Evaluation of Right Neck, Shoulder, and Leg Pain
Initial Diagnostic Approach
Begin with plain radiographs of the cervical spine and right shoulder as the first-line imaging to exclude fractures, dislocations, degenerative changes, and structural abnormalities. 1, 2, 3
The combination of neck, shoulder, and leg pain on the same side suggests either:
- Cervical radiculopathy with referred pain patterns (most likely given the distribution) 1, 4
- Concurrent cervical spine and shoulder pathology requiring separate evaluation 5
- Cervical myelopathy if leg symptoms suggest upper motor neuron involvement 6
Critical History Elements to Obtain
Document these specific red-flag symptoms immediately: 1, 2
- Progressive neurological deficits (weakness, numbness, gait disturbance)
- Fever or constitutional symptoms suggesting infection
- Significant trauma history
- Unexplained weight loss or history of malignancy
- Bowel/bladder dysfunction
Characterize the pain distribution precisely: 1, 3, 5
- Neck pain radiating down the arm into specific dermatomal patterns indicates cervical radiculopathy 1, 4
- Anterior shoulder pain suggests rotator cuff or biceps pathology 3
- Leg pain with neck/shoulder involvement raises concern for myelopathy or multilevel radiculopathy 6
Determine the temporal pattern: 1, 3
- Acute onset (<2 weeks) versus chronic (>6 months)
- Mechanism of injury if traumatic
- Activities that aggravate symptoms (overhead activities suggest shoulder pathology; neck rotation/extension suggest cervical spine) 3, 5
Physical Examination Priorities
Perform these specific maneuvers to differentiate cervical from shoulder pathology: 1, 3, 5
For cervical radiculopathy: 1, 4
- Spurling test (neck extension with rotation and axial compression toward symptomatic side)
- Upper limb tension tests
- Dermatomal sensory examination
- Myotomal strength testing (C5-T1)
- Deep tendon reflexes (biceps C5-C6, triceps C7, brachioradialis C6)
For shoulder pathology: 3
- Hawkins test (92% sensitive for impingement)
- Neer test (88% sensitive for impingement)
- Empty can test for supraspinatus
- External rotation strength testing
- Passive versus active range of motion (preserved passive with limited active suggests rotator cuff tear)
For myelopathy (critical if leg symptoms present): 6, 7
- Gait assessment
- Hoffmann sign
- Hyperreflexia in lower extremities
- Clonus
- Babinski sign
- Fine motor coordination (button test, coin test)
Imaging Algorithm
Step 1: Initial Radiographs (First-Line)
Obtain these views immediately: 1, 2, 3
- Cervical spine: AP, lateral, oblique views 1
- Right shoulder: AP (internal and external rotation), axillary or scapular-Y views 3
- Chest radiograph if intercostal pain component present 2
Step 2: Advanced Imaging Based on Initial Findings
If radiographs are normal or equivocal AND red flags are absent: 1
- Trial of conservative management for 4-6 weeks is appropriate
- Reserve MRI for persistent symptoms despite conservative care
If radiographs are normal BUT red flags are present or neurological deficits exist: 1, 2
- MRI cervical spine without contrast is the next appropriate study 1
- MRI is the most sensitive modality for disc herniations, osteophytes, spinal cord compression, and nerve root impingement 1, 4, 7
If shoulder radiographs are normal but clinical examination strongly suggests rotator cuff pathology: 3
- MRI shoulder without contrast for patients >35 years with suspected rotator cuff tear 1, 3
- Ultrasound is equivalent to MRI for rotator cuff evaluation when performed by experienced operators (85% sensitivity, 90% specificity) 3
If myelopathy is suspected (leg involvement with upper motor neuron signs): 6, 7
- MRI cervical spine without contrast is mandatory to assess for spinal cord compression 6
- This is a surgical urgency if progressive deficits are present 6, 7
Laboratory Testing
Order these tests if infection or inflammatory process is suspected: 2
- Complete blood count
- Erythrocyte sedimentation rate
- C-reactive protein
Consider cardiac workup if atypical pain characteristics or cardiovascular risk factors: 2
- Troponin
- ECG
Conservative Management (If No Red Flags)
For cervical radiculopathy: 1, 4, 7
- 75-90% of patients improve with conservative care 1
- NSAIDs (ibuprofen 400-600 mg every 8 hours or naproxen 500 mg every 12 hours) 2
- Pregabalin 150 mg twice daily for neuropathic pain (if radicular symptoms confirmed) 2
- Physical therapy focusing on gentle range of motion and strengthening 4, 7
- Avoid aggressive manipulation or traction initially 7
For shoulder impingement/rotator cuff tendinopathy: 3
- Complete rest from aggravating activities 3
- NSAIDs for pain control 2, 3
- Physical therapy with focus on external rotation and scapular stabilization 3
- Avoid overhead pulley exercises (worsen rotator cuff pathology) 3
- Consider subacromial corticosteroid injection if conservative measures fail after 4-6 weeks 3
Critical Pitfalls to Avoid
Do not assume "muscle tension" without excluding structural cervical pathology, especially with red flags present. 2
Do not delay MRI if progressive neurological deficits are present—this may represent myelopathy requiring urgent surgical decompression. 6, 7
Do not confuse cervical radiculopathy with isolated shoulder pathology—cervical spondylosis commonly causes radiating arm pain that mimics rotator cuff disease. 5
Do not overlook multilevel pathology—concurrent cervical and shoulder disease is common, particularly in patients >40 years. 5
Urgent Referral Indications
Immediate neurosurgical or orthopedic spine consultation if: 6, 7
- Progressive myelopathy (gait disturbance, hyperreflexia, upper motor neuron signs)
- Acute spinal cord compression on imaging
- Progressive motor weakness despite conservative care
Orthopedic shoulder referral if: 3
- Complete rotator cuff tear on imaging in active patient
- Failure of 3-6 months conservative management for impingement
- Acute traumatic shoulder dislocation with suspected labral injury