Shoulder and Neck Pain

Shoulder pain may be an issue with joints or muscles or could indicate another systemic problem.

Your neck and shoulders contain muscles, bones, nerves, arteries, and veins, as well as many ligaments and other supporting structures. Many conditions can cause pain in the neck and shoulder area. Some are life-threatening (such as heart attack and major trauma), and others are not so dangerous (such as simple strains or contusions).

The most common cause of shoulder pain and neck pain is an injury to the soft tissues, including the muscles, tendons, and ligaments within these structures.

• This can occur from whiplash or another injury to these areas.
• Degenerative arthritis of the spine in the neck (cervical spine) can pinch nerves that can cause both neck pain and shoulder pain.
• Degenerative disc disease in the neck (cervical spondylosis) can cause local neck pain or radiating pain from disc herniation, causing pinching of nerves (cervical radiculopathy).
• Abnormal conditions involving the spinal cord, heart, lungs, and some abdominal organs also can cause neck and shoulder pain. Here are some examples:
  • Broken collarbone: Falling on your outstretched arm can cause your collarbone to break. This is particularly common when cyclers fall off of their bicycles.
  • Bursitis: A bursa is a sac over the joints to provide a cushion to the joints and muscles. These bursae can become swollen, stiff, and painful after injuries.
  • Heart attacks: Although the problem is the heart, heart attacks can cause shoulder or neck pain, known as "referred" pain.
  • Broken shoulder blade: An injury to the shoulder blade usually is associated with relatively forceful trauma.
  • Rotator cuff injuries: A rotator cuff is a group of tendons that support the shoulder. These tendons can be injured during lifting when playing sports with a lot of throwing, or after repetitive use over a long time. This can lead to pain with motion of the shoulder due to shoulder impingement syndrome and eventually to a chronic loss of range of motion of the shoulder (frozen shoulder).
  • Shoulder or A-C separation: The collarbone (clavicle) and the shoulder blade (scapula) are connected by ligaments. With trauma to the shoulder, these ligaments can be stretched or torn.
  • Whiplash injury: Injury to the ligamentous and muscular structures of the neck and shoulder can be caused by sudden acceleration or deceleration, as in a car accident. This can also cause muscle spasms in the neck and shoulder areas.
  • Tendonitis: The tendons connect the muscles to the bones. With strain, the tendons can become swollen and cause pain. This is also referred to as tendinitis.
  • Gallbladder disease: This can cause pain referred to the right shoulder.
• Any cause of inflammation under the diaphragm can also cause referred pain in the shoulder.

Risk factors for shoulder and neck pain include athletic activity, heavy lifting, throwing, moving luggage or other heavy objects, and aging.

• Pain: All pain seems sharp, but pain can also be described as dull, burning, crampy, shock-like, or stabbing. Pain can lead to a stiff neck or shoulder and loss of range of motion. Headache may result. The character of each symptom is important to your doctor because the particular features can be clues to the cause of your pain.
• Weakness: Weakness can be due to severe pain from muscle or bone movement. The nerves that supply the muscles, however, also could be injured. It is important to distinguish true weakness (muscle or nerve damage) from inability or reluctance to move because of pain or inflammation.
• Numbness: If the nerves are pinched, bruised, or cut, you may not be able to feel things normally. This may cause a burning or tingling sensation, a loss of sensation, or an altered sensation similar to having your arm "fall asleep."
• Coolness: A cool arm or hand suggests that the arteries, veins, or both have been injured or blocked. This may mean that not enough blood is getting into the arm.
• Color changes: A blue or white tinge to the skin of your arm or shoulder is another sign that the arteries or veins could have been injured. Redness can indicate infection or inflammation. Rashes may be noted as well. Bruising may be evident.
• Swelling: This may be generalized to the whole arm or may be localized over the involved structures (a fracture area or an inflamed bursa, for example). Muscle spasms or tightness may simulate actual swelling. Dislocation or deformity may cause a swollen appearance or, paradoxically, a sunken area.
• Deformity: A deformity may be present if you have a fracture or a dislocation. Certain ligament tears can cause an abnormal positioning of the bony structures.

If pain or other symptoms start to worsen, call your doctor or immediately go to a hospital emergency department.

• For milder cases, basic home care measures (see below) are adequate until your doctor can see you.
• In many cases, simple injuries, such as strains and bruises, heal themselves and do not require an office visit.
• For persisting pain in the shoulder or neck, an evaluation by a health care professional is appropriate.
• If you have severe or worsening pain, weakness, numbness, coolness, deformity, or color changes, you should go to a hospital emergency department immediately.
• If you develop a high fever (temperature < 102.5 F), severe headache, chest pain, shortness of breath, dizziness, nausea, or sweatiness, or if you develop the sudden onset of numbness or weakness, particularly on one side of the body, call 911 for emergency services to go to the nearest emergency department by ambulance.

Shoulder and neck pain is treated by primary care physicians, including

• general practitioners,
• internists, and family medicine doctors, as well as orthopedists,
• neurosurgeons,
• rheumatologists,
• neurologists, and
• physiatrists.
• Ancillary health care professionals who treat shoulder and neck pain include physical therapists and chiropractors.

A thorough history and physical examination are usually adequate to establish the diagnosis for most injuries. However, your doctor may do a series of tests, depending on the cause of your injury, the location of your pain, or your other symptoms. The list is extensive and may include X-rays, an electrocardiogram (ECG), blood tests, and CT scans.

• X-rays: These may be done if you have tenderness to touch along the bony areas of your spine or shoulder, a history of significant trauma, deformity of the area, or your doctor suspects a condition related to your heart or lungs.
• ECG: An electrocardiogram may be ordered if you also have chest pain, shortness of breath, and risk factors for a heart attack (such as high blood pressure, diabetes, high cholesterol, or tobacco use).
• Blood tests: These may be performed if you also have chest pain, shortness of breath, and risk factors for a heart attack (such as high blood pressure, diabetes, high cholesterol, or tobacco use) or if your doctor suspects an underlying illness as the cause of the pain.
• CT scan: This may be performed when X-rays are difficult to read or suggest a fracture, when more detail is needed, or when other structures are suspected to be the source of the pain (possibly the large artery known as the aorta leading from the heart or the lungs).
• MRI: An MRI is often not indicated during an initial evaluation but can be helpful in assessing ongoing pain and failure to respond to basic treatment measures.

Minor injuries that have only slight pain can be treated at home. If the source of the pain and the cause of the pain is not known, or if symptoms suggest you might have a more serious condition, you should contact your doctor while initiating basic care measures.

• Rest: Use the injured area as little as possible for the first two to three days, then slowly begin to exercise the injured area. This speeds recovery.
• Ice: Place the ice in a plastic bag, wrap the bag with a towel, and then apply to the injured area for 15-20 minutes every hour. Directly applying ice can damage the skin.
• Elevation: Elevation of the injured area above your heart helps the swelling go down. This reduces your pain. Use pillows to prop yourself up.
• Pain control: Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can help control swelling and pain.
• Heat: Do not apply heat in the first week after an injury because it can increase the swelling in the injured area and worsen your pain.

A treatment plan will be developed after a complete history and physical examination (and any tests, if indicated). Treatment options vary for each condition. Clearly, a simple strain is treated far differently than a heart attack.

• If you have a minor sprain or strain, then you can expect a combination of the following treatments:
  • Pain medications: It may take several days to settle the pain down using acetaminophen (Tylenol) with or without an anti-inflammatory medicine such as ibuprofen (Advil or Motrin) or naproxen (Aleve). Stronger narcotic-containing medicines are usually not necessary, but your doctor may provide these for the first few days.
  • Immobilization: This may be accomplished possibly using a splint, cast, or sling. It is very important to follow your doctor's instructions regarding the use of these devices, particularly when it is advised to discontinue the use and begin moving the area.
  • Instructions: It's best to rest and elevate the injured area. Continued use of the injured area may not necessarily make the injury worse, but it can prolong the symptoms. In most cases, limited use is acceptable within normal ranges of motion and without weight or strain.
  • Hospital stay: If you are more severely injured, you may need to be admitted to the hospital for further testing or may be referred to an orthopedist (bone and joint specialist) for care.

Timely follow-up visits to your doctor plus following his or her recommendations will enable you to recover faster. Eventually, gradual exercises and/or rehabilitation with physical therapy can be used to help recovery and prevent further injury.

• To prevent injuries, examine your home for potential hazards and correct them to reduce the chance of accidental injury.
• The proper exercise of the shoulders and neck can reduce the risk of injury.
• When performing hazardous tasks, have someone present to reduce the likelihood of injury. For example, when climbing a ladder, have someone hold the base of the ladder to keep it from sliding to either side.
• Know your limitations. Do not perform activities that you do not have the training, skills, tools, or strength to accomplish.
• Wear seat belts and use other safety equipment to reduce injuries.

Because most neck and shoulder pain is caused by sprains and strains, you can expect a full recovery or to recover with minor limitations on your activities.

Some conditions require hospitalization, surgical repair, physical therapy, or other rehabilitative measures. The extent of recovery may be complete or limited. Some conditions can be recurrent or persistent; thus, you should have a treatment plan to learn how to deal with and adapt to any limitations.