I'm an adult with no significant medical history and I'm experiencing shoulder pain radiating to my elbow, worsened by supine positioning - what could be the cause and treatment?

Shoulder Pain Radiating to Elbow: Cervical Radiculopathy Until Proven Otherwise

Your shoulder pain radiating to the elbow that worsens when lying supine most likely represents cervical spine pathology causing referred pain, not primary shoulder or elbow disease. 1

Why This Is Cervical Spine Disease

The key diagnostic feature here is pain radiating from shoulder to elbow—this distribution follows a dermatomal pattern characteristic of cervical nerve root compression. 1 The supine position worsens symptoms because lying flat can increase pressure on cervical nerve roots or alter cervical spine alignment. 2

Common extrinsic causes of shoulder pain include postural problems and cervical spine disorders, and these must be ruled out before attributing symptoms to intrinsic shoulder pathology. 1

Immediate Diagnostic Steps

Clinical Examination Priorities

• Perform Spurling's test: extend and rotate the neck toward the symptomatic side while applying axial compression—reproduction of radiating pain confirms cervical radiculopathy. 1
• Assess for neurological deficits: test upper extremity strength, reflexes (biceps, triceps, brachioradialis), and sensation in dermatomal distributions C5-T1. 3
• Document exact pain distribution: cervical radiculopathy typically follows specific patterns (C5: lateral shoulder; C6: lateral arm to thumb; C7: posterior arm to middle finger; C8: medial forearm to small finger). 1

Initial Imaging

• Start with cervical spine radiographs (AP, lateral, oblique views) to evaluate for degenerative changes, foraminal narrowing, or alignment abnormalities causing nerve root compression. 1
• Shoulder radiographs are NOT indicated initially unless there is specific shoulder trauma, point tenderness over bony structures, or restricted shoulder range of motion on examination. 2, 4

Treatment Algorithm

Conservative Management (First 6-8 Weeks)

• Activity modification: avoid positions that provoke symptoms, particularly prolonged neck extension or rotation. 1
• Analgesics: start with acetaminophen 650-1000 mg every 6 hours (maximum 4 grams daily) as first-line therapy. 3
• Physical therapy: cervical traction, postural correction, and neck strengthening exercises address the root cause. 1
• Short-term NSAIDs (if no contraindications): ibuprofen 400-600 mg three times daily for 7-10 days maximum, given cardiovascular and gastrointestinal risks. 3

When Conservative Treatment Fails

• MRI cervical spine without contrast is indicated if symptoms persist beyond 6-8 weeks or if neurological deficits develop, to visualize disc herniation, spinal stenosis, or nerve root compression. 1
• Electromyography (EMG) assists in confirming nerve involvement and localizing the specific nerve root affected. 2

Red Flags Requiring Urgent Referral

• Progressive neurological deficits (weakness, sensory loss, reflex changes) mandate urgent neurosurgical or spine specialist evaluation. 3
• Bilateral upper extremity symptoms with gait disturbance suggest cervical myelopathy requiring immediate specialist assessment. 3
• Severe, unrelenting pain unresponsive to conservative measures within 2-3 weeks warrants expedited specialist referral. 1

Critical Pitfall to Avoid

Do not pursue extensive shoulder or elbow imaging and treatment when the pain pattern clearly suggests cervical origin. 1 The most common error is attributing radiating arm pain to primary shoulder pathology (rotator cuff disease, impingement) when the true source is cervical radiculopathy. This leads to unnecessary shoulder interventions (injections, surgery) that fail because they don't address the actual problem. 1

The supine positional worsening is your clinical clue—intrinsic shoulder pathology (rotator cuff tears, impingement, labral tears) typically worsens with active shoulder movement and overhead activities, not with passive supine positioning. 2, 5