What are the potential causes and treatment options for a patient with forearm, shoulder, and neck pain, considering factors such as age, occupation, and underlying medical conditions like arthritis or fibromyalgia?

Causes of Forearm, Shoulder, and Neck Pain

Primary Mechanical and Degenerative Causes

The most common cause of combined forearm, shoulder, and neck pain is cervical radiculopathy from nerve root compression, typically from herniated discs or osteophytes, which affects approximately 83 per 100,000 persons annually and presents with radiating pain in the upper limb distribution. 1

Cervical Spine Pathology

• Nerve root compression from soft disc herniation or hard disc (spondylarthrosis of facet or uncovertebral joints) is the primary neuropathic cause, presenting with upper limb pain and varying degrees of sensory or motor deficits in the affected nerve root distribution 1
• Cervical spondylosis and degenerative disc disease are extremely common, affecting 53.9% of individuals aged 18-97, with prevalence increasing with age 1
• Facet joint arthropathy causes localized mechanical pain that may be unilateral and radiate to the trapezius region and upper back 1
• Cervical spine pathology can cause radiating pain in the arm and forearm that mimics rotator cuff pathology or nerve compression in the shoulder area 2

Shoulder Pathology

• Rotator cuff disease is the predominant cause of shoulder pain in patients over 35-40 years, involving tears or inflammation of the rotator cuff tendons 3
• Shoulder impingement syndrome can present as neck pain near the superomedial aspect of the scapula, representing referred pain from chronic shoulder inflammation 4
• Trauma-related injuries including fractures (clavicle, scapula, proximal humerus) or soft tissue injuries (rotator cuff, acromioclavicular ligaments, labroligamentous complex) disproportionately affect young adults and males 5

Forearm and Elbow Pathology

• Tendon, ligament, or muscle injuries in the elbow and forearm can contribute to regional pain patterns 5
• Lateral and medial epicondylitis (tennis/golfer's elbow) cause forearm pain that may radiate proximally 5

Critical Red Flags Requiring Urgent Evaluation

Every patient must be screened for red flags that indicate potentially life-threatening conditions requiring immediate imaging with MRI cervical spine without contrast. 1, 6

Red Flag Indicators

• Constitutional symptoms (fever, night sweats, unexplained weight loss) 1
• Elevated inflammatory markers (ESR, CRP) 1, 6
• History of malignancy or immunosuppression 1
• History of IV drug use 1
• Progressive neurological deficits (motor weakness, sensory loss, bowel/bladder dysfunction) 1
• Intractable pain unresponsive to conservative therapy 1
• Vertebral body tenderness on palpation 1

Serious Etiologies to Consider

• Vertebral osteomyelitis or discitis 1
• Metastatic disease to cervical vertebrae 1
• Inflammatory arthritis 1
• Cervical myelopathy 1
• Primary spinal tumors 1

Diagnostic Algorithm

Initial Assessment Without Red Flags

• Do not order imaging in the absence of red flags, as most acute cervical neck pain resolves spontaneously or with conservative treatment, with approximately 50% of patients having residual or recurrent pain up to 1 year after initial presentation 1
• Radiographs are the preferred initial diagnostic modality for acute shoulder pain to delineate shoulder malalignment and fractures 5
• Standard shoulder radiographs should include anteroposterior views in internal and external rotation plus an axillary or scapula-Y view 5

Assessment With Red Flags Present

• Obtain MRI cervical spine without contrast immediately when red flags are present 1, 6
• MRI is the most sensitive imaging modality for detecting soft tissue abnormalities, disc herniation, nerve root impingement, inflammatory processes, infection, and tumor 1

Persistent Symptoms Beyond 6-8 Weeks

• Consider MRI cervical spine without contrast if no red flags but persistent symptoms beyond 6-8 weeks of conservative therapy 1
• For shoulder-specific concerns with normal radiographs, MRI shoulder without contrast is appropriate to evaluate rotator cuff tears, labral tears, and other soft tissue injuries 5

Distinguishing Cervical from Shoulder Pathology

Clinical Examination Pearls

• Spurling's test (cervical compression with rotation and lateral flexion) is highly specific for nerve root compression from herniated cervical disc 1
• Positive impingement sign with pain referred to the neck suggests shoulder impingement as the primary source 4
• Relief of neck pain after injection of lidocaine and cortisone into the subacromial space confirms shoulder impingement as the cause of neck pain 4
• Active neck range-of-movement testing and neurological examination are the most commonly used methods to assess cervical contribution 7

Key Differentiating Features

• Rotator cuff tears typically do not cause numbness in specific digits, whereas cervical radiculopathy presents with dermatomal sensory deficits 3
• Shoulder pathology pain worsens with arm elevation above 90 degrees, while cervical pathology worsens with neck movements 4
• Cervical radiculopathy follows specific nerve root distributions (C5-T1), while shoulder pain is typically localized to the deltoid region 2

Treatment Approach Based on Etiology

Conservative Management

• 75-90% of cervical radiculopathy cases resolve with conservative nonoperative therapy including NSAIDs, physical therapy, and activity modification 1
• For shoulder impingement presenting as neck pain, avoidance of the shoulder impingement position (forward elevation above 90 degrees) minimizes recurrences 4

Surgical Considerations

• Unstable or significantly displaced fractures and joint instability require acute surgical treatment 5
• Traumatic massive rotator cuff tears may require expedited surgical repair to achieve optimal postoperative functional outcomes 5
• Massive nerve compression with progressive motor deficits requires urgent surgical evaluation 3

Age and Occupation Considerations

• Patients over 35-40 years: Rotator cuff disease becomes the predominant cause of shoulder pain 3
• Young adults and males: Higher incidence of traumatic shoulder injuries from sports participation and high activity levels 5
• Occupational factors: Repetitive overhead work increases risk of shoulder impingement; repetitive forearm activities increase risk of epicondylitis 5

Underlying Medical Conditions

Fibromyalgia

• Presents with widespread musculoskeletal pain including neck, shoulder, and forearm regions 5
• Diagnosis requires careful history taking and understanding of psychosocial background 8

Arthritis

• Inflammatory arthritis (rheumatoid, seronegative spondyloarthropathy) can affect multiple joints including shoulder and cervical spine 5
• Crystal-associated arthritis (gout, pseudogout) may present with acute joint pain 5
• Degenerative changes on imaging correlate poorly with symptoms and are common in asymptomatic individuals over 30 years 5