Muscle and shoulder and pain and nerve and numbness
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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There are many causes of shoulder pain that don't necessarily originate in the shoulder.
The spinal cord originates at the base of the brain, descends through the cervical and thoracic spine, and ends at the lower part of the thoracic spine. Therefore, spinal cord injury or damage can be due to trauma or diseases of the cervical spine or thoracic spine.
Nerves exit from the spinal cord and consist of 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal nerve. The nerve roots run through the bony canal of the spinal column, and at each level a pair of nerve roots exits from the spine.
In the cervical spine (neck), the nerve root is named for the lower segment that it runs between (e.g. C6 nerve root at C5-C6 segment).
Sometimes, a herniated disc will cause only arm pain and not neck pain.
Arm pain from a cervical disc herniation is usually accompanied by numbness/tingling extending to the fingers
Most cervical pathology will lead to pinching of either C6 or C7 nerve roots in the neck, although sometimes the C5 or C8 nerves may be pinched. Depending on which nerve root is pinched, the following symptoms are likely:
•Pinched nerve at C5. This can cause shoulder pain, deltoid weakness, and possibly a small area of numbness in the shoulder. On physical exam, a patient’s biceps reflex may be diminished.
•Pinched nerve at C6. This can cause weakness in the biceps and wrist extensors, and pain/numbness that runs down the arm to the thumb. On physical exam, the brachioradialis reflex (mid-forearm) may be diminished.
•Pinched nerve at C7. This can cause pain/numbness that runs down the arm to the middle finger. On physical exam, the triceps reflex may be diminished.
•Pinched nerve at C8. This can cause hand dysfunction (this nerve supplies innervation to the small muscles of the hand). Pain/numbness can run to the outside of the hand (little finger) and impair its reflex.
Nerves tend to heal slowly. The nerves heal from the top down, and depending on how much damage is done at the time the nerve becomes impinged (pinched), it may take weeks to months for the nerve to fully to heal.
Treatment of nerve impingement is directed at relieving the pain and then allowing the nerve to heal.
Pain in the cervical and shoulder area is common and may reflect many conditions. However, when a patient develops neurologic deficits, the list of differential diagnoses becomes shorter.
Cervical radiculopathy is the most common condition. Patients with cervical radiculopathy present with cervical pain and neurologic deficits resulting from a herniated nucleus pulposus or an osteophyte (bone spur).
Patients with cervical radiculopathy present with pain beginning in the neck area and radiating down the arm for variable distances. The pain may occur after a documented trauma but, not uncommonly, patients may awake in the morning with the pain and no obvious preceding cause. The pain is associated with partial weakness in the muscles supplied by the involved nerve root.
An MRI scan can help confirm the diagnosis.
Acute brachial plexus neuritis mimics cervical radiculopathy, but the treatments are significantly different. The hallmark clinical presentation of patients with acute brachial plexus neuritis is acute, burning pain in the shoulder and upper arm. On occasion, it may awaken the patient from sleep. In the majority of patients, the pain subsides over days to weeks, resulting in weakness in the upper arm. The weakness may be profound. This temporal profile of initial arm and shoulder pain followed by muscle weakness as the pain subsides is an important characteristic of acute brachial plexus neuritis.
The usual abnormality evident on physical examination is a brachial plexus lesion, as indicated by involvement of two or more nerves. Weakness commonly occurs in the supraspinatus, infraspinatus, deltoid and/or the biceps muscles usually involving the upper plexus. The course of the neuritis is usually one of gradual improvement and recovery of muscle strength in three to four months. Some patients may experience several years of muscle weakness or permanent weakness. In general, the longer pain is an issue, the longer a return to normal strength can be expected.
MRI of the clinically weak muscles may reveal high signal intensity of the affected muscles on the T2 study. These changes may appear within days following the onset of symptoms and persist for months. A delayed MRI scan may also reveal muscle atrophy.
Electromyographic testing in patients with acute brachial plexus may be helpful. It localizes the lesion to the brachial plexus (usually the upper aspect of the plexus), and helps establish the diagnosis.
Treatment of patients with acute brachial plexus neuritis includes analgesics and physical therapy for three to eight weeks to help maintain strength and mobility The profound weakness in the shoulder muscles may require the use of a sling. Corticosteroids are not of proven benefit.
Repetitive stress injury is an occupational overuse syndrome affecting muscles, tendons and nerves in the arms and upper back. It occurs when muscles in these areas are kept tense for long periods of time, due to poor posture and/or repetitive motions.
It is most common among assembly line and computer workers. Good posture and ergonomic working conditions can help prevent or halt the progress of the disorder; stretches, strengthening exercises, massages and biofeedback training to reduce neck and shoulder muscle tension can help heal existing disorders.
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