Musculoskeletal Care

ain of the neck and shoulder is commonly seenin primary and acute care settings. These twotypes of pain often present with the same symp-

toms, making differentiating between the two somewhatdifficult. Shoulder pain accounts for approximately 5% ofvisits to primary care offices and is the third most com-mon musculoskeletal complaint.1 Neck pain is the secondmost common reason for visits to pain clinics and hospi-tals.2 Symptoms of shoulder pain can range from veryspecific to quite vague. Thorough knowledge of the neu-romuscular anatomy and cervical nerve innervations canmake the differential diagnosis easier.

■ Cervical AnatomyThe neural anatomy of the cervical spine includes thenerves, which supply the shoulder girdle and rotator cuffmuscles at the C4 through C6 levels. The cervical nerveroots at the C5 through C6 levels divide into the long tho-racic nerve, which innervates the serratus anterior mus-cle. The dorsal scapular nerve arises mainly from the C5nerve root and provides variable innervations to the lev-ator scapula muscle and full innervation of the rhom-boid muscles. The C5 also supplies the outer aspect of theshoulder tip. The nerve roots of the C5 and C6 combineto form the upper, middle, and lower trunks. These trunksare separated into two divisions: the anterior and poste-

rior. These divisions reunite to form the lateral, poste-rior, and medial cords. The posterior cords are the baseof two nerves that innervate the neuromusculature of theshoulder stabilizers. The upper subscapular nerve inner-vates the subscapularis muscle. The lower subscapularnerve also provides a branch to the subscapularis. Theaxillary nerve provides sensation to the skin over the lowerdeltoid as well as motor function to the entire deltoid.Radiculopathy arising from C5 and C6 is very difficult todifferentiate from shoulder pathology because the sen-sory distribution runs from the base of the neck to theouter edge of the shoulder.3

Radiculopathy of any of the cervical nerves 4 to 6 canproduce pain in the scapula, shoulder, upper arm, lowerarm, and hand. Weakness of shoulder strength withoutpain suggests cervical pathology.4 The muscles of the del-toid are innervated by the C5 nerve root and can presentas acute rotator cuff pathology. Cervical radiculopathy pri-marily presents with motor and sensory symptoms on theaffected limb, and acute symptoms generally result fromcervical disk herniation.5

■ Rotator Cuff AnatomyThe rotator cuff consists of four muscles that attach to thegreater and lesser tuberosities of the proximal humerus(see Figure: “Muscles of the Rotator Cuff”). The muscles

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Rotator Cuff VersusCervical Spine Making the Diagnosis

Chil Wilson, ACNP, MSN, RNFA, CNOR

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form a tendon band that provides range of motion for theupper arm. The four musculotendinous structures thatmake up the rotator cuff are the supraspinatus, infraspina-tus, teres minor, and subscapularis. These four muscles jointogether, forming a single tendon that covers the humeralhead. Each muscle plays a crucial role in the stability andmovement of the shoulder joint. The rotator cuff is sepa-rated from the posterior surface of the acromion by thesubacromial bursa. The subacromial bursa is a fluid-filledsack that reduces friction and allows pain-free movementof the space. The subdeltoid bursa provides the same func-tion. In rotator cuff pathology, the supraspinatus tendonis the most commonly injured tendon because the track-ing of the tendon is directly under the anterior edge of theacromion.

■ Physical Examination and Special TestsThe best way to diagnose these conditions is to reproducethe complaint symptoms using physical examination andspecial tests. Since the pathologies of both the rotator cuffand cervical nerve root impingement often replicate eachother, special tests are used to differentiate them. The phys-ical exam should follow a course of events to avoid miss-ing any important factors that may be contributing to thechief complaint. After a thorough history is obtained, theactual physical exam can begin. The exam includes specialtests that are considered the hallmarks of specific symp-toms. These tests include the Neer’s, Hawkins’, and Jobe’s

tests for rotator cuff pathology. The tests for cervical in-volvement use the neurological dermatome chart and theSpurling’s and Bakody’s tests. If performed correctly, thechief complaint can be narrowed down to either shoulderor cervical pathology.

