Shoulder Pain: Hidden causes and 6 top tips for assessment and treatment

By David Pope

Shoulder conf BJSM 1200W (1)

Is your patient’s referred or radicular shoulder pain pretending to be from irritation of the local structures?

Referred cervical and thoracic pain may present with similarities to pathological local structures internal or external to the joint capsule (Ponappan et al. 2015). Keeping in mind local pathology, which may occur in combination with referred pain, and the potential for central sensitisation to be involved in the pain experience, there are clues that will help you identify referred pain.

The Cervical and Thoracic spine commonly cause referred or radicular pain in the shoulder and arm (Van Zundert et al., 2010), not necessarily dermatomal in pattern. Provocative tests have questionable value in identifying the contribution of the cervical or thoracic spine (Rubinstein, Pool, van Tulder, Riphagen, & de Vet, 2007). Research into referred pain in the shoulder is limited, however when you accurately identify using treatment direction or symptom modification procedures, and target your treatment at the referring structures, you can have immediate changes in shoulder pain, range of movement and function.

Here are some clues that may help you identify cervical or thoracic spine referred pain in your patients history (Ponnappan et al., 2015). These clues are not definitive, but will guide you, to know when to explore the cervical and thoracic spine more in your objective assessment, and identify a treatment direction.


  • Pain in the neck that radiates across into to the shoulder
  • Pain proximal to the shoulder eg across the upper trapezius as well as into the shoulder
  • Pain radiating below the elbow, and potentially in the anterior or posterior


  • Pins and needles or numbness in the arm or hand


  • Pain occurring at similar times eg pain in the neck comes on and gets worse then pain in the shoulder occurs, or vice versa


  • Vague pain in the shoulder. Not a specific pain eg over the supraspinatus or biceps tendon, it is often a vague pain. It may move around, sometimes anterior, sometimes posterior. It may also have a feeling of a dead arm, or a position in range where it all of a sudden just feels weak.

Aggravating activities

  • Pain with cervical movement, or shoulder movement while turning the head or body one way eg turning to reverse the car while putting the arm up onto the seat is worse than just putting the arm on the seat.


  • May have a gradual onset, with increased activities that place the neck and thorax towards end of range eg increasing surfing as the weather warms up or painting the ceiling (this could also be local irritation, but also keep the Cervical and Thoracic spine in mind), or may be follwing a neck injury eg faceplant while snowboarding). Pain following sleeping on a plane or bus is also a common presentation.

As mentioned, these clues are not definitive, but can act as a guide within the patients subjective examination that will help you to explore the cervical and thoracic spine, identify the referring structures using treatment direction or symptom modification procedures and help improve your patients cervical or thoracic referred or radicular shoulder pain.


David Pope, Physiotherapist

For more information on David or shoulder assessment and treatment, you can find information on the upcoming Shoulder Pain Virtual Conference at


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