Imaging is not justified in patients with mild symptoms or those under the age of 65 [3]. In more severe cases plain X-rays, CT or MRI scans are often performed but rarely demonstrate any abnormality. Most patients with mild pain can be reassured and advised to lead a normal life without restrictions [3].

With more severe pain a period of abstinence from intense training and sporting activities is recommended. Simple analgesia or a non-steroidal anti-inflammatory drug (NSAID) can be prescribed. In patients with severe pain it is important to advise them that recovery is very likely to occur but may take months and, in these cases, lifestyle including work is often restricted.

The role of physical therapy is controversial. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders concluded that ‘best evidence suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain’ [9].

Management of cervical nerve root compression is discussed in the section ‘Pain with or without focal neurological symptoms in the shoulder and upper arm’ in this chapter.

Cervical radiculopathy

Cervical radiculopathy arising from the 3rd and 4th cervical nerve roots is very rare. Unilateral pain in the suboccipital region, extending to the back of the ear, and in the dorsal or lateral aspect of the neck occurs with radiculopathy of the 3rd cervical nerve root. C4 radiculopathy results in unilateral pain that may radiate to the posterior neck and trapezius region and to the anterior chest but does not typically radiate into the upper extremity [7]. Neither is associated with any discernible weakness although neurological symptoms may occur with sensory symptoms in the distribution of the C3 or C4 nerve root and, in the very rare occurrence when a radiculopathy is associated with spinal cord compression, an upper motor neuron pattern of weakness in all four or just the lower limbs with or without sensory symptoms and a possible sensory level may result. The term ‘sensory level’ refers to the level within the central nervous system that the spinothalamic dermatomal sensory loss extends up to on the trunk or in the limbs.

PROBLEMS AROUND THE SHOULDER AND UPPER ARM

This section discusses common neurological and non-neurological conditions affecting the shoulder and upper arm that can result in pain with or without focal neurological symptoms or focal neurological symptoms in the absence of pain.

Pain with or without focal neurological symptoms in the shoulder and upper arm

There are a number of conditions, both neurological and non-neurological, that can cause pain in and around the shoulder. These include:

• nerve root compression of the 4th, 5th and 6th cervical nerve roots

• brachial neuritis

• suprascapular nerve entrapment syndrome

• arthritis of the shoulder joint

• adhesive capsulitis

• bursitis

• rotator cuff pathology.

Pain in the shoulder and upper arm most often relates to diseases of the joints, ligaments or bones where pain occurs in the absence of neurological symptoms and is aggravated by movement of the affected joint or there is localised tenderness at the site of the pain. The presence of joint swelling and/or tenderness is another clue that the pain is not of neurological origin.

Figure 11.1 lists the common causes of pain in the region of the shoulder.

FIGURE 11.1 Painful conditions affecting the shoulder region

NEUROLOGICAL CAUSES

Radicular pain: Pain from nerve root compression, if associated with weakness and/or sensory disturbance in the distribution of the nerve root, is readily diagnosed. However, pain may occur in the absence of or precede neurological symptoms by days or even weeks. Although radicular pain may affect the upper (C4–C5) arm, it is more common in the lower (C6–8) arm.

Numbness and/or localised shoulder pain not influenced by movement of the shoulder suggests a possible C5 nerve root problem. Where neurological symptoms and signs develop, the numbness is located over the top of the shoulder along its mid-portion and extends laterally to the upper arm but not into the forearm. There may be weakness of the supraspinatus, infraspinatus and deltoid muscles [7].

Brachial neuritis or neuralgic amyotrophy: The diagnosis should be suspected when severe shoulder pain aggravated by movement of the shoulder is associated with weakness and sensory disturbance in the arm. Van Alfen et al [10] have described the clinical details in a large series of patients. As there is no ‘gold standard’ diagnostic test for brachial neuritis, the clinical features of neuralgic amyotrophy are likely to evolve.

• Ascertain whether the arm pain is aggravated by movement of the arm, suggesting local pathology in the arm, or aggravated by movement of the neck, indicating possible referred pain from nerve root compression.

• Pain occurring simultaneously with neurological symptoms is very likely to be related to a neurological cause. The pain may not be neurological in origin when it occurs in the absence of neurological symptoms.

• If testing the strength of muscles around a joint evokes marked pain, this may cause the patient not to exert a full effort and give the incorrect impression that there may be associated weakness when it is the pain that is limiting the effort, not the weakness.

SYMPTOMS: The classic symptoms begin with the subacute onset over weeks of increasingly severe constant unilateral pain predominantly in the shoulder girdle; less commonly, the pain may come on rapidly. Rarely, bilateral cases occur but one side is usually affected for some hours or up to 2 days before the other side is involved [11]. This constant pain persists on average for approximately 3–4 weeks but may last as little as a few days or up to 60 days or more. In many patients it may be followed by a movement-evoked severe stabbing pain that can persist for months. In a small proportion of cases the pain can radiate from the shoulder to the arm, the cervical spine or neck down into the arm, the scapular or dorsal region to the chest wall and/or arm, or be confined to a lower plexus distribution (e.g. medial arm and/or hand, axilla).

The shoulder pain is aggravated by movement of the shoulder, not the neck, but here there are neurological symptoms such as weakness and sensory disturbance in the arm that indicate a neurological cause for the pain. Although local heat to the shoulder region occasionally provides some relief from the pain, this is non-specific and cannot be used in diagnosis. Individual nerves can be affected in brachial neuritis, in particular the suprascapular, axillary, musculocutaneous, long thoracic and radial nerves [11].

Progressive weakness developing over days may commence within 24 hours after the onset of the pain or may be delayed for up to 4 weeks [11]. Although any part of the plexus can be involved, the upper brachial plexus is more commonly affected in males whereas the middle and lower brachial plexus is more commonly affected in females. Wasting may occur with prolonged symptoms. Recovery can take months or even years. Sensory involvement is common and sensory symptoms can be very diffuse and non-localising.

Recurrence is rare but can occur and familial cases, termed hereditary neuralgic amyotrophy, have been described. Hereditary neuropathy with pressure palsy can also cause neuralgic amyotrophy and is related to a defect in the peripheral myelin protein 22 and is regarded as a distinct disorder [12].

Axillary nerve lesion: Axillary nerve lesions are usually related to traumatic dislocation of the shoulder joint as a result of either a sporting injury or secondary to a tonic–clonic seizure. Less commonly they occur with a fracture of the neck of the humerus or following shoulder surgery. As with all single nerve (mononeuritis) lesions, some are idiopathic (unknown cause).

EXAMINATION: There is weakness of shoulder abduction beyond the first 30° (the initial 30° is supplied by the supraspinatus muscle) due to weakness of the deltoid muscle (see Figure 11.2). There may be a small patch of numbness over the lower aspect of the deltoid muscle. When the lesion relates to dislocation, there is often pain in the shoulder aggravated by movement of the shoulder. The presence of pain and weakness with a history of trauma to the shoulder is a strong pointer to the diagnosis. The prognosis for recovery is variable [13].

FIGURE 11.2 Testing the deltoid muscle (the arrow points to the deltoid muscle/axillary nerve)

Suprascapular nerve entrapment: The suprascapular nerve arises from the junction of the 5th and 6th cervical nerve roots and traverses an oblique course across the supraspinatus fossa, relatively fixed on the floor of the fossa and tethered underneath the transverse scapular ligament, to the scapular notch and supplies the supraspinatus and infraspinatus muscles. Most often the suprascapular entrapment syndrome relates to local compression by the suprascapular ligament although it may be idiopathic in origin or due to rarer causes [14]. Although very rare, it is a diagnosis not to be missed as prompt treatment is more likely to result in resolution of the problem.

SYMPTOMS: The pain is deep and diffuse, localised to the posterior and lateral aspects of the shoulder and may be referred into the arm, neck or upper anterior chest wall. Certain scapular motions may be painful, causing the patient to restict shoulder movement. Adduction of the arm across the body tenses the nerve and may increase the pain. Occasionally, the patient may complain of burning, aching or crushing pain.

EXAMINATION: It is important to test the supraspinatus and infraspinatus muscles, looking for weakness confined to those muscles. Remember, pain may give the appearance of weakness with the patient not exerting a full effort as a result of the pain. The clue that the weakness relates to pain from the shoulder is that, in addition to the supraspinatus and infraspinatus appearing weak, the deltoid and subscapularis muscles will also appear weak. Severe suprascapular nerve entrapment results in atrophy and permanent weakness of the supraspinatus and infraspinatus muscles (see Figure 11.3).

FIGURE 11.3 Suprascapular entrapment with marked wasting of the supraspinatus and infraspinatus muscles

FIGURE 11.4 A Method of testing the supraspinatus. The arm is abducted approximately 20–30° away from the chest wall while the examiner pushes on the elbow, trying to force the arm back against the chest wall.
B Method of testing the infraspinatus. The elbow is kept next to the chest wall and the semi-flexed forearm is externally rotated against resistance.
C Method of testing the subscapularis. The arm is bent at a right angle at the elbow and the forearm is semi-pronated. The elbow is kept at the side and the patient is asked to rotate the forearm in towards the body while the examiner tries to prevent this by pushing the forearm in the opposite direction.

