Neck Pain: Is It Coming From Your Neck — or Your Shoulder?
Neck pain is one of the most common reasons patients seek medical care. Sometimes the cause is relatively straightforward: a strained muscle, an awkward sleeping position, or hours spent looking down at a phone or computer.
Other times, neck pain can be caused by arthritis, a herniated disc, spinal stenosis, or pressure on a nerve.
But there is another possibility that patients—and sometimes even clinicians—can overlook:
The pain may actually be coming from your shoulder.
The neck and shoulder are closely connected, and problems in either area can produce symptoms that overlap. Figuring out where the pain is actually coming from is one of the most important steps in choosing the right treatment.
What Causes Neck Pain?
The neck, or cervical spine, is made up of seven vertebrae along with discs, joints, muscles, ligaments, nerves, and the spinal cord.
Common causes of neck pain include:
Muscle strains and sprains
Arthritis of the cervical spine
Degenerative disc disease
Herniated or bulging discs
Cervical spinal stenosis
Facet joint arthritis
Pinched nerves
Injuries such as whiplash
Many of these changes become increasingly common as we age. Importantly, degenerative changes on an X-ray or MRI do not necessarily mean they are responsible for someone's pain.
That's why I tell patients:
We don't treat an MRI. We treat the patient.
Your symptoms, physical examination, imaging, and overall clinical picture have to fit together.
When Neck Pain Travels Into the Arm
When a nerve in the neck becomes compressed or irritated, it can cause cervical radiculopathy, often called a pinched nerve.
Instead of staying in the neck, the symptoms may travel into the shoulder, shoulder blade, arm, or hand. A cervical disc herniation, for example, can produce burning pain or numbness involving the neck, shoulder, or arm.
Patients may experience:
Sharp or burning pain down the arm
Numbness or tingling
Pins and needles in the hand or fingers
Weakness in the shoulder, arm, or hand
Pain around the shoulder blade
This is where things can become confusing.
Shoulder pain doesn't always mean you have a shoulder problem.
A nerve problem in the neck can make the shoulder hurt even when the shoulder joint itself is perfectly healthy.
But the opposite is also true.
When Should You Think About Your Shoulder?
One of the first things I consider when evaluating neck and upper-arm pain is whether the symptoms could actually be originating from the shoulder.
Problems such as rotator cuff disease, shoulder arthritis, bursitis, and other shoulder conditions can produce pain that patients may interpret as coming from their neck.
There are a few clues that make me think more about the shoulder.
Pain with shoulder movement
If your pain consistently gets worse when you raise your arm, reach overhead, reach behind your back, put on a jacket, or perform similar shoulder movements, the shoulder deserves a closer look.
The rotator cuff plays an important role in lifting and rotating the arm, and rotator cuff problems can make everyday activities such as reaching overhead, getting dressed, or combing your hair painful or difficult.
Difficulty lifting your arm
If you feel like you physically cannot raise the arm—or you have significant pain or weakness when trying—the problem may be in the shoulder rather than the cervical spine.
A stiff shoulder
Loss of shoulder motion is another important clue.
Patients with shoulder arthritis, for example, can develop progressively restricted motion along with pain.
If turning your neck doesn't reproduce your symptoms but moving the shoulder does, that can help point us toward the shoulder.
Pain when sleeping on that shoulder
Night pain can occur with several conditions, but pain that becomes particularly noticeable when lying directly on the affected shoulder can raise suspicion for shoulder pathology.
Pain centered around the shoulder rather than traveling down the arm
A pinched nerve frequently produces symptoms that radiate beyond the shoulder into the arm or hand.
Shoulder conditions are more likely to produce symptoms centered around the shoulder and upper arm, although there is considerable overlap.
That's why location alone isn't enough to make the diagnosis.
Neck or Shoulder? Sometimes It's Both.
This is an important point.
You don't necessarily have to choose one.
