Management of Neck and Shoulder Pain with Normal X-ray
When X-rays are normal in patients with neck and shoulder pain, proceed directly to MRI of the shoulder without IV contrast as the next most appropriate imaging study. 1
Immediate Next Steps After Normal X-ray
Advanced Imaging Strategy
MRI shoulder without IV contrast is the definitive next imaging modality for nonlocalized shoulder pain when radiographs are negative, as it can identify rotator cuff tears, labral injuries, osseous contusions, and acromioclavicular sprains that are invisible on plain films 1
MRI without contrast is specifically preferred over MR arthrography in the acute setting because it better visualizes soft tissue pathology without requiring intra-articular injection 1
If clinical examination suggests specific findings (prior dislocation, instability, or labral tear), both MRI without contrast and MR arthrography are appropriate options 1
Clinical Evaluation Priorities
Critical examination findings to document:
Presence of shoulder deformity - this is the strongest predictor of significant pathology requiring specific treatment 2
Impingement signs with pain referred to the neck - shoulder impingement can present as isolated neck pain near the superomedial scapula, and diagnostic subacromial injection with lidocaine and cortisone can both diagnose and treat this condition 3
Age >43.5 years with history of precipitating fall - this combination significantly increases likelihood of occult fracture despite normal initial radiographs 2
Range of motion limitations, point tenderness, and provocative maneuvers to localize pathology 4
Conservative Management During Diagnostic Workup
Pharmacologic Treatment
Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, but should only be used for short periods (2-3 weeks maximum) 5
Pain relief and muscle relaxation can improve function while awaiting advanced imaging or specialist evaluation 5
Physical Therapy Interventions
Implement a structured neck and shoulder stretching exercise program performed twice daily, five days per week, which has been shown to significantly reduce pain (VAS improvement of -1.4 points) and improve neck function in patients with chronic moderate-to-severe neck/shoulder pain 6
Exercises performed ≥3 times per week yield significantly greater improvement in neck function and quality of life compared to less frequent exercise 6
Provide ergonomic education regarding proper positioning during daily activities 6
Common Pitfalls to Avoid
Do not assume neck pain originates from cervical spine pathology - shoulder impingement frequently presents as isolated neck pain, and 30 of 34 patients in one series obtained immediate relief of neck pain following subacromial injection 3
Do not delay MRI if symptoms persist despite normal radiographs - soft tissue injuries including rotator cuff tears and labral pathology are completely invisible on X-ray but readily identified on MRI 1
Avoid inadequate initial radiographic views - ensure at minimum three views were obtained (AP in internal/external rotation plus axillary or scapula-Y view), as acromioclavicular and glenohumeral dislocations can be missed on AP views alone 1, 7
Do not overlook the need for orthopedic referral if MRI reveals unstable injuries, significant rotator cuff tears (especially traumatic massive tears requiring expedited repair), or neurological deficits 1, 7
When to Consider Alternative Diagnoses
If pain persists chronically without clear etiology after negative MRI, consider bone scintigraphy to rule out complex regional pain syndrome (CRPS), which has high specificity though only moderate sensitivity 1
For suspected peripheral nerve injury, MR neurography using 3-T imaging can delineate focal nerve discontinuities, neuromas, and musculofascial edema 1
Ultrasound has limited utility in this scenario unless pain is clearly localized to rotator cuff or biceps tendon 1