What are the causes of bilateral shoulder pain radiating to the arms and hands?

Bilateral Shoulder Pain Radiating to Arms and Hands: Differential Diagnosis and Evaluation

Most Likely Etiologies

Cervical spine pathology is the most common cause of bilateral shoulder pain radiating to the arms and hands, particularly cervical spondylosis with radiculopathy or myelopathy. 1 This presentation strongly suggests a neurologic origin rather than primary shoulder pathology, as bilateral involvement with distal radiation below the elbow is characteristic of cervical nerve root or spinal cord involvement. 2

Primary Diagnostic Considerations

Cervical Radiculopathy/Myelopathy

• Cervical spondylosis causes not only neck and shoulder pain but also radiating pain into the arms and forearms that mimics rotator cuff pathology or nerve compression. 1
• Radiating pain accompanied by motor or sensory changes, particularly below the elbow, strongly indicates neurologic etiology. 2
• The pain may originate from the spinal cord, extruded intervertebral discs, or foraminal root compression syndromes. 2

Brachial Plexopathy (Bilateral)

• Plexopathy manifests as neuropathic pain in the shoulder and arm with dysesthesia or burning sensations occurring in multiple peripheral nerve distributions. 3
• Complete plexopathy causes weakness, sensory loss, and flaccid loss of tendon reflexes in regions innervated by the affected nerves. 3
• Bilateral presentation suggests systemic causes including inflammatory, infectious, autoimmune, or neoplastic etiologies. 3

Thoracic Outlet Syndrome (Bilateral)

• Neurogenic TOS (nTOS) presents with compression of the brachial plexus, most commonly in the costoclavicular space (53% positional, 36% congenital bone variations, 11% fibromuscular anomalies). 3
• Bilateral involvement is less common but can occur with anatomic predisposition. 3

Polymyalgia Rheumatica (PMR)

• PMR commonly presents with bilateral shoulder pain, though it typically does not radiate significantly into the hands. 3
• Shoulder pain in PMR might be due to disease activity or unrelated conditions such as osteoarthritis, adhesive capsulitis, or rotator cuff disease. 3
• Up to 60% of patients experience relapses during glucocorticoid tapering. 3

Bilateral Suprascapular Nerve Entrapment

• Very rare condition presenting with bilateral shoulder pain, weakness, and atrophy of supraspinatus and infraspinatus muscles. 4
• Should be considered when weakness and atrophy accompany the pain. 4

Critical Red Flags Requiring Urgent Evaluation

Vascular Compromise

• Giant cell arteritis (GCA) can cause peripheral limb ischemia requiring multidisciplinary management including vascular surgeons. 3
• Sight loss, strokes, tongue or scalp necrosis indicate GCA with vascular territory damage. 3

Infectious Etiologies

• Bilateral gonococcal arthritis can present with bilateral shoulder pain, though this is uncommon. 5
• Inflammatory conditions must be distinguished from disease-related symptoms. 3

Recommended Diagnostic Algorithm

Initial Imaging

Step 1: Radiography

• Obtain bilateral shoulder radiographs (AP views in internal and external rotation, plus axillary or scapula-Y views) to assess for fracture, dislocation, or bony abnormalities. 3
• Cervical spine radiographs to evaluate for spondylosis, foraminal narrowing, or cervical rib abnormalities. 3, 2

Step 2: Advanced Imaging Based on Clinical Suspicion

For suspected cervical spine pathology:

• MRI cervical spine without contrast is the preferred study to evaluate for disc herniation, spinal cord compression, foraminal stenosis, or myelopathy. 3
• Precise identification usually requires myelography or discography in addition to routine investigation for spinal cord tumors or extruded discs. 2

For suspected brachial plexopathy:

• MRI of the brachial plexus (bilateral) with dedicated sequences including orthogonal views through oblique planes, T1-weighted, T2-weighted, fat-saturated T2-weighted or STIR sequences. 3
• MRI has inherent advantages in delineating extravascular anatomy and characterizing soft tissues. 3
• MR neurography refers to high-resolution T2-weighted sequences of peripheral nerves routinely performed in dedicated plexus imaging. 3

For suspected thoracic outlet syndrome:

• MRI chest without contrast to define the brachial plexus, cervical spine, and dynamic evaluation of neurovascular bundles in costoclavicular, interscalene, and pectoralis minor spaces. 3
• CT chest without contrast allows quantification of costoclavicular or interscalene space changes with provocative maneuvers and identifies bony abnormalities. 3

Electrodiagnostic Studies

Clinical diagnosis of plexopathy must be confirmed by electrodiagnostic studies. 3 EMG and nerve conduction studies reveal neupraxic states, axonal loss, and denervation patterns that localize the lesion. 4

Common Pitfalls to Avoid

• Do not assume primary shoulder pathology when bilateral symptoms radiate below the elbow—this strongly suggests cervical or plexus involvement rather than rotator cuff disease. 1, 2
• Do not delay diagnostic workup for suspected GCA, as treatment should not be delayed for pending procedures, and sight loss almost exclusively occurs before glucocorticoid initiation. 3
• Do not order routine shoulder MRI when cervical radiculopathy is suspected—the movable fulcrum of the shoulder joint may be a site of secondary irritation rather than the primary pathology. 2
• Do not overlook systemic inflammatory conditions such as PMR or psoriatic arthritis, which can present with bilateral shoulder involvement. 3, 6

Key Distinguishing Features

Cervical origin: Pain radiates in dermatomal distribution with sensory loss or motor weakness reflecting spinal nerve root innervation. 3

Plexopathy: Pain occurs in multiple peripheral nerve distributions (not dermatomal), with weakness and sensory loss in regions innervated by the plexus. 3

Primary shoulder pathology: Bilateral rotator cuff tears or adhesive capsulitis would be unusual without trauma or systemic inflammatory condition, and typically do not cause significant hand symptoms. 3, 7