The neck and shoulder are linked and influence one another. Sometimes it can be difficult to sort out the primary problem.

Why does this matter? Because treatment for one won’t help - if the problem is being caused by the other.

Treatment can include surgery. Unnecessary surgery is obviously unnecessary, but can result in delays in appropriate treatment and complications from the surgery itself.

Here’s a case scenario:

Ms S is a 48 year-old with pain in her right arm. The pain extends from the top of her right shoulder, down into the front of her arm - to the level of her elbow. The pain does not extend below this point.

She has pins and needles in her index and long finger. The pins and needles occur only occasionally and are not a prominent feature of her condition. She has increased arm pain on elevating her arm above shoulder height and is sore when she tries to do up her bra. There are no clear-cut signs of the impingement, i.e. increased pain when the shoulder muscles are placed under stress. She has associated soreness over the right side of her neck, as well as mildly limited neck movement.

Ms S’s shoulder scan shows a partial thickness tear of the rotator cuff at the right shoulder. Her neck x-rays are unremarkable.

Her general practitioner sends the case to an orthopaedic surgeon. The orthopod considers that Ms S has a shoulder problem - noting the area of her pain, the shoulder scan, and the fact that her pain increases with elevating her arm.

Shoulder surgery is recommended, but Ms S’s condition does not improve with surgery that opens up the space around the rotator cuff.

This lady has features of a shoulder problem, but she also has some features of a neck problem. The pins and needles in her fingers cannot be explained on the basis of her shoulder problem. However, people often report of symptoms in their arm, so the pins and needles doesn't necessarily mean she is free from having a shoulder problem as the cause of her arm pain.

Further complicating the clinical picture is that people with a distinct shoulder problem often have neck soreness. This may be muscular, secondary to abnormal use of the shoulder and arm, but it adds to the chance of misdiagnosis.

There is no simple answer to this issue. We point out that it can be challenging to separate the neck and shoulder problems causing pain in the arm. An open mind and good history, combined with a cautious approach, can minimise inappropriate treatment.

If there is a question about whether the arm pain is coming from the shoulder or from the neck, identifying this as a clinical conundrum can help the doctor think through the options and minimise unnecessary procedures.

Patients can suffer significantly when the wrong source of the pain is chosen.