As we get older, it's common to develop degenerative changes in both the cervical spine and the shoulder. A patient can have cervical arthritis on an MRI and a rotator cuff problem at the same time.
The challenge is determining which problem is actually responsible for the symptoms you're experiencing.
A careful physical examination can be extremely helpful. I can evaluate neck motion, strength, sensation and reflexes while also examining shoulder range of motion and strength and looking for maneuvers that reproduce the patient's pain.
In some situations, additional imaging or diagnostic injections can help clarify the source of the symptoms.
This is one reason an MRI by itself shouldn't dictate treatment.
The Neck Symptoms You Shouldn't Ignore
There is also an important difference between pressure on a nerve and pressure on the spinal cord.
Compression of the spinal cord in the cervical spine can lead to cervical myelopathy.
Patients may notice symptoms that don't initially seem related to their neck:
Difficulty with balance or walking
Increasing clumsiness
Dropping objects
Difficulty buttoning shirts
Changes in handwriting
Loss of fine motor control
Weakness in the arms or legs
Numbness or tingling in the hands
These symptoms deserve medical evaluation, particularly when they are new or progressing.
Likewise, sudden or progressive neurologic weakness, symptoms following significant trauma, or other severe or rapidly changing symptoms should be evaluated promptly.
Do You Need an MRI for Neck Pain?
Not everyone with neck pain needs an MRI.
If the symptoms appear muscular and there are no concerning neurologic findings, conservative treatment may be appropriate before advanced imaging.
An MRI becomes more useful when symptoms suggest a problem involving the discs, nerves, spinal canal, or spinal cord.
But again, the MRI needs to be interpreted in context.
It's extremely common to see disc degeneration, bulging discs, arthritis, and other abnormalities as people age. The question isn't simply:
“Is something abnormal on my MRI?”
The better question is:
“Does what we're seeing explain what I'm experiencing?”
How Is Neck Pain Treated?
Treatment depends on the cause.
Many neck conditions can initially be treated without surgery. Depending on the diagnosis, treatment may include physical therapy, exercise, activity modification, medications when appropriate, and occasionally injections. Spinal injections may have both therapeutic and diagnostic roles when neck or arm pain is believed to originate from the spine.
And if the evaluation suggests the shoulder is actually responsible for the symptoms, treating the cervical spine obviously isn't going to solve the problem.
That's why getting the diagnosis right comes first.
Does Seeing a Spine Surgeon Mean I'll Need Surgery?
No.
One of the misconceptions I hear frequently is that seeing a spine surgeon automatically means you're going to be offered surgery.
Most patients don't start with surgery.
The purpose of the evaluation is to determine where the pain is coming from, identify any concerning neurologic problems, and then discuss the least invasive treatment that makes sense.
Surgery becomes a consideration when there is a structural problem that clearly corresponds with the patient's symptoms and when the expected benefits justify the risks.
The Bottom Line
If your neck hurts, don't automatically assume the problem is a disc.
And if your shoulder hurts, don't automatically assume it's your shoulder.
The cervical spine and shoulder can produce surprisingly similar symptoms.
Pain traveling down the arm with numbness, tingling, or weakness may suggest a nerve problem in the neck. Pain that's strongly associated with lifting or moving the arm, significant shoulder stiffness, or difficulty performing overhead activities may make us think more about the shoulder. Rotator cuff disorders in particular commonly affect lifting and rotation of the arm.
Sometimes it's the neck.
Sometimes it's the shoulder.
Sometimes it's both.
The first step isn't deciding on a treatment. It's figuring out what we're actually treating.
Neck or Shoulder Pain That Isn't Getting Better?
If you're experiencing persistent neck or shoulder pain, pain traveling into your arm, numbness, weakness, loss of hand coordination, or balance problems, an evaluation can help determine where your symptoms are coming from and what treatment options may be appropriate.
Domingo Molina IV, MD, FAAOS
Orthopedic Spine Surgeon
This article is for general educational purposes and is not a substitute for individual medical advice, diagnosis, or treatment.