Neck and upper extremity pain

Introduction

Neck pain is one of the most common pain complaints heard by primary care practitioners. After low back pain, the neck and upper extremity are the next most common sites of musculoskeletal pain (4.1)¹. Neck and upper extremity pain are often disabling. A community survey of musculoskeletal pain in the Netherlands reported limitations to daily life from pain in about one in three people and work absences for one in four people with neck, shoulder, or upper extremity pain¹. Interestingly, disability due to neck and upper extremity pain was similar to that for people with low back or lower extremity pain.

4.1 Community survey of musculoskeletal pain. A population-based survey of 3,664 adults ≥25 years old in the Netherlands was used to determine the prevalence of musculoskeletal pain. The most frequently reported anatomical sites for musculoskeletal pain were ranked as follows: low back, neck, shoulder, knee, and wrist/hand. People were about twice as likely to report musculoskeletal pain in the preceding year than chronic pain in each location. (Based on Picavet HJ, Schouten JG, 2003¹.)

A 12-month survey of general practice patients revealed that neck and upper extremity complaints resulted in 147 general practice consultations for every 1,000 registered patients². Complaints were most commonly attributed to the neck (23.1 per 1,000 person-years) and shoulder (19.0 per 1,000 person-years). The incidence of neck and upper extremity pain was higher in women and increased until ages 40-49 (4.2).

A recent survey of 5,752 patients registered with a primary care practitioner identified hand pain in 7% of men and women between ages 16 and 44 and 13% of men and 20% of women ≥45 years old³. A similar survey of 6,038 adult primary care patients (ages 25-64 years) reported a specific hand and/or wrist pain syndrome (De Quervain’s or wrist tenosynovitis or carpal tunnel syndrome) in about 3% of patients, with nonspecific hand and/or wrist pain in about 10%⁴. Hand pain can significantly impair both work and leisure activities.

Assessing neck and upper extremity pain

Chronic neck and upper extremity pain is often caused by musculoskeletal or neurological conditions (Table 4.1). Myofascial pain is characterized by muscle spasm and tender muscles. Areas of discrete tenderness within the muscles, called trigger points, can be locally painful (latent trigger point) and refer pain (active trigger point). Myofascial trigger points in the neck typically refer pain to the head. Myofascial pain from the scalene and serratus anterior muscles refer pain into the upper extremity, while myofascial triggers in the levator scapulae and rhomboids refer to the shoulder (4.3). Pain may also be referred from the heart and lungs.

4.2 Lifetime epidemiology of neck and upper extremity pain. In this Dutch survey, all patient contacts for 96 general practices were evaluated for 12 consecutive months. Incidence density was calculated by determining the number of patients with a first, new episode of a neck or upper extremity complaint during the study year, divided by the sum of person-years at risk. Incidence peaked in the fifth decade, with a higher incidence in women in all age brackets (A). Among the different anatomical locations evaluated, neck and shoulder pain were the most common (B). International Classification of Primary Care (ICPC) codes are shown next to each anatomical location. (Based on Bot AM, et al., 2005².)

Table 4.1 Common causes of neck and upper extremity pain

Pain location	Diagnosis
Neck	Arthritis
	Cervical radiculopathy
	Myofascial pain
Shoulder	Arthritis
	Bursitis
	Myofascial pain
	Rotator cuff tendonitis/tear
Upper extremity	Carpal tunnel syndrome
	Cervical radiculopathy
	De Quervain’s tenosynovitis
	Myofascial pain

Table 4.2 Evaluation for common cervical radiculopathies

Nerve involved	Motor loss	Reflex loss	Sensory loss
C5	Biceps	Biceps	Lateral upper arm
C6	Brachioradialis	Biceps	Lateral lower arm
C7	Triceps	Triceps	Middle finger
C8	Finger flexors	None	Medial lower arm
A herniated cervical disc usually affects the nerve for the vertebra below, e.g. C5 radiculopathy occurs when the C4-C5 disc is herniated. A C8 radiculopathy occurs with a C7-T1 herniated disc.

4.3 Myofascial pain patterns in the shoulder and upper extremity. A: Scalene; B: serratus anterior; C: levator scapulae; D: rhomboids.

4.4 Motor testing for cervical radiculopathy. Arrows denote direction of movement required to test specific muscles. Test biceps strength with the palm facing up. Test brachioradialis strength with thumb pointed up.

Neurological causes of chronic neck and upper extremity pain can be diagnosed by establishing patterns of motor and sensory loss that suggest peripheral nerve or radicular dysfunction. Neurological loss in cervical radiculopathies can be localized to specific nerves by evaluating motor and sensory tests (4.4, 4.5, Table 4.2).

4.5 Sensory testing for cervical radiculopathy. Arm viewed from the anterior aspect, with palm facing toward the viewer. Skin areas served by specific cervical nerve roots are marked.

Case presentation

A 43-year-old pharmaceutical representative presents with neck and right upper extremity pain that began after a work injury. While lifting boxes of drug samples and other supplies from her car, she experienced a popping in her neck and searing pain into her right forearm and hand. She also notes tingling and hyperesthesia in her right middle finger. Her pain drawing is below. She is in good general health, except for two previous episodes of work absence for low back pain and foot drop after lifting at work. Current examination reveals decreased triceps strength and reflex on the right, suggesting a C7 radiculopathy.

