When is a Shoulder not a Shoulder
A: When it’s a Neck
Why labels matter in the differential diagnosis of Neck and Shoulder pain.
Joe walks into the Doctor and says “Doctor, Doctor, I have an excruciating pain in my head”
The Doctor, has a quick look at the patient and notes nothing protruding externally from the patients head and recommends getting an MRI of the brain to make sure there’s nothing wrong.
Joe is happy he is getting an MRI so it can show what is wrong.
The MRI result comes back clear except some Cerebral Lesions — the Doctor receives the report before the patient comes back and plans to organise a referral to a neurosurgeon to see if surgery is needed to remove the “lesions”. However, that Doctor is away sick the day that patient comes back into the clinic to review their MRI and another Doctor reviews the patient in their absence.
This Doctor notices that the patient always arrives at their clinic with an ice-cream from the ice-cream parlour next door. The Doctor asks Joe how often he gets ice-cream, and he says he loves ice cream so much he has it twice/day, every day.
The doctor informs the patient that not only is their blood sugar level too high due to an obsession with Ice Cream, but the pain in their head is most likely common Brain Freeze or Ice Cream Headache. The Doctor (who keeps up to date with research) lets the patient know that it’s common to have “lesions” on MRI and often their nothing to be worried about if there are no other symptoms.
Joe stops eating ice cream for 3 days straight and has no more pain in the head, however he’s still stressed about the “lesions” found on MRI, even though the GP reassured him.
Joe gets stressed, loses sleep quality and quantity, and eventually develops unrelated neck pain with headaches from a lack of quality sleep. He now attributes the headaches (referred from the Neck) to the “lesions” he saw on MRI, and he’s concerned that that the 2nd Doctor was wrong.
STOP THE SCENARIO THERE
My Brain Hurts
This may scenario seem silly to those of us who’ve experienced a “Brain Freeze” after eating something cold. We’ve grown up experiencing “pain in the brain” every now and then, which we’ve correctly connected with eating something cold. Some of us even understand that it’s something to do with ‘referred pain’ from the mouth being cold. However this scenario also demonstrates the difficulty in healthcare with ‘diagnostic imaging’, often it can present ‘normal findings’ which appear to be abnormal and once a patient knows of something it’s very difficult to ‘unknow’ it.. or ‘clear the memory of it’.
Where is the Ouchy
One of the primary roles of a Clinician who works in healthcare is to work out what causes different feelings that patients get.
Commonly this feeling is ‘pain’, however it can also be a mix bag of “tightness”, “discomfort”, “pins and needles”, “numbness”, “burning” and the list goes on.
It’s a tricky job as the Clinician must listen and interpret to the story of the patient who usually does not have the same high level of anatomical knowledge that the Clinician does. Often there can be a mismatch between the terminology the Public uses to identify a part of the body and the anatomical terminology the medical community use.
What we saw go wrong in that first scenario is unfortunately a common occurrence:
- A lack of a physical examination on the first appointment to help differentially diagnose
- A decision to get diagnostic imaging straight away (although “brain pain” is pretty concerning and would normally warrant an urgent investigation)
- Not enough time to reassure the patient about incidental findings
Fortunately, that second Doctor took the time to look at the big picture and probe a little further.
Let’s know watch how this plays out in an unfortunately-too-common scenario:
My “Shoulder” Hurts
Joe is back (poor Joe!) at his Doctors clinic, seeing the original Doctor who ordered the MRI for the “brain pain”.
Joe reports to his Doctor that he now has “Shoulder Tightness and Pain” and he grabs near his shoulder, this pain is very disabling and it’s causing him great difficulty including at night sleeping.
The Doctor feels sorry for the patient and recommends they get an Ultrasound and an MRI of the affected Shoulder.
The Ultrasound and MRI comes back with nothing significant except for a mild “Bursitis”. Joe comes back to the Doctor to review the imaging results and the Doctor recommends a cortisone injection for the “Bursitis” which was seen on MRI and ultrasound.
Joe goes and has an injection in his shoulder (local anaesthetic and cortisone) and 2 weeks later he see’s his Doctor again and reports that his “shoulder” pain is still there. His Doctor shrugs and recommends he “tries Physiotherapy”. Joe shrugs and agrees that it’s worth a shot.
Joe ends up at nearby local Musculoskeletal Physiotherapist clinic (Physios that deal with “issues with the tissues”), fortunately this Physiotherapist has 45mins when they first meet Joe.
Joe tells the Physio that the Doctor has said to get “some physio” for his shoulder pain and tightness. When the Physio asks the Joe where his “shoulder pain” is, Joe points to the area between his Neck and Shoulder.
The Physio is a little confused and performs an assessment of the shoulder ball and socket joint (known as the glenohumeral joint) and finds that it’s actually happy and strong but using it in certain positions causes the patients “shoulder pain” near the neck.
The Physio conducts a Cervical Spine examination on finds that certain neck positions and palpation of the neck refers pain into the patients “shoulder” (the area near the neck).
The Physio informs the patient that they have “cervical spine referred pain” and their “shoulder is completely fine”.
