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neck pain

Upper Extremity Pain: Where's the pathology—Neck or Shoulder?

Teaser: 

Andrew Trenholm, MD, MSc, FRCSC,1
Fred Xavier, MD, PhD,2
Sean Christie, MD, FRCSC,3

1 Associate Professor Orthopaedics (Upper Extremity and Trauma) Dalhousie University, Halifax, NS.
2Fellow, Combined Spine Program, Department of Surgery, Dalhousie University, Halifax, NS.
3 Associate Professor, Dalhousie University, Department of Surgery (Neurosurgery), Halifax, NS.

CLINICAL TOOLS

Abstract: Neck and shoulder disorders are among the leading causes of pain and disability. History and physical examination are key components to clinical diagnosis and to determining whether the source of the arm pain is the neck or the shoulder. When consistent with the history, it is recommended to perform targeted provocative tests or manoeuvers. Several studies have shown that using a test item cluster improves diagnostic accuracy more than any single test item alone. Imaging, electrophysiological and laboratory studies are usually unnecessary unless there are clear clinical indications.
Key Words: Cervical radiculopathy, Neck pain, Shoulder pain, Clinical diagnosis, Provocative tests.

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1. Sinister pathology is rarely produces completely intermittent pain.
2. Neck pain is frequently associated with psychosocial stress and heightened emotional response.
3. The first step in taking the history is to establish the site of the dominant pain.
4. A neurological examination should include tests for spinal cord involvement causing cervical myelopathy.
5. Neck dominant pain can include pain felt in the face, upper back, top of the shoulder, anterior chest and headache.
The best way to differentiate between the neck and the shoulder as the source of upper limb pain is to assess the effect of movement in each area on the patient's typical pain.
The provocative tests should be chosen to confirm a suspected diagnosis. By themselves they are not a reliable guide to the specific pathology.
Neck and shoulder problems may coexist particularly in older patients and the examination of one should always include a screen of the other.
Radicular arm pain is more often caused by boney foraminal nerve root entrapment than by a new "soft" disc herniation.
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A Pain in the Neck

Image Description
Teaser: 

Dr. Hamilton Hall, MD, FRCSC,1 Greg McIntosh, MSc,2 Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,3 Dr. Pierre Côté, DC, PhD,4

1Professor, Department of Surgery, University of Toronto. Medical Director, CBI Health Group, Executive Director of the Canadian Spine Society, Toronto, ON.
2Masters in Epidemiology, University of Toronto, Faculty of Medicine. Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.
3Family Physician practising Sport and Exercise Medicine, Toronto Rehabilitation Institute, University Health Network. Appointed at the University of Toronto, Department of Family and Community Medicine, Associate Clinical Professor.
4Canada Research Chair in Disability Prevention and Rehabilitation; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation.

CLINICAL TOOLS

Abstract: Neck pain is common and disabling. Associated with poor posture, sedentary work and stress it is long lasting and recurrent. Most neck pain is mechanical from the structural elements within the cervical spine and can be referred to a number of remote locations. Radicular arm dominant pain is infrequent. Neck pain is diagnosed on history and confirmed with the physical examination. Routine imaging is inappropriate and the Canadian C-spine rules are recommended. Management focuses on education, range of movement exercises with associated postural improvement and strengthening exercises; neck braces should not be used.
Key Words: cervical spine, neck pain, Canadian C-spine rules, range of movement, exercise.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Most neck pain is benign mechanical pain and serious pathology is uncommon.
Neck pain is longer lasting and more disabling than generally recognized.
Referred neck pain can be felt on top the shoulders, between the shoulder blades, along the jaw, in the front of the chest and as a headache.
Nerve root involvement is unusual but when it occurs typically affects C5, C6 or C7.
Routine imaging is unproductive.
Management is based on education, range of movement exercises and strengthening.
A careful history to locate the site of the dominant symptoms and a physical examination to assess posture and rule out radiculopathy will identify common mechanical neck pain.
The need for an x-ray should be based on the Canadian C spine rules.
Improving mechanical neck pain starts with educating the patient about the favourable prognosis and increasing the range of neck movement: a cervical collar is contraindicated.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is only $20 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.