TREATMENT of SUPRASCAPULAR NERVE ENTRAPMENT

Confirmation of the diagnosis depends on the electromyogram. Some authorities [15] feel that a normal result of an electromyogram is consistent with the diagnosis of suprascapular nerve entrapment, whereas others [16] think that a positive result of an electromyogram is essential in confirming the diagnosis. The diagnostic finding is a prolonged latency from stimulation at Erb’s point to the recording needle in either the supraspinatus or infraspinatus muscle. Treatment is surgical decompression [14].

NON-NEUROLOGICAL CAUSES OF SHOULDER PAIN

The following section may seem out of place but neurologists are frequently asked to see patients with pain of non-neurological origin when the patient would more appropriately be referred to a rheumatologist or orthopaedic surgeon. It is hoped that a detail discussion will aid the non-neurologist to sort out the neurological and non-neurological causes of pain.

Pain that radiates past the elbow to the hand is usually not related to shoulder pathology.

Ascertain whether the arm pain is aggravated by:

• movement of the arm, suggesting local pathology in the arm

• movement of the neck, indicating possible referred pain from nerve root compression.

Adhesive capsulitis: Adhesive capsulitis or the ‘frozen shoulder’ results in a gradual onset of pain and stiffness that leads to a restricted range of movement at the shoulder joint. It is usually seen in patients over the age of 40. A normal range of movement of the shoulder is incompatible with the diagnosis and X-rays are usually normal. The aetiology of this condition is unclear but it is not uncommon in the setting of a hemiplegia.

Rotator cuff syndrome: Probably the commonest cause of pain affecting the shoulder joint is non-neurological and is related to rotator cuff syndrome, also referred to as impingement syndrome. There are four tendons in the rotator cuff and these tendons are related individually to the following muscles: teres minor, subscapularis, infraspinatus and supraspinatus. The rotator cuff is compressed against the acromium causing bursitis, tendinitis and eventually a rotator cuff tear. Partial or complete tears or inflammation (tendinitis, tendinosis, calcific tendinitis) associated with rotator cuff injury occur in the region near where these tendon/muscle complexes attach to the humerus [17]. Other causes of pain in the shoulder joint include adhesive capsulitis and arthritis.

SYMPTOMS: Symptoms are generally those of pain, initially after and then during activity. The pain can often be relieved by rest. Patients over 40 years of age are more susceptible to rotator cuff tendinosis with overuse. In this age group the most prominent complaint is pain with overhead use and athletic activities. Night pain and an inability to lie on that side are also common [17]. Although the pain may radiate into the arm and the neck it is clearly related to movement of the shoulder and not the neck, indicating local shoulder pathology and not radicular pain. Pain in the shoulder between 60° and 180° of elevation is typical of a rotator cuff problem and is termed the painful arc syndrome (see Figure 11.5).

FIGURE 11.5 Testing of the painful arc and the impingement test

MANAGEMENT of ROTATOR CUFF SYNDROME

Plain X-rays can be helpful to diagnose calcific tendinitis, acromial spur, humeral head cysts or superior migration of the humeral head, but in most cases are typically normal. Arthrography, ultrasound, CT and MRI are the definitive tests in the diagnosis of rotator cuff injury. Arthrography and ultrasound of the shoulder can help determine whether or not there is a full tear in the rotator cuff. An MRI can detect a full or partial tear, chronic tendinosis or other cause of the shoulder pain [18].

• Physiotherapy is superior to NSAIDs alone [19]. Physical therapy in the form of stretching exercises will lead to improvement in the majority of patients but the pain may take several months to subside [20].

• Subacromial corticosteroid injections are recommended for non-responders [21]; however, these injections are difficult to give and the needle is not always placed accurately [22]. Corticosteroid injections may, however, increase the subsequent risk of tendon rupture and repeated injections are associated with a higher failure rate for surgical repair of ruptured tendons [23]. Corticosteroid injection is the preferred and definitive treatment for trochanteric bursitis [24].

• Surgery is recommended for patients who fail to respond to non-surgical measures after 3 months. Subacromial decompression has been recommended for the impingement syndrome but has not been shown in randomised trials to be more beneficial than physical therapy [25, 26]. Surgical repair of rotator cuff tears can result in less pain and increased strength and movement but recovery can take up to 6 months [27].

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