Is neck instability causing your shoulder pain?

We will often get emails from people that tell us about their shoulder pain. Some go something like this:

I have very bad shoulder pain. My MRI is “pretty clean,” some osteoarthritis, some wear and tear, no obvious tears that require surgery. My doctor does not know what is wrong with me. When I tell my doctor that I also have headaches and sometimes I have a little disorientation and dizziness, I get the feeling the doctor thinks that there is something wrong in my head and I need counseling.

-or-

My doctor says my shoulder pain and limited range of motion is being caused by shoulder impingement and I need decompression surgery, I have been going to doctors and specialists for many years. I have had cortisone, prescriptions for NSAIDs which do not help,  muscle relaxants, physical therapy, nothing has helped my shoulder pain. My MRI really does not show anything bad. I do not trust the surgery but my doctor will think that I do not want to get well if I decline it and I will need a “different kind of help.”

Is neck instability causing your shoulder pain?

For some people, the chase for alleviation of their shoulder pain centers on MRIs, conservative care, alternative treatments, and a lot of researching on the internet. Especially on those days that their shoulder pain flares us.

In many people, there is a neck component to their shoulder pain that may not be so obvious.

In this image, we see the interplay between the shoulder and the cervical spine. Here we see that shoulder instability can cause neck pain and equally neck instability can cause shoulder pain. If the shoulder is stable but painful, an examination of the upper cervical spine may reveal the answer to shoulder pain that did not appear on a shoulder MRI.

In this image we see the interplay between the shoulder and the cervical spine. Here we that shoulder instability can cause neck pain and equally neck instability can cause shoulder pain. If the shoulder is stable but painful, examination of the upper cervical spine may find the answer to a shoulder pain that does not appear on a shoulder MRI.

In the video below, Dr. Brian Hutcheson, DC, explains some of the components and factors that may lead our providers to believe that difficult to treat shoulder pain may be coming from a problem in the cervical spine.

Today I want to review with you a case of a 35-year-old male that had unresolved shoulder pain. The patient had tried multiple, different treatments. The patient had unique shoulder pain in that it only bothered him during certain movements.

  • If he lifted his hand over his head, if he was washing his hair, or just scratching the top of his head, he would have a lot of shoulder pain, but only with certain movements. But at rest, he had no shoulder pain.
  • Shoulder pain can be in different areas whether it’s in the front of your arm, or if it’s in the back or can be up closer to your neck in the trapezius region.
  • For this patient, he had pain in his trapezius region and also on his rear deltoid area.

We felt his shoulder pain was coming from something in his neck. That is why he had a lot of previous failed treatments

When he came into our office, he was examined by Dr. Hauser (Ross Hauser, MD) and myself and we came up with an idea that we felt his pain was coming from something in his neck. Dr. Hauser suggested he do a DMX (Digital Motion X-ray) and have him do the motion to see if his neck was the cause of his shoulder pain.

Explanatory note: DMX Open Mouth View – What is it? What does it do? How did it help determine this patient’s pain source?

At 0:55 seconds of the video:

In this still from the video, Dr. Hutcheson describes the DMX image of this patient with unresolved shoulder pain that our team suspected was originating in his cervical spine. Facing the DMX machine, the patient opens his/her mouth to reveal a clearer image of what is happening at the C1-C2 vertebrae and if a malalignment in these vertebrae are causing shoulder pain.

In this still from the video, Dr. Hutcheson describes the DMX image of this patient with unresolved shoulder pain that our team suspected was originating in his cervical spine. Facing the DMX machine, the patient opens his/her mouth to reveal a clearer image of what is happening at the C1-C2 vertebrae and if a malalignment in these vertebrae are causing shoulder pain.

This patient had many shoulder treatments for his pain. His imaging showed a shoulder joint that was very stable. Our main finding was that his C2 was shifting when he was lifting his arm. This was causing his shoulder pain.

At 1:10 of the video, the patient is asked to move his head so we can observe what is happening in his cervical spine.