The Neer’s Test The Neer’s test was first developed in 1972 (see Figure:“Neer’s Test”).6 This test is used for impingement of therotator cuff tendon. Ask the patient to partially forward-flex the arm, with arm fully pronated. The examiner pre-vents the scapula from moving by placing one hand onthe scapula to stabilize it. The examiner’s other hand isplaced on the patient’s forearm to force resistance againstfurther forward flexion. A positive test result is pain inthe anterior portion of the shoulder due to impinge-ment of the greater tuberosity against the acromion.This test will cause pain in patients with cuff pathologyat all stages. It should be noted that this test will alsocause pain in persons with other sources of pain, suchas arthritis, partial frozen shoulder, calcific tendonosis,and bone lesions. For further differentiation, the exam-iner can place a 1% lidocaine injection into the subacro-mial space and retest. If the pain is still present, thenanother diagnosis must be considered. One study re-vealed that the sensitivity of the Neer’s test was 75% forbursitis and 88% for cuff abnormality; specificity was48% and 51% respectively.7

Musculoskeletal Care

Muscles of the Rotator Cuff

5 Active movement against full resistance without evi-dent fatigue. This is normal muscle strength.

■ Cervical PathologyWhen testing the muscles of the shoulder to differentiatefrom cervical pathology, the examiner must remember thatthere are two different types of shoulder stabilizers: dy-namic and static. If there is cervical pathology, the dynamicneuromuscular stabilizers fail to functionwhile the static stabilizers do not fail. Dy-namic neuromuscular control is lost sec-ondary to spinal cord or cervical nerveroot compression, suprascapular nerveinjury, or brachial plexus injury. Any ofthese types of injuries can lead to shoul-der symptoms. The tests used to help de-termine the possibility of cervical involvement are theSpurling’s and Bakody’s tests.

Spurling’s Sign To test for the Spurling’s sign, the patient should extendthe neck and laterally tilt the head to the affected side (seeFigure: “Spurling’s Sign Test”). The examiner should applydownward force to the top of the head. If the test is posi-tive, the recreation of the radicular pain or paresthesia willbe evident. This occurs due to the narrowing of the foram-ina against the inflamed nerve root or spinal cord from aruptured disk. While this test will recreate the pain of the

affected shoulder, it differs from rotator cuff pathology inthat standard rotator cuff tests will not cause dermatomalpain. In one study,12 the Spurling’s test was examined forits effectiveness in diagnosing cervical radiculopathy. Thefinal results of the study revealed that the Spurling’s testwas not very sensitive (average of 30%), but it was foundto be highly specific (average of 93%). This makes the testa useful tool in differentiating shoulder pathology fromcervical radiculopathy.

The Bakody’s test13 is also used in differentiating shoul-der pathology from cervical radiculopathy. This test ex-amines the cervical nerves C4 and C5.In this test,the patientraises the affected arm over the head through abductionso that the hand rests on top of it. Symptoms in this areaindicate extradural compression problems such as a her-niated disk, epidural vein compression, or nerve root com-pression. The cervical differentiation is made by thedermatome distribution of the symptoms. If the symp-toms increase with the test, there is a problem within theinterscalene triangle.

■ Additional TestsAdditional tests that may be necessary are more invasive,and some are much more expensive. Magnetic resonanceimaging (MRI) for cervical neck and shoulder, ultrasoundfor rotator cuff,and electromyogram (EMG) for nerve con-duction, are additional tests that may need to be performedto further differentiate the cause of pain.

Shoulder ultrasound has recently been studied andwas found to have very high rates of sensitivity and speci-ficity in diagnosing rotator impingement. A study con-

ducted in 2004 in the United Kingdom14 found thatultrasonography was 100% sensitive and 85% specific forfull-thickness rotator cuff tears and had a sensitivity of93% for partial tears. Ultrasound is also less expensive andmore accessible than MRI.

Magnetic resonance imaging has become the exam ofchoice for most surgeons today in the final diagnosis of ro-tator cuff lesions and impingement, with an accuracy rateapproaching 95% specificity and 100% sensitivity.15 Mag-netic resonance imaging can also detect cervical stenosis,disk herniation, and nerve root impingement.

Electromyelogram is a study of the nerves and their

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Spurling’s sign test is a useful tool in

differentiating shoulder pathology

from cervical radiculopathy.

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Musculoskeletal Care

Spurling’s Sign Test

The Hawkins’ Test The Hawkins’ test was first described in 1980 as an alter-native to the Neer’s test (see Figure: “The Hawkins’ Test”).8

The test adds to the certainty of a diagnosis. In this test,the patient forward-flexes the arm to 90 degrees and flexesthe elbow to 90 degrees. The examiner then internally ro-tates the humerus with force to try to impinge the greatertuberosity against the acromion. The analysis of the test inone study revealed a sensitivity of 92% for bursitis, and88% for cuff abnormality, with a specificity of 44% and43% respectively.7

The Jobe’s TestThe Jobe’s test was first described by Jobe and Jobe in1983 as the “supraspinatus test.”9 This test isolates thesupraspinatus tendon, which is the most often injuredtendon of the rotator cuff because of its orientation tothe anterior acromion. The patient abducts the arm to 90degrees, and from there the arm is angled forward 30 de-grees. The thumb is then turned towards the floor, inter-nally rotating the humerus and isolating the tendon. Theexaminer places his hand on top of the arm to provideresistance while the patient tries to lift against the resis-tance. A positive test is made when there is pain referredalong the superior lateral deltoid muscle with muscleweakness.

During these tests, the strength of the rotator cuff mus-cles should be evaluated in every plane.10 Charts should beused to determine the extent of the deficit, which can givethe examiner a clue to the origin of the problem. The mus-cle grading system is as follows:11

0 No muscular contraction detected1 A barely detectable flicker or trace of contraction2 Active movement of the body part with gravity elimi-

nated3 Active movement against gravity4 Active movement against gravity and some resistance

Supraspinatus Test (“Jobe’s Test”)

Neer’s Test Hawkins’ Test

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Musculoskeletal Care

conduction disturbances. This test differentiates the shoul-der pain and muscle weakness due to an impinged nerve.Nerve conduction studies are usually done at the same timeas an EMG. Precise locations of a nerve disorder can be lo-cated with this test. There is no special preparation for thistest, and it is fairly inexpensive as well as readily accessible.

These various tests demonstrate how a patient withdiffuse complaints of shoulder pain may actually have ei-ther shoulder pathology or cervical pathology. By per-forming a complete history and physical exam and usingthese special tests, the examiner can discover the underly-ing cause of the symptoms.

With all of the tests available to the examiner today, adifferential diagnosis can be made with great accuracy. Di-agnosis may eventually end in pathology coming from boththe shoulder and the cervical spine, especially in traumacases. With these examinations, diagnostic tools, and prac-tice, the correct diagnosis and treatments can be made.

REFERENCES 1. Stevenson H, Trojian T: Evaluation of shoulder pain. J Fam Pract 2002; 51(7)

605-11.

2. Gordon SJ,Trott P,Grimmer KA:Waking cervical pain and stiffness,headache,scapular or arm pain. Aust J Physiother 2002;48(1):9-15.3.

3. Herkowitz HN, Garfin SR, Balderston RA, et al: Arthritis and disk disease in

the adult: cervical disk disease. The Spine. Saunders, Philadelphia, PA; 1999;14(1), 456.

4. Malanga GA: Cervical radiculopathy: Department of Physical Medicine andPhysiotherapy: University of Medicine and Dentistry at New Jersey, 2001.

5. Malanga GA: The diagnosis and treatment of cervical radiculopathy. SportsExer 1997; 29: 5236-45.

6. Neer CS, II: Anterior acromioplasty for chronic impingement syndrome ofthe shoulder: A preliminary report. J Bone and Joint Surg 1972; 54A:41-50.

7. McDonald PB, Clark P, Sutherland K: An analysis of the accuracy of theHawkins and Neer impingement signs. Journ of Should and Elb Surg 2000;9: 299-301.

8. Hawkins RJ, Kennedy JC: Impingement syndrome in athletes. Am Journ ofSports Med 1980; 8:151-158.

9. Jobe FW, Jobe CW: Painful athletic injuries of the shoulder. Clin Orthoped1983; 173:117-24.

10. Sutherland S: Nerves and nerve injuries 2nd edition. Edinburgh. Church-hill-Livingston: 1973.

11. Bickley LS, Szilagyi PG: Bates’ guide to physical examination. Eighth edi-tion. Philadelphia, PA: Lippincott Williams and Wilkins, 2003; 574.

12. Tong HC, Haig AC, Yamakawa K: The Spurling’s test and cervical radicu-lopathy. The Spine: January, 2002; 27(2):156-9.

13. Evans RC: Illustrated essentials in orthopedic physical assessment. St. Louis.Mosby Year Book: 1994.

14. Hide G: Shoulder rotator cuff injury. Sonography. May 2004. Found athttp://www.eMedicine.com. Accessed June 6, 2004.

15. Connor PM, Banks DM, Tyson AB et al: Magnetic resonance imaging of theasymptomatic shoulder in overhead athletes: A 5-year follow up study. Am JSports Med, September 1, 2003;31(5):724-27.

ABOUT THE AUTHORChil Wilson is an Acute Care Nurse Practitioner and Surgical First Assistant atSouthwest Neuroscience and Spine Center, Amarillo, Tex.