One potentially confusing cause of pain in the shoulder is that which is referred from the cervical spine. Herniated disks can cause pressure on the C5-T1 nerve roots, which can cause vague symptoms in the anterior and posterior shoulder girdle. Patients may interpret this as shoulder pain, and thus it is incumbent on the examiner to determine exactly where the pain comes from. In such cases, the patient will not often localize the pain. The various tests that are good indicators of cervical pathology are described.
In patients in whom the examiner suspects cervical pathology, testing should begin with gently stressing the limits of range of motion, especially in extension, where patients with cervical pathology will often have pain. In addition, posterior cervical tenderness is often present in these patients. Finally, there are some specific maneuvers (discussed following) that can help to define cervical pathology as the source of the pain.
The Neer Relief Test In patients with cervical spine pathology, symptoms will often be relieved when the patient places his or
her arm above the head. This maneuver may relieve tension on an inflamed nerve and would be expected to exacerbate pain in the shoulder with impingement. This test may help differentiate between pain from a cervical spine source and pain from shoulder pathology and can be elicited by history as well as on physical examination.
Spurling's Test This test is performed by stressing the neck in lateral flexion, rotation to the side tested, and compression (Fig. 16-19). A positive test is heralded by reproduction of the patient's specific symptoms with special attention to radiation of pain or numbness into the dermatome of a specific nerve root or into the shoulder. In one evaluation of Spurling's test,27 it was shown to have a sensitivity of only 30% but showed a specificity of 93%. The authors therefore concluded that the test is not useful as a screening test but may be helpful in confirming the diagnosis of cervical radiculopathy. We find this test, when positive, to be the most helpful to us in determining the presence of cervical spine disease.
Valsalva Maneuver This maneuver is performed by asking the patient to bear down, thereby increasing intrathecal pressure. Such an increase would be more likely to exacerbate pain from a cervical spine source than a shoulder cause.
Compression and Distraction Tests In the patient with cervical pain, compression of the top of the spine in extension would be expected to exacerbate the patient's symptoms, while distraction in flexion might provide relief.
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