiz Question #2 Which special test for cervical pathology involves adding axial compression to the cervical spine to decrease the patency of the neural foramen? a. Spurling test. b. Shoulder abduction test. c. Arm squeeze test. d. Drop arm test.
According to Katsuura et al. (2020), the following tests can help differentiate shoulder and cervical spine pathology. ● Spurling test : The Spurling test has been shown to be highly specific and sensitive in diagnosing cervical radiculopathy as confirmed by magnetic resonance imaging (MRI) and electrodiagnostic findings (Childress & Becker, 2016). For this test, the patient is seated, and the clinician side bends the neck toward the affected side then applies compression force downward from the top of the head. The purpose of this test is to constrict the patency of the neural foramen, thus increasing compression on the nerve root. The test is considered positive if the client’s symptoms are reproduced (Flynn et al., 2008). ● Shoulder abduction test : The shoulder abduction test has been shown via electrodiagnostic testing to have specificity that is like the Spurling test. For this test, the client could be sitting or lying supine. Next, the assessor puts the palm of the affected arm on top of the patient’s head. If radicular symptoms are relieved, this is a positive result. The suggested mechanism for reduction of pain is that this position relieves mechanical traction to the nerve (Flynn et al., 2008). ● Loss of biceps reflex: An absent bicep reflex is frequently indicative of a neck pathology. This test has a specificity of 0.94 for neck pathology (Wainner & Gill, 2000). ● Arm squeeze test : This test involves squeezing the middle third of the upper arm in the area of the biceps and triceps. An intense reaction of local pain indicates Neurological examination According to Katsuura et al. (2020), the prevalence of patients with cervical pathology presenting with shoulder pain is 50%. Neurological examination of the cervical dermatomes and myotomes and testing of the upper extremity reflexes can also be used to differentiate symptoms that are cervical in origin. If the nerve roots
emerging from the cervical spine are compromised, this can lead to upper extremity symptoms. Sensory changes will show up in level-specific dermatomes, while motor changes will affect level-specific muscle weakness. Additionally, upper extremity reflexes may be affected. Refer to Table 2 for specific information.
Table 2: Neurological Examination C-Spine Level Dermatome
Myotome
Reflex
C4 C5 C6 C7 C8
Shoulder area, clavicular area, upper scapular area.
—
—
Deltoid area, anterior aspect of entire arm to base of thumb.
Shoulder abduction Biceps
Anterior arm, radial side of hand to thumb and index finger.
Elbow flexion, wrist extension
Biceps; brachioradialis
Lateral arm and forearm to index, long, and ring fingers.
Elbow extension Triceps
Medial arm and forearm to long, ring, and little fingers.
Finger abduction —
Healthcare Consideration: Identification of the specific nerve root causing radiculopathy is an important part of assessment. Motor weakness can be an indicator of a specific level of cervical radiculopathy, and it can help differentiate cervical nerve involvement from shoulder pathology. However, according to Hong & Nam (2022), there is high individual variability in myotomes and dermatomes, especially at the C6 level.
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