Neck Pain

One of the most common symptoms in general practice, this is often degenerative (cervical spondylosis), but there are other causes.

History

‘Have you had an accident lately?’ Trauma is significant.

• Ask about mode of onset, relieving and aggravating factors (SOCRATES).
  
• Ask about lifestyle (e.g. carrying infants, heavy work, sports).

Examination

• Look for stiff tender trapezius muscle on one side in torticollis.
  
• Check active movements – they may be normal or reduced in cervical spondylosis.
  
• Look for long tract signs – refer if you find any.

Except after trauma, X-rays are usually unhelpful. By the age of 50, at least 50% of people have neck X-ray changes, and they correlate poorly with symptoms.

Management

• Try simple analgesia. Muscle relaxants relieve spasm, but can be habit forming.
  
• Lifestyle advice (e.g. sleeping with one pillow, a lighter handbag or case, adjusting height of monitor, hourly breaks from the PC). Laptops stress the neck unless used with an external keyboard.
  
• Physiotherapy, especially for persistent pain.

Patients often ask about manipulation, particularly by com­plementary practitioners. This can be hazardous.

Shoulder Pain

After back and neck pain, shoulder disorders are the most common musculoskeletal problem in general practice. Most improve within 3 months, but some become chronic.

History

• Ask about pain. Pain from the shoulder joint itself is usually felt in the lateral upper arm.
  
• Is there loss of movement, disturbed sleep or difficulty with daily activities? It’s not always possible to relieve them all, so establish which symptom troubles your patient most. Is the patient right or left-handed? Always ask with any upper limb symptoms.
  
• Find out about other joint problems, a history of trauma or dislocation, and occupational and leisure activities.
  
• Enquire after general health, as heart disease and diabetes are linked with adhesive capsulitis.
  
• Ask about red flag symptoms:
   Acute onset of severe weakness (probable rotator cuff tear)
   History of cancer
   Fever or weight loss.

Examination

• Is there deformity, asymmetry or bony protrusion?
  
• Wasting above the scapular spine suggests neck problem.
  
• Compare active and passive movements. Both are usually reduced (and painful) in adhesive capsulitis (‘frozen shoulder’), especially external rotation. Passive movements are near-normal in rotator cuff disorders.
   Unexplained deformity or lump (could be infection, malignancy or dislocation)
   Any signs of infection, such as warmth or fever
   Wasting, or muscle or sensory deficit (could be cervical radiculopathy)
   Inability to support the abducted arm suggests a significant rotator cuff tear, which may need surgery.

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