We’ve spent the last couple weeks at The Massage Development Center exploring a variety of shoulder diagnoses and treatments. But what happens when shoulder pain isn’t coming from a source in the glenohumeral joint or its structures? Are you able to screen for these conditions?
Now, I am a physical therapist and it was in my training to look at the cervical spine when evaluating a patient for a shoulder injury.
However, depending on your schooling and licensure, it may not have been part of your education. From my understanding, if you are a massage therapist, even what state or province you work in determines if you can do a full screen of the cervical spine.
However, I want to argue it is in everybody’s scope of practice to do due diligence to take a good history and make sure an outside referral isn’t warranted. My goal with this post is not to teach a bunch of cervical screening tests, but to familiarize everybody with risk factors in patient’s history and signs and symptom that would warrant further investigation either from you or outside referral.
Recognizing Referral Pain
The cervical nerve roots and cervical discs can refer to the shoulder area. Your patient may come in complaining of upper trapezius pain or rhomboid pain but it could be a C6-7 nerve root radiculopathy causing pain.
The referred pain may continue further down the upper extremity or may stop in the shoulder region. The following table outlines the common areas for referral:
Nerve Root Shoulder area referral pattern:
C2 – Pain primarily in the posterior aspect of skull, headaches, ears, eyes
C3 – Pain in necks and Upper Trapezius
C4 – Pain in Upper Trapezius, lower neck
C5 – Pain in upper lateral arm, neck, shoulder Weakness in Deltoid and Elbow Flexion
C6 – Pain in the dorsolateral arm, Neck upper/middle trapezius Weakness in biceps
C7 – Pain Middle trapezius/rhomboid area and neck Weakness in triceps
C8 – Pain in neck and middle/lower trapezius Weakness largely in hand
T1 – Pain in lower trapezius and forearm Weakness largely in hand
If your practice acts allow differential assessment and shoulder tests are negative, it is worth considering cervical radiculopathy. Research shows that grouping the Spurlings Test (also known as the Foraminal Compression Test), Upper limb nerve tension testing, Cervical Distraction Test and the patient presenting with involved side cervical rotation of less than 60 degrees has a 90% positive likelihood ration that cervical radiculopathy is present.
What if your practice acts do not allow you to perform special tests for the neck?
Ask some questions and observe, to help determine if it might be cervical radiculopathy.
First does it look like your patient has less than 60 degrees of cervical rotation of their symptomatic side? Do they describe their pain as “pins-and-needles or tingling or stinging” or occasional numbness? Do they have muscle weakness? Does the pain increase when they rotate to that side and concurrently extend their neck (a sign of compressing the nerve root)?
In younger patients, the most common cause of nerve root irritation is disc herniation or a direct blow such as in football or hockey game (a “stinger”). In older patients, the leading cause is stenosis or bony spurs.
If the answer to these questions is yes, you may want to consider having your patient follow-up with another healthcare practitioner if they have not had the cervical spine evaluated (particularly if they have significant weakness present). However, largely these conditions will respond to massage therapy and strengthening along with other physical therapy treatments and potentially other medical management.
However, you may have patients whose history is not as straight forward or the presentation may be more serious and you need to do a more immediate referral. The cervical spine structures can also refer to the shoulder complex for much more serious reasons.
Knowing When To Refer Out
Upper cervical fractures can irritate nerve roots and refer to the shoulder as well. These typically won’t refer into the glenohumeral joint proper but may refer into the upper trap area. You may wonder how somebody could be walking around with an undiagnosed cervical vertebral fracture, but it is actually not that uncommon.
A Dens fracture of C2, for example, is often not seen unless an open mouth x-ray is performed (which is not always standard protocol or people think they are “fine” after an MVA). It is typically injured with a hyperextension type of injury (i.e. whiplash in a car accident or hyperextension of the neck in football with another player falling on the injured player). The fracture can compress the spinal cord and cause swelling which can also cause the nerve roots to refer pain. The injury does have a good outcome potential with proper treatment.
However, if your patient has the appropriate mechanism of injury and has neck pain, neck swelling, complaints of swallowing and has muscle weakness and has not been evaluated for a fracture you should refer out prior to treatment.
Cervical Central Cord Compression is probably the most severe diagnosis to should be making sure you screen. This occurs when the spinal cord becomes compressed from bone fragments from a fracture or disc, swelling due to an injury from a trauma or a tumor.
Because it may take time for swelling to develop and compress the cord, symptoms may develop over many hours or days so they may be walking in your office now experiencing a medical emergency. Your patient will have a history of major trauma (fall, motor vehicle accident, a blunt blow to the spine). Classic signs of central cord compression include: gait disturbances (they may be walking with a wide base of support or say they feel unsteady since the accident), arm and hand sensory complaints and muscle weakness including very quick atrophy of the muscles, and complaints of sudden onset incontinence (not just a few drops, full bladder uncontrollably leaking).
If these are new-onset symptoms with a trauma history, immediately send your patient to a physician or emergency room. You cannot be too careful with this sort of diagnosis.
It’s also important to remember that shoulder pain may not be referring from the cervical spine at all but from another area of the body such as abdominal gas, heart issues such as a heart attack or from an organ such as the gallbladder. We shared such a case of referred pain in a post you can find here. In summary, it is important to get a good patient history prior to treating their shoulder to assess whether the cervical spine may be involved. If it is out of the scope of your practice to assess the spine, then make sure you know the red flags and history that would warrant a referral to an outside practitioner. The human body is so interconnected and we should never work in isolation!
Childress MA, Becker BA. Nonoperative Management of Cervical Radiculopathy. American Family Physician. 2016;93(9):746-754
Clark, Charles R. The Cervical Spine. Fourth ed. 2005. Web.
Hashmi SZ, Marra A, Jenis LG, Patel AA. Current Concepts: Central Cord Syndrome. Clinical Spine Surgery. 2018;31(10):407-412
Hutting N, Scholten-Peeters GGM, Vijverman V, Keesenberg MDM, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Physical Therapy. 2013;93(12):1686-1695
Schroeder GD, Vaccaro AR. Cervical Spine Injuries in the Athlete. Instructional Course Lectures. 2017;66:391-402.