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Provocative tests

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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Pre-test CME Quiz Post-test CME Quiz
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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Related Terms: Back Health, cervical radiculopathy, neck pain, Shoulder pain, clinical diagnosis, Provocative tests
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