Joe is confused! He asks if the Physio is sure, and the Physio says they’re pretty sure, especially because the ball-and-socket joint (glenohumeral joint) aka The Shoulder only refers pain at the shoulder and down, but not up towards the Neck, and that it’s very common for the public to call the area where the Cervical Spine refers “The Shoulder”.
Joe asks about the “Bursitis” and whether it’s still there, the Physio asks whether there was any relief following the injection (which included a local anaesthetic into the bursa), Joe reports that there was no immediate relief, or relief in the 2 weeks following it. The Physio informs the patient that it’s a common finding to have a “thickened bursa” on imaging and it doesn’t necessarily indicate it’s inflamed or sensitive.
The patient is a little bit annoyed upon hearing this news, but is happy to trial the Physio plan.
After 2–4 weeks of Cervical Spine pain management, the patient feels a lot better.
STOP THE SCENARIO THERE
When is a “Shoulder” Not a Shoulder
…when it’s a Neck.
The main “shoulder” joint is the Glenohumeral Joint (GHJ), it’s first suspect when someone reports “shoulder pain”.
Fortunately, we have a good idea where the GHJ refers symptoms, from the shoulder and down the arm (but not past the elbow).
This doesn’t exactly match up with the terminology the Public uses for “Shoulder”, which looks a little more like this:
We also have a good idea where the Cervical Spine (neck) refers symptoms:
And again this doesn’t match up with the Public’s perception of where “neck pain” is felt, which looks a little like this:
So let’s get back to Joe and his “Shoulder Pain” which ended up in MRI and Ultrasound, and an injection of the GHJ (shoulder ball and socket joint).
He told the Doctor about his pain here:
Which we know can’t be the GHJ as it doesn’t refer up there, but is much more likely to fall into the area the Cervical Spine refers pain.
Now we can see where things go wrong if a patient turns up to a Healthcare Professional reporting “shoulder pain” but they don’t have the time to do a thorough examination to work out whether the “Shoulder Pain”.
- Wrong Area gets attention
- Patients pain is prolonged, and prolonged painful conditions often take longer to get better
- Unnecessary and expensive diagnostic imaging is ordered, sometimes this imaging with incidental findings can then become ‘Nocebic’, it can cause harm leading to the patient becoming a VOMIT.
- Unnecessary and expensive procedures (and even surgery) can be done.
“If both are out, think in”
Just a quick note at this point about bilaterality of symptoms (fancy way of saying things are ouchy on both “shoulders”).
If both “shoudlers” have pain it makes it highly likely that it is not localised shoulder pain (glenohumeral/acromioclavicular) rather it is Cervical Spine related.
How do we fix this problem?
Should we healthcare professionals launch a public campaign centred around the “correct terminology” of the neck and shoulder?
Of course not!
It should come down to the Healthcare Professional to ensure they do their job:
Conduct a thorough examination of the patient to diagnose the problem.
or at the very least simply ask the patient to point with their finger where their pain is, as this can be very useful in differentiating shoulder (glenohumeral joint) pain from neck (cervical spine) pain.
Seems pretty simple, except it isn’t.
Time
Doctors get 10–15mins with a patient, and they’re pretty overwhelmed in most healthcare systems. Additionally, and sadly, not all of them will be up to date with their Musculoskeletal clinical skills.
For a skilled musculoskeletal Clinician, it takes about 20–30mins to fully assess the neck and shoulder to help diagnose a patient and rule in/out different cause of pain. Some of us are fortunate to have 45mins and even 60mins for our initial consults.
Clinical Skills/Education
If we rewind to Joe’s area of pain, we’ll notice it’s in an area that is commonly called the “upper traps”.
Upper Traps Tightness is the cause for all evil, responsible for all painful conditions of the neck and back and it was also responsible for the assassination of JFK and the outbreak of COVID….
Upper Traps “Tightness” is the Ice Cream Headache of the neck. “Tightness” is often a ‘feeling’ referred from the Cervical Spine, a form of discomfort, from an irritation in the Cervical Spine or it’s nerve roots. This is not breaking news, this is not a hot take, this is medical science.
Summary
It’s important for Healthcare Professionals to have the time to do a thorough assessment in order to correctly diagnose patients, at the very least to identify the area of the body that is causing their pain.
If a Healthcare Professional is not in an environment that allows them the time or space to carry out this duty then they should refer on to an appropriate healthcare professional with experience in that area who does have the time and space.
Misdiagnosis (and then mismanagement) of neck and shoulder pain can create a significant burden for the patient and the healthcare system.
Isolating Cervical Spine Related Pain vs Shoulder Pain clinically is very difficult most of the time, sometimes there will be BOTH neck and shoulder pain present.
However we (clinicians) must be very aware that patients will use the terminology that they know — which often isn’t anatomically correct. Clinicians must ask the patient to point to where they feel their pain and clinicians must correlate this with known referral patterns.
The purpose of this blog was is certainly not to be a definitive ‘this is how you diagnose one or the other’, rather it is aimed to be a ‘location of pain is so simple that it should not be missed when trying to differentiate pain’ — which is probably <5% of the clinicians diagnostic toolbox.
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