How to differentiate and manage radicular pain due to rotator cuff tear versus cervical spine pain in a patient?

Differentiating Radicular Pain from Rotator Cuff Tear versus Cervical Spine Pathology

The key to differentiation lies in the Spurling test (highly specific for cervical radiculopathy) and shoulder abduction relief test, combined with targeted physical examination maneuvers that reproduce symptoms through specific provocative positions—cervical radiculopathy worsens with neck extension/rotation toward the affected side, while rotator cuff pathology worsens with shoulder-specific movements like abduction and internal rotation. 1, 2

Clinical Examination Algorithm

Primary Differentiating Maneuvers

• Spurling Test: Extend and rotate the neck toward the symptomatic side while applying axial compression—positive test (reproducing radicular symptoms) is highly specific for cervical nerve root compression from disc herniation or foraminal stenosis 1, 2
• Shoulder Abduction Relief Test: Patient actively abducts arm and places hand on top of head—relief of symptoms suggests cervical radiculopathy, as this maneuver reduces tension on the nerve root 2
• Active shoulder range of motion: Pain reproduced specifically during shoulder abduction (60-120 degrees) or internal rotation suggests rotator cuff pathology rather than cervical origin 1
• Resisted shoulder testing: Weakness or pain with resisted external rotation (infraspinatus), internal rotation (subscapularis), or abduction (supraspinatus) localizes to rotator cuff pathology 1

Critical Distinguishing Features

Cervical radiculopathy characteristics:

• Dermatomal pain distribution following specific nerve root patterns (C5: lateral shoulder; C6: lateral arm/thumb; C7: middle finger) 1, 3
• Symptoms worsen with neck extension, rotation, or lateral bending toward the affected side 2, 3
• Paresthesias and numbness in specific dermatomal distributions 3
• Relief with shoulder abduction (placing hand on head) 2

Rotator cuff tear characteristics:

• Pain localized to lateral shoulder, worse with overhead activities 1
• Night pain when lying on affected shoulder 4
• Weakness with specific resisted movements (external rotation, abduction) 1
• Pain arc during active shoulder abduction (60-120 degrees) 1
• No dermatomal sensory changes 5

Imaging Strategy

When to Image and What to Order

For suspected cervical radiculopathy:

• Do NOT image immediately if acute symptoms (<6 weeks) without red flags—75-90% resolve with conservative management 1, 2
• MRI cervical spine without contrast is the preferred modality when imaging is indicated, as it is most sensitive for disc herniation and nerve root impingement 1, 3
• Image immediately if red flags present: constitutional symptoms (fever, weight loss), progressive neurological deficits, history of malignancy, immunosuppression, elevated inflammatory markers (ESR, CRP, WBC), or intractable pain 1, 6

For suspected rotator cuff pathology:

• Plain radiographs first (AP internal/external rotation, axillary or scapular-Y view) to exclude fracture, dislocation, or significant degenerative changes 1
• MRI shoulder without contrast or ultrasound (if local expertise available) for soft tissue evaluation if radiographs noncontributory and rotator cuff tear suspected 1

Critical Imaging Pitfall

Do not over-interpret degenerative changes on cervical MRI—53.9% of asymptomatic individuals demonstrate disc degeneration, with prevalence increasing with age, and these findings correlate poorly with clinical symptoms 1, 7. Always correlate imaging with clinical examination findings 1, 3.

Management Algorithm

Initial Conservative Management (First 6-8 Weeks)

For cervical radiculopathy without red flags:

• Exercise therapy with or without manual therapy—demonstrated significant pain improvement and functional gains 1, 2
• NSAIDs for symptomatic relief, though evidence is limited 2
• Neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants) have scant evidence but may be considered 2
• Avoid immediate imaging unless red flags present 1, 2

For rotator cuff-related symptoms without full-thickness tear:

• Exercise therapy and/or NSAIDs as initial treatment—multiple studies demonstrate beneficial effects in decreasing pain and improving function 1
• Subacromial corticosteroid injection shows conflicting evidence for 2-6 week duration; may be considered but not definitively recommended 1

When Conservative Management Fails

Cervical radiculopathy (persistent >6-8 weeks):

• Epidural corticosteroid injection (interlaminar approach preferred) for acute/subacute symptoms—demonstrates good response 2
• For chronic cervical radicular pain, epidural steroids have limited efficacy; consider pulsed radiofrequency treatment adjacent to dorsal root ganglion 2
• Obtain MRI cervical spine if not already done to guide intervention 1, 2

Rotator cuff pathology:

• MRI or ultrasound to confirm diagnosis if not already obtained 1
• Surgical repair may be considered for full-thickness tears, though timing remains controversial 1

Overlapping Presentations: Critical Considerations

Important clinical reality: Patients can have BOTH conditions simultaneously, though no significant association exists between rotator cuff tears and cervical foraminal stenosis at C5/C6 levels 4. When presentations overlap:

• Systematically evaluate BOTH regions with specific physical examination maneuvers 5, 8
• Consider diagnostic injections (subacromial injection for shoulder, selective nerve root block for cervical spine) to clarify pain generators when examination remains equivocal 5, 8
• Age is the only significant predictor of rotator cuff tears (odds ratio 1.04 per year), not cervical pathology 4
• In complex cases with combined neck-shoulder pain, 8 of 13 patients in one surgical series had nearly equal contributions from both sources 8

Red Flags Requiring Urgent Evaluation

Immediate MRI cervical spine indicated for:

• Constitutional symptoms: fever, unexplained weight loss, night sweats 1, 6
• Progressive neurological deficits, weakness, or myelopathic signs (gait disturbance, bowel/bladder dysfunction) 1, 6
• History of malignancy, IV drug use, or immunosuppression 1, 6
• Elevated inflammatory markers (ESR, CRP, WBC) 1, 6
• Intractable pain despite appropriate conservative therapy 6, 7