  • When the patient reaches his arm over his head, we can see that his C2 spinous process rotated (maligned) way to the left, and when he brought his arm down it rotated back almost to the middle (a more natural position)
  • His C2 vertebrae, the second bone of his neck, was rotating really far to the left every time that he lifted his arm over his head.

This patient had many shoulder treatments for his pain. His imaging showed a shoulder joint that was very stable. Our main finding was that his C2 was shifting when he was lifting his arm.

How we treated this patient

After the examination, we ended up adjusting him with our  Dynamic ortho neurological correction which is a specific kind of chiropractic adjustment that we do in the office.

In Dynamic ortho neurological correction, we watch the movement of the bones under the Digital Motion X-Ray and then we do a palpation and then try to correct the bone’s position and get them back into a better alignment.

At 2:28 of the video, the patient’s motion was reexamined about manipulation with Dynamic ortho neurological correction

  • The patient received a Dynamic ortho neurological correction. When we observed his C2 again, while he lifted his arm over his head, we saw that his C2 spinous process, had a greatly reduced shift to the left. The patient had symptomatic improvement and then the next step was he was going to get Prolotherapy treatment from Dr. Hauser to strengthen the cervical ligament in the neck to help provide neck stability. That we have identified a C2 shift to the left, we can really target the injections to help pull the C2 back to midline.

That cervical neck instability can cause shoulder pain, is not a new concept, but it seemingly does not get the attention it deserves.

In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including severe shoulder pain and loss of mobility and range of motion in that shoulder. These people are often confused because they are told that their shoulder pain does not exist on an MRI and that they may need to seek a different type of treatment to include counseling.

That cervical neck instability can cause shoulder pain, is not a new concept, but it seemingly does not get the attention it deserves.

In December 2016, doctors reported two case studies in the International Journal of Sports Physical Therapy (1), where cervical spine instability and neck problems were the cause of functional subacromial impingement.

Here is what was reported: 

“The signs of functional subacromial impingement often include weakness of the supraspinatus and infraspinatus. The cause of the weakness in the two cases appeared to be the result of stresses associated with forward head posture contributing to a possible intermittent C5 nerve root compression. The findings in the two cases would suggest the cervical spine should be considered as a potential cause of rotator cuff weakness in individuals presenting with subacromial impingement.”

Overlapping and masquerading: Is neck instability mistaken for shoulder pain? Does the shoulder cause neck pain?

An April 2020 study in the Global Spine Journal (2), suggested that: “Shoulder and spine pathology commonly overlap. Knowledge of anatomy, pain referral patterns, shoulder kinematics, and examination techniques are invaluable to the clinician in making an appropriate diagnosis and guiding treatment.”

This is the challenge many providers see in trying to figure out why someone has such severe shoulder pain and nothing obvious shows up on an MRI.

Patients suffer because cervical ligament laxity is a mystery

Digital motion X-ray showing C1-C2

This is another of our videos, it gives a clearer view of the DMX demonstrating C1-C2 instability in another patient.

  • Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
  • The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
  • This is treated with Prolotherapy injections (explained below) to the posterior ligaments that can cause instability.
  • At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.

Demonstration of Prolotherapy treatment

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders.

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Treating cervical ligaments – published research from Caring Medical

In 2014 headed by Danielle R. Steilen-Matias, PA-C, our Caring Medical team published these findings in The Open Orthopaedics Journal.(3)

The capsular ligaments (the ligaments of the joint capsule) are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain.

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.

  • In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, SHOULDER and ARM pain, and migraine headaches.

Questions? Get help and information from our Caring Medical Staff

References

1 Pheasant S. Cervical contribution to functional shoulder impingement: two case reports. International journal of sports physical therapy. 2016 Dec;11(6):980. [Google Scholar]
2 Katsuura Y, Bruce J, Taylor S, Gullota L, Kim HJ. Overlapping, Masquerading, and Causative Cervical Spine and Shoulder Pathology: A Systematic Review. Global Spine Journal. 2020 Apr;10(2):195-208. [Global Scholar]
3 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326.  [Google Scholar]

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