The clinical diagnosis of right C7 radiculopathy was confirmed with MRI testing. Similar to this patient, about 40% of patients with cervical radiculopathy have a prior history of lumbar radiculopathy⁵.

Shoulder pain

The shoulder is a complex structure (4.6). Shoulder pain can be caused by overuse in older adults or trauma in young patients (Table 4.3). Pain in the anterior shoulder often results from osteoarthritis of the true shoulder joint (glenohumeral joint) or more commonly acromioclavicular joint or biceps tendonitis. Anterior and lateral pain occur with subacromial bursitis and rotator cuff tendonitis.

4.6 Anatomy of the shoulder. The shoulder contains four articulations: the glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic joints. The rotator cuff is composed of four muscles and their tendons, providing full shoulder motion and joint stability. The subacromial bursa sits on top of the supraspinatus tendon, helping to reduce friction with tendon movement.

Table 4.3 Common causes of shoulder pain

•	Adhesive capsulitis
•	Osteoarthritis glenohumeral or acromioclavicular joint
•	Rotator cuff tear
•	Rotator cuff tendonitis/impingement syndrome
•	Subacromial bursitis
•	Tendonitis of biceps or supraspinatus tendons

History of trauma or overuse, pain features, and physical examination can help distinguish among common causes of shoulder pain (Table 4.4). Although these features can assist in determining a diagnosis, the clinical evaluation of shoulder pain can be difficult. Several studies have compared results among clinicians when evaluating patients with shoulder pain complaints. In general, diagnostic agreement is poor to moderate. In one study, 44 patients
with shoulder pain were evaluated by three rheumatologists⁶. Agreement among clinicians was only 46%. When the three rheumatologists evaluated the patients together and discussed diagnostic signs and symptoms, agreement improved to 78%. In another study, diagnostic agreement between two experienced physical therapists for 201 patients with shoulder pain was only moderate (60%)⁷. Agreement was worse among patients with bilateral, chronic, or severe pain. Clinical tests assessing shoulder function and range of motion are also notoriously unreliable in shoulder pain patients⁸,⁹,¹⁰. For this reason, most patients with chronic shoulder pain will require radiographic studies in addition to history and physical examination (Table 4.5). Partial rotator cuff tears are best assessed with MRI or ultrasound. A comparison of both techniques against arthroscopic findings in 71 patients with rotator cuff tears showed similar good identification and size measurement for both full and partial tears¹¹.

Table 4.4 Distinguishing features among shoulder pain diagnoses

Diagnosis	Pain at night	Range of motion		Crepitus
		Active	Passive
Osteoarthritis	No	Reduced	Reduced	Present
Rotator cuff tendonitis/impingement	Yes	Reduced	Normal	Absent
Rotator cuff tear	Yes	Reduced	Normal	Absent
Subacromial bursitis	Yes	Reduced	Reduced	Absent

Table 4.5 Radiographic studies for shoulder pain

Test priority	Imaging study	Conditions diagnosed
First-line	Plain X-ray	Osteoarthritis, complete rotator cuff tear
	Arthrogram	Adhesive capsulitis, bursitis, complete rotator cuff tear
Second-line	Magnetic resonance imaging	Partial rotator cuff tear
	Ultrasound	Partial rotator cuff tear

Subacromial bursitis

Inflammation of the subacromial bursa results in pain in the lateral shoulder and upper arm, aggravated with overhead activities. Pain is generally relieved by rest. There is no pain when elevating the upper extremity in front of the body or behind. Shoulder rotation and abduction, however, are painful (4.7).

4.7 Shoulder motion. Patients with subacromial bursitis report pain and weakness with shoulder abduction (A). Flexion and extension are generally not impaired (B).

Rotator cuff tendonitis

Rotator cuff tendonitis is a common cause of shoulder pain. A prospective, 1-year survey of 131 patients presenting to their primary care physicians for shoulder pain identified rotator cuff tendonopathy in 85%¹². Inflammation within the rotator cuff is often combined with subacromial bursitis and termed impingement syndrome. Pain is generally
located over the anterior and lateral shoulder. Impingement syndrome can be confirmed with the Hawkins test (4.8). Rotator cuff tendonitis pain is aggravated with overhead activities and is worse at night. Clicking or popping may occur in the affected shoulder.

4.8 Hawkins test. With the elbow flexed and arm elevated in front of the body, the examiner passively internally rotates the upper extremity.

Hand pain

Hand pain is commonly caused by musculoskeletal, neurological, and vascular pathology (Table 4.6). Hand pain may occur in isolation, e.g. De Quervain’s tenosynovitis and carpal tunnel syndrome, or as part of a more diffuse pain condition, e.g. cervical radiculopathy and rheumatoid arthritis. Sensory dysfunction in the hand can help distinguish pain caused by cervical radiculopathy or compressive mononeuropathy (4.9).

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