In a 62‑year‑old woman with known moderate‑to‑severe lumbar foraminal narrowing and lumbar canal stenosis, how can I differentiate whether her static and movement‑related shoulder pain is neurogenic versus a primary musculoskeletal shoulder disorder?

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Differentiating Neurogenic vs. Musculoskeletal Shoulder Pain in a 62-Year-Old Woman with Known Lumbar Stenosis

The shoulder pain is almost certainly a primary musculoskeletal shoulder disorder, not referred pain from lumbar foraminal narrowing or canal stenosis, and should be evaluated with cervical spine imaging and shoulder-specific examination.

Key Anatomical Principle

Lumbar foraminal narrowing and canal stenosis affect the lumbosacral nerve roots (L1-S1), which innervate the lower extremities, pelvis, and lower trunk—not the shoulder 1. The shoulder is innervated by cervical nerve roots (primarily C5-C6) and the brachial plexus 1. There is no anatomical pathway by which lumbar pathology can cause shoulder pain.

Clinical Differentiation Algorithm

Step 1: Assess Pain Distribution and Dermatomal Pattern

Lumbar radiculopathy characteristics:

  • Pain radiates into the lower extremities in specific nerve root distributions (L4: anterior thigh and knee; L5: lateral leg and dorsum of foot; S1: posterior leg and plantar foot) 1
  • Associated with neurogenic claudication: leg pain worsened by walking/standing, relieved by sitting or forward flexion 1
  • May include lower extremity weakness, numbness, or absent reflexes 1

Cervical radiculopathy characteristics (if shoulder pain is neurogenic):

  • Neck pain with arm pain in cervical nerve root distribution 1
  • C5 radiculopathy: shoulder and lateral arm pain with deltoid weakness
  • C6 radiculopathy: lateral forearm pain with biceps weakness and diminished brachioradialis reflex 1

Step 2: Perform Targeted Physical Examination

For cervical spine evaluation:

  • Spurling's test (neck extension with lateral rotation toward symptomatic side)
  • Straight-leg raise test is not relevant for shoulder pain—it tests for lumbar radiculopathy 1
  • Assess shoulder range of motion both actively and passively
  • Evaluate rotator cuff strength (supraspinatus, infraspinatus, subscapularis)
  • Check for cervical spine tenderness 1

Red flags requiring urgent imaging:

  • Progressive neurological deficits
  • Myelopathic signs (gait instability, hyperreflexia, Babinski sign)
  • Fever, weight loss, or history suggesting malignancy 1

Step 3: Order Appropriate Imaging

Initial imaging should focus on the cervical spine and shoulder, NOT the lumbar spine:

  • Shoulder radiographs (AP in internal/external rotation, axillary or scapula-Y view) are the first-line study for traumatic or atraumatic shoulder pain to assess for fracture, dislocation, or degenerative changes 1

  • MRI cervical spine without contrast is the gold standard if cervical radiculopathy is suspected based on neck pain with arm symptoms 1. MRI accurately depicts cervical foraminal stenosis, disc herniation, and nerve root compression 1

  • MRI shoulder without contrast or MR arthrography if rotator cuff tear, labral pathology, or other soft-tissue shoulder injury is suspected 1

Step 4: Recognize Common Pitfalls

Critical caveat: Degenerative changes on imaging correlate poorly with symptoms 1. Asymptomatic individuals over 30 years commonly show cervical spondylosis on MRI 1. Similarly, lumbar stenosis findings do not explain shoulder symptoms 2, 3.

Do not attribute shoulder pain to lumbar pathology simply because lumbar stenosis is known to exist. The patient may have two separate conditions: lumbar stenosis (which may be asymptomatic or causing lower extremity symptoms) and a distinct shoulder disorder 1.

Specific Diagnostic Considerations

If Pain is Static and Movement-Related at the Shoulder:

This pattern strongly suggests primary shoulder pathology such as:

  • Rotator cuff tendinopathy or tear (pain with overhead activities, weakness with abduction/external rotation)
  • Adhesive capsulitis (global restriction of passive range of motion)
  • Glenohumeral osteoarthritis (pain with all shoulder movements)
  • Acromioclavicular joint arthritis (pain localized to AC joint, worse with cross-body adduction) 1

If There is Concurrent Neck Pain:

Consider cervical spine pathology with referred shoulder pain:

  • Cervical foraminal stenosis at C5-C6 can cause shoulder and arm pain 1
  • Physical examination showing limited cervical range of motion and positive Spurling's test supports cervical origin 1

Management Approach

For presumed musculoskeletal shoulder pain:

  • Begin with shoulder radiographs 1
  • If radiographs are unrevealing and symptoms persist, proceed to MRI shoulder 1
  • Consider cervical spine imaging if neck symptoms are present 1

The known lumbar stenosis should be managed separately based on lower extremity symptoms, not shoulder complaints 1. If the patient has neurogenic claudication or progressive lower extremity weakness, that warrants its own evaluation and treatment pathway 1.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Spinal stenosis.

Handbook of clinical neurology, 2014

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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