What is the most likely cause of right‑sided neck, shoulder, and arm pain radiating to the hand with a burning sensation in a 51‑year‑old female that worsens with activity and improves with rest?

Most Likely Diagnosis: Cervical Radiculopathy

This 51-year-old woman most likely has cervical radiculopathy, given her unilateral burning pain radiating from neck through shoulder to hand that worsens with activity (keyboard work) and improves with rest, in the absence of inflammatory signs. 1

Clinical Reasoning

Classic Presentation Features Present

• Unilateral neck pain with radiation to the ipsilateral arm extending to the hand is the hallmark of cervical radiculopathy 1
• Burning quality pain is characteristic of nerve root compression 1
• Activity-related exacerbation (keyboard work) and rest improvement strongly suggest mechanical nerve root compression that worsens with neck positioning during repetitive activities 2
• Normal range of motion does not exclude radiculopathy, as pain rather than mechanical restriction is the primary symptom 1

Key Differential Considerations to Exclude

Myofascial referred pain must be considered but is less likely because:

• Myofascial pain from infraspinatus or brachioradialis typically causes more localized symptoms rather than continuous radiation from neck to hand 3, 4
• The burning quality and dermatomal distribution favor radiculopathy over trigger point referral 4

Peripheral nerve entrapment (carpal tunnel, radial tunnel) is unlikely because:

• These conditions don't cause neck and shoulder pain 3
• The continuous radiation pattern from neck to hand suggests proximal nerve root pathology 2

Red Flags Assessment (All Absent in This Case)

• No fever, weight loss, or night sweats (excludes infection/malignancy) 5
• No bilateral symptoms (excludes myelopathy) 2
• No motor weakness reported 1
• No constitutional symptoms 5

Diagnostic Approach

Initial Management Without Imaging

Do not order MRI in the first 6 weeks unless red flags develop, as 75-90% of cervical radiculopathy cases resolve with conservative treatment 2

The American College of Radiology guidelines emphasize that imaging for acute neck symptoms without red flags rarely alters initial management, since degenerative changes are ubiquitous in asymptomatic individuals over age 30 2

When to Image

MRI cervical spine without contrast becomes appropriate if:

• Symptoms persist beyond 6 weeks despite conservative management 2
• Progressive motor weakness develops 2
• New bilateral symptoms emerge 2
• Bladder/bowel dysfunction occurs 2

MRI is the most sensitive modality for detecting disc herniation and nerve root compression 6, 2

Initial Treatment Protocol

Conservative Management (First 6 Weeks)

• Activity modification: Reduce keyboard time and ergonomic adjustments for workstation 1
• NSAIDs or acetaminophen for pain control 1
• Physical therapy focusing on cervical traction and neuromobilization 4
• Avoid prolonged neck flexion during work activities 1

Reassessment Timeline

Evaluate at 4-6 weeks to determine if symptoms are resolving, stable, or progressing 2

Critical Pitfalls to Avoid

• Do not immediately order MRI in the acute phase without red flags, as this identifies incidental degenerative findings that don't correlate with symptoms and may drive unnecessary interventions 2
• Do not assume clinical examination alone can accurately localize the affected nerve root – studies show only 31% agreement between clinical evaluation and MRI findings, with another 28% identifying an adjacent level 7
• Do not overlook the need for serial neurological examinations to detect development of motor weakness or myelopathy 1
• Watch specifically for development of bilateral symptoms, gait disturbance, or bowel/bladder changes that would indicate myelopathy requiring urgent evaluation 2