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Step-by-Step Algorithm: Localizing the Origin of Neck Pain with Shoulder/Arm Pain and Numbness

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PHASE 1 — TRIAGE: RED FLAGS FIRST

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PHASE 2 — STRUCTURED HISTORY (Localizing the Pain Generator)

Ask these targeted questions:

• Neck + posterior head + shoulder + radiating down arm with electric/burning/shooting quality → strongly suggests cervical radiculopathy
• Pain in supraclavicular fossa, axilla, medial arm, worsened by arm elevation → suggests brachial plexopathy / thoracic outlet syndrome (TOS)
• Pain localized to shoulder joint, worsened by shoulder rotation and abduction, no numbness/weakness → suggests shoulder pathology (rotator cuff, subacromial bursitis)
• Diffuse axial neck pain, no arm radiation, stiff neck → suggests cervical facet, muscle, or ligamentous origin

• Pain worsened by neck extension + rotation toward the painful side → cervical foraminal compression (radiculopathy)
• Pain relieved by placing hand on top of head (shoulder abduction relief sign) → positive in ~49% sensitivity, 76% specificity for radiculopathy (Thoomes 2026)
• Pain worsened by Valsalva, coughing, sneezing → nerve root compression (intradiscal pressure increase)
• Pain worsened by shoulder/arm movement, independent of neck movement → primary shoulder pathology
• Pain worsened by arm elevation above head (especially with repetitive tasks) → TOS or brachial plexus

• Ask the patient to draw the pain. Dermatomal radiation pattern is key:
  • Lateral arm, lateral deltoid: C5
  • Lateral forearm, thumb and index finger: C6
  • Posterior arm, dorsal forearm, middle finger: C7
  • Medial forearm, ring and little finger: C8
  • Medial arm, axilla: T1
  • Diffuse medial arm + hand, worse with arm overhead: brachial plexus / TOS (medial cord)

• Focal dermatomal numbness → nerve root
• Numbness in ulnar distribution (4th + 5th fingers) without neck pain → consider cubital tunnel or C8/T1 root
• Diffuse hand numbness worse at night, bilateral → consider carpal tunnel or myelopathy
• Progressive hand clumsiness (difficulty with buttons, deteriorating handwriting) → cervical myelopathy until proven otherwise (Harrison's 22E)

• Age < 45 + acute onset + radiation: likely disc herniation
• Age > 45 + gradual onset + multiple root levels: likely cervical spondylosis/foraminal stenosis
• Young female + droopy shoulders + medial arm symptoms: consider TOS (neurogenic)
• History of cancer anywhere: always consider metastatic disease

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PHASE 3 — PHYSICAL EXAMINATION (Systematic Sequence)

Step 1: Observation

• Posture: forward head, shoulder asymmetry, muscle wasting
• Skin: herpes zoster eruption (consider segmental zoster paresis)
• Neck mass above clavicle (Pancoast tumor, cervical rib, enlarged lymph node)

Step 2: Cervical Range of Motion (ROM)

• Assess flexion, extension, lateral bending, rotation
• 50% of cervical rotation originates from C1–C2 (atlantoaxial); restriction here suggests upper cervical pathology
• Restriction + pain reproduction in extension + rotation toward symptomatic side → foraminal stenosis / disc herniation
• Global restriction with spasm → muscular or inflammatory

Step 3: Palpation

• Midline spinous process tenderness → disc, fracture, infection
• Paraspinal tenderness → muscular origin, facet referral
• Supraclavicular fullness or pulsation → TOS, Pancoast, aneurysm
• Shoulder tenderness → greater tuberosity (rotator cuff), AC joint, