NECK AND SHOULDER PROBLEMS 
Last month I wrote about shoulder impingement syndrome. This is due to the arm bone hitting part of the shoulder socket bone on top. It’s fairly common. However neck problems can cause pain to be referred to the shoulder and these too are fairly common. We had an older gentleman yesterday whose neck was extremely stiff with right shoulder pain. He had physical therapy and three steroid injections in his right shoulder but no relief for his aching shoulder. He had intense pain prior to seeing us for nine months. We evaluated him and when we pushed on his nerve roots in his neck on the right side, he had the same pain intensify in the same right shoulder. Pressure on top of the shoulder where the trapezius meets the deltoid also reproduced his pain. We suspected his pain was coming from his neck and the suprascapular nerve. Cervical traction relieved his symptoms almost immediately. His shoulder felt better for the first time in almost a year. For a picture of the suprascapular nerve, see Illustration A. Suprascapular nerve. Illustration B. Pain radiation, shows a typical suprascapular nerve pain pattern. You may read this and say, ‘so what?’ Well I can tell you this happens more often than you might think. I am not sure why but, I suspect it’s because neck anatomy is fairly complicated. Most people shy away from studying it and I think, find it somewhat intimidating. It can seem complicated but certain patterns are fairly common in most cases we see here. First of all, problems that involve nerves are called neuropathies. Nerves emerge from the neck going to the shoulder can be compressed or entrapped. This can happen in the neck or in the shoulder. The most common is the Suprascapular Nerve. — (See illustration A) It comes from the neck directly to the top of the shoulder diving deep into the back of the shoulder blade. It can be pinched at the neck or irritated at the top of the shoulder by a muscle. The rubbing of this muscle can irritate the nerve and cause a painful neuritis. This pain should not be ignored. It is often misdiagnosed as a rotator cuff problem. Unfortunately, if left untreated this nerve can be permanently damaged and very painful. If unchecked it can cause serious pain and disability in the shoulder. Another nerve less commonly affected is the Long Thoracic Nerve. – (See illustration C) It too originates in the neck and dives deep after emerging from the muscles in the side of the neck. It supplies the muscle to the inside of the shoulder blade between it and the ribs. It holds the shoulder blade close to the ribs. If it is affected the shoulder blade can “wing out” away from the spine. Strong downward force such as carrying a heavy suitcase with a strap or backpack can irritate and compress this nerve. The winging of the shoulder blade is tested by having the patient push against a wall and see if the shoulder blade wings out from the spine Scapular Winging. – (See illustration D) Lastly, another nerve involved in the shoulder is the Axillary Nerve. – (See illustration A) The patient describes vague pain on the outside of the shoulder where the deltoid inserts on the arm bone. This innervates the deltoid and teres minor muscle as well as the skin on the outside part of the shoulder. This nerve can be injured during shoulder dislocation, because it is a taut nerve and passes through the bottom of the shoulder joint (armpit). It also can be injured by excessive chicken winging (abduction) of the shoulder and the arm. I’ve noticed when a patient has an injured tight shoulder this nerve is easily stretched when the arm is moved away from the body. Treatment for acute neck and shoulder nerve pain is done with ice and beginning gentle range of motion. We can use other modalities as well such as electrical stimulation to facilitate blood flow or assist in strengthening certain muscles. Cervical traction may be necessary Moist heat can be helpful to more chronic cases. Also certain muscles need to be stretched to loosen the shoulder and the shoulder capsule. This needs to be done carefully so that the nerves in the shoulder are stretched but not so severely that they are re-injured. Nerves that are injured swell. Because these nerves are not attached to the lymph system, there is no way for the swelling to drain directly out of the nerve. If pain and swelling are suspected, dexamethasone or other steroidal products can be given orally. A sling may need to be worn intermittently. If the neck itself is involved X-rays or MRI may be helpful but not necessarily conclusive. We also use digital Pressure Specified Sensory Device testing to ‘map’ the area that has loss to determine which nerve(s) may be involved. Treatment should be sensitive to the response of the patient. The doctor and the therapist working together, closely communicating is also helpful. The patient too has a role to help us know if the treatment is making the symptoms better or worse. Injuries that are more than a year or so old are more difficult to treat. The key once again is early detection, diagnosis and treatment. We encourage you to consider us helping you find the subtle signs and symptoms of these complex problems. Working together we can accomplish great and gratifying results for you and your patients. |
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© Tri State Hand and Occupational Therapy, Inc
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