Shoulder Pain—Is It From the Shoulder, Neck, or Both?

Discussion

The patient’s cervical disc herniation most likely was due to his earlier grappling episode when he had acute trauma to the neck or an exacerbation of an older asymptomatic herniation. His external shoulder impingement likely was due to overuse with heavy weight lifting, which also caused enough mechanical strain to exacerbate the patient’s cervical disc herniation symptoms. What is most unusual about this case is the right-sided cervical radicular symptoms due to a left-sided cervical disc herniation.

With an annual incidence of 107.3 in men and 63.5 in women per 100,000 patients, cervical radiculopathy is caused by compression or irritation of the cervical nerve roots as they exit the spine. The most common cause of cervical radiculopathy is spondylosis followed by disc herniation, but both can be present in the same patient. Spondylosis refers to degeneration of the discs and facet joints but generally without frank disc herniation.⁵

External shoulder impingement and cervical radiculopathy can have nearly identical symptoms of shoulder and upper arm pain as in this illustrated case. Patients with cervical radiculopathy generally present with neck, shoulder, and arm pain or neurologic deficits. These symptoms alone are very broad and present a wide differential diagnosis. One must determine whether the pain is from the neck or shoulder region.¹ The Table and Figures 1 to 6 describe the physical examination maneuvers used to differentiate the etiology.

The decision to pursue imaging should be based on injury severity and patient treatment goals. Although plain radiographic imaging may reveal spondylotic changes, such as degenerative joint changes at the vertebral facets and uncovertebral joints as well as decreased disc space, MRI is the imaging modality of choice for viewing disc herniations.⁶Nonoperative management of cervical radiculopathy focuses on restoration of full pain-free neck ROM, cervical muscle strengthening, and consideration for cervical traction. The use of either topical or oral medications can be considered if needed to aid in sleep and/or participation in active rehabilitation. Complimentary methods, such as acupuncture, yoga, or therapeutic massage also should be considered. Additionally, corticosteroid epidural injections can be considered, but these have increased risk compared with lumbar epidural injections.⁷ Surgical indications include persistent symptoms after 6 to 12 weeks of conservative therapy with no improvement of symptoms or progressively worsening motor/neurologic deficits.⁸

Conclusion

This case illustrates how 2 different conditions can present similarly and lead to diagnostic uncertainty. In this case, both the shoulder impingement and cervical radiculopathy manifested as shoulder and upper arm pain and could be separated only once the impingement had been treated. In addition the left-sided disc herniation causing right-sided symptoms was very unusual. To the best of the authors’ knowledge, this is only the second report of cervical disc herniation causing contralateral symptoms. In the only other available case report on cervical disc herniation with contralateral symptoms, the symptoms occurred in both the contralateral arm and leg.⁹