I had a stable, non‑displaced C6 vertebral fracture two weeks ago and now have intermittent left shoulder pain that worsens with coughing or deep breathing; what evaluation and management steps should I take?

Urgent Evaluation for New Shoulder Pain After C6 Fracture

You need immediate clinical re-evaluation to rule out secondary injury or referred pain from cervical nerve root irritation, as new shoulder pain 2 weeks post-fracture—especially pain worsened by coughing or deep breathing—may indicate C5-C6 nerve root involvement, diaphragmatic irritation, or evolving instability.

Immediate Assessment Required

Your new symptoms warrant urgent evaluation because:

• Pain triggered by coughing or deep breathing suggests either referred pain from cervical nerve root irritation at C5-C6 (which innervates the shoulder) or diaphragmatic irritation 1, 2
• C6 fractures can involve the lateral mass or facet joints, which may not be fully visible on initial plain radiographs and can cause delayed nerve root compression 3
• The 2-week timeframe coincides with when patients may begin mobilizing more, potentially causing fracture displacement in initially "stable" injuries 2, 4

Specific Clinical Red Flags to Assess

Contact your physician immediately if you experience:

• Weakness in shoulder abduction, elbow flexion, or wrist extension (C5-C6 nerve root motor function) 5, 4
• Numbness or tingling in the thumb and index finger (C6 dermatome) 2, 4
• Increasing neck pain or new neurological symptoms suggesting fracture displacement 2, 3
• Shortness of breath or difficulty breathing (diaphragmatic involvement from C5 nerve root, which contributes to phrenic nerve) 5, 1

Required Imaging Evaluation

Your physician should obtain CT imaging of the cervical spine if not already done, as plain radiographs miss up to 20% of cervical fractures, particularly lateral mass and facet injuries 5, 3:

• CT with 1.5-2mm collimation is the gold standard for detecting occult fractures and assessing stability 5
• One case report documented a C6 lateral mass fracture completely missed on plain X-ray and MRI, only detected on CT after suspecting high-energy trauma 3
• MRI may be indicated if nerve root compression or soft tissue injury is suspected, though it can miss bony injuries 5, 3

Pain Mechanism Considerations

Your symptom pattern (intermittent shoulder pain with coughing/deep breathing) suggests:

• Referred pain from C5-C6 nerve root irritation: The C6 nerve root exits at the C5-C6 level and refers pain to the shoulder and lateral arm 2, 4
• Diaphragmatic irritation: The phrenic nerve (C3-C5, predominantly C4) can cause referred shoulder pain when irritated, and forceful breathing/coughing increases diaphragmatic excursion 5, 1
• Muscle spasm or strain: Compensatory muscle guarding around a healing fracture can cause referred shoulder pain, though this typically doesn't worsen specifically with coughing 2

Management Pending Evaluation

Until you can be evaluated:

• Maintain cervical immobilization as prescribed (collar if ordered) to prevent secondary injury 1, 2
• Avoid activities that reproduce the pain, particularly those involving Valsalva maneuvers (straining, heavy lifting) 2, 4
• NSAIDs like ibuprofen can be used for pain control at the lowest effective dose, though avoid if you have contraindications (GI bleeding history, kidney disease, recent heart attack) 6
• Do not use corticosteroids (like prednisone) for pain control without physician guidance, as they can impair bone healing and have significant side effects 7

Common Pitfalls to Avoid

• Do not assume stable fractures remain stable: Up to 8-14% of cervical injuries are missed on initial imaging, and "stable" fractures can displace with mobilization 5, 3
• Do not dismiss shoulder pain as "muscle strain": New neurological symptoms after cervical fracture require investigation for nerve root compression or fracture progression 2, 3, 4
• Do not delay seeking care if symptoms worsen: Respiratory symptoms or progressive weakness require emergency evaluation, as high cervical injuries can compromise respiratory function 5, 1

Contact your treating physician today to report these new symptoms and arrange urgent clinical and imaging re-evaluation.