Dr. Dallin Page, DPT
Understanding Shoulder Pain: Is the problem really your neck?
At some time during your life you will likely suffer from pain or stiffness in the shoulder region, or pain arising from the shoulder that is felt in the upper arm. It is one of the most common problems affecting the joints and muscles of the body (after back and neck pain).
What's more, these problems frequently persist or recur, with about 50% of people still having problems up to a year after the onset of their shoulder pain!
Shoulder problems are often referred to in different ways, including tendonitis, rotator cuff strain or tear, impingement syndrome, frozen shoulder, capsulitis or arthritis. But even health professionals often have difficulty identifying a specific source of the shoulder pain due to the complex nature of the shoulder and its close involvement with the neck.
In many cases, even the use of X-rays, ultrasound scans and MRI scans do not given an exact picture of the site or severity of the injury, or give clear guidance for the most effective treatment strategy.
In reality, the emphasis is often on labelling the patient's condition, without doing much to actually resolve it!
Common treatments for shoulder pain are medication, injections, surgery, acupuncture or electrical modalities such as ultrasound, TENS and interferential therapy. However, while some of the treatments may appear to have short-term benefits, there is no strong evidence that they provide effective long-term relief from pain and loss of function.
You may also have been given exercises to perform and maybe even found that these provided some benefit. However, many people do not realize that stretching and strengthening your muscles alone does not automatically give you relief from shoulder pain.
Other Things To Consider...
Doing the correct exercises is only part of the solution; the other part we need to consider is the aggravating factors that contribute to your shoulder pain, especially prolonged positions or postures.
Here are some common aggravating activities, positions or postures for those suffering with shoulder pain:
1. Prolonged sitting at a computer
2. Lying on the painful side
3. Sleeping on the stomach with the arm raised overhead
4. Reaching or lifting overhead or away from the body (either repetitively or in a sustained position)
If you don't identify and alter these aggravating activities or postures throughout the day then improvement and relief from performing the correct exercises will be short lived.
Shoulder vs Neck?
The shoulder has a close relationship with the neck or cervical region of the spine, and commonly the pain and loss of movement you feel in your shoulder is actually coming from a problem in your neck.
Therefore, with all shoulder problems it's important to attempt to exclude the neck as the source of the pain before focusing treatment and/or exercises to the shoulder itself.
Here are three important questions to consider:
Do you have pain in your central neck area, and particularly neck pain on the same side as the shoulder pain?
Does coughing, sneezing or taking a deep breath produce or increase your shoulder or neck pain?
Do you have any areas of numbness, pins and needles or weakness in the arm or hand on the same side as your shoulder pain?
If you answered YES to any of these questions, it is likely your pain is coming from your neck.
However, if you answered NO to the questions, here are two other aspects to consider to help determine the source of your shoulder pain: pain location and pain behavior.
The site of pain caused by both shoulder and neck problems can be similar in some cases.
But as a general rule, pain originating in the shoulder will usually be felt on the front or outer part of the shoulder and commonly in the upper third of the arm (Figure 1), and may be associated with stiffness or weakness.
It may radiate down to the elbow and in severe cases you may occasionally feel a dull ache as far down your arm as the wrist (Figure 2).
Affected shoulder structures do not usually cause pain to be felt above the shoulder or into the neck. Therefore, if pain is felt between the point of the shoulder and the neck, or in the region of the shoulder blade, it is unlikely to be coming from the shoulder. Also, a shoulder problem will not give you a sensation of pins and needles, or numbness, in the hand.
On the other hand, pain originating from structures in the neck will generally cause some pain or aching at or near the base of the neck or into the shoulder blade (Figure 3).
However, the most pain may also be felt between the shoulder and upper arm, and extend below the elbow to the wrist or hand (Figure 4). Pain from a neck problem may also be associated with a sensation of pins and needles or numbness in the arm or hand.
Shoulder pain, in most cases, is produced or aggravated by moving the shoulder and arm - particularly lifting your arm to the front or side, or putting your hand behind your back.
On the other hand, shoulder pain originating from the neck is frequently altered by neck positions or movements.
Luckily, there are some simple test movements that you can perform with your neck to help determine if the neck may be the source of your shoulder pain.
While performing the test movements below it is important that you carefully note any change in your pain location and intensity.
If these neck movements have no effect on your shoulder or arm pain it probable that the shoulder is the source of your pain. However, if these neck movements either produce, or alter the intensity or location of your shoulder pain, the source of your pain may be the structures in your neck.
Test Movements of the Neck
Retraction and Extension
As your starting position, sit or stand upright with both arms relaxed by your side. Take careful note of where you have been feeling your pain. Retract your neck (Photo 6) and slowly lift your chin upwards as if looking at the sky (Photo 7). Hold for 1-2 seconds, then slowly lower it again and return to the starting position. Repeat this action of retraction with extension ten times.
If you are still in doubt as to whether this movement is affecting your shoulder pain you may test your neck movements in side bending and rotation by following these instructions:
Make sure you are still sitting or standing upright with both arms relaxed by your side, taking note again of where you have been feeling your pain. This time, slowly side bend your neck towards your painful shoulder (Photo 8). Hold for 1-2 seconds, then slowly return to the starting position. Repeat this action ten times, and re-assess your pain. Now repeat this movement ten times to the non-painful side (Photo 9).
From the upright sitting or standing position as above, take note again of where you have been feeling your pain. Slowly turn your head towards the painful shoulder (Photo 10). Hold for 1-2 seconds, then slowly return to the starting position. Repeat this action ten times, and re-assess your pain. Now repeat this action ten times to the non-painful side (Photo 11).
If these neck movements have no effect on your shoulder pain it is probable that the shoulder is the source of your pain. However, if any of these repeated movements of your neck appear to either produce, or alter the intensity or location of your shoulder pain, the source of the pain is probably the structures in your neck.
If you still have any doubt as to whether your neck is affecting your shoulder pain you can perform the test movements again. But this time, rather than standing or sitting with your arm relaxed by your side, raise your arm into a painful position, and repeat the sequence of movements as above, starting with the retraction in Photo 6. Relax your arm between the sequences test movements, then return to the painful position as you attempt next movement.
You Found the Source, Now What About the Solution...
If you made it this far, then congrats! Hopefully you've got a better idea of the true source of your shoulder pain.