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Jerrold M. Gorski, MD Lawrence
H. Schwartz, MD ABSTRACT A variation in Neer’s impingement
sign and impingement test, along with radiographic evidence suggested by
Codman can be used to determine if shoulder dysfunction can be causing
cervical pain. This study
used 34 individuals with pain at the superomedial border of the scapula. All reported reproduced in this area when the forearm was
pronated and the arm taken through full overhead positions both passively
and actively. The test was
positive if the position reproduced their cervical/scapular pain. No patients were included who had shoulder impingement pain
during the test. Radiographs
were used to determine if there was either trabecular atrophy or sclerosis
of the acromial undersurface, as described by Codman.
The last test was injection of an anesthetic and corticosteroid in
the subacromial space. In
almost all of the subjects, this test immediately and completely
eliminated their symptom reproduction on testing.
Another 3 had their symptoms resolve by the 3-week follow-up
period. The authors believe that the
injection may block antidromic nerve conduction. Also, common innervation and/or overlapping nerve fibers that
supply the neck, upper back, and the shoulder may be sources of referred
pain. Muscle overload from
protection in the neck region may also cause strain and pain, and
injection into the subacromial space may cause the supraspinatus muscle to
relax, therefore alleviating the pain.
The authors did note that mild to moderate limitations in neck
motion were almost always present in the subjects, and almost 75% of the
subjects were MVA patients. COMMENTS The injection of an anesthetic into
the subacromial space is usually considered the gold standard for true
diagnosis of shoulder impingement. If
the pain goes away, that is where the problem came from.
We often see patients with shoulder pain that is actually caused by
the neck, and this is often overlooked.
I have had both of my recent students perform evaluations on me for
what really appears to be a shoulder problem.
The pain is in the infraspinatus/teres tendon region, it occurred
while military pressing, my rotator cuff tendons are quite sore, and there
is even some impingement, along with a history of AC joint separation.
However, more careful evaluation would reveal that I have the same
impingement pain on the OTHER shoulder, along with the same tenderness to
the cuff tendons on the other side, which is often not assessed.
Just because we found a sore spot does not mean that is the
problem! Careful evaluation of my cervical
spine motion and history would find that facet and nerve root encroachment
reproduces my pain. A quick
matter-of-fact screen will not, and did not.
Therefore, I would have been treated for a shoulder problem that
was coming from somewhere else. This
study indicates that neck pain may also come from somewhere else, and the
therapist should be quite sure that he/she does know where it is coming
from. As this weekend’s
course reminded us, listen to the patient and they will tell you what you
need to know. Don’t lead
them into telling you what you want to know. One should also consider an overlap
syndrome, meaning one problem created the other, and by the time they saw
you, there are actually two problems.
A cervical dysfunction causing some C6 encroachment will affect the
strength of the supraspinatus, teres, and infraspinatus, leading to
dysfunctional movement patterns and possibly impingement.
On the other hand, reduced shoulder mechanics could lead to
substitution by the upper trapezius, leading to increased cervical
vertebrae compression, and thus dysfunction in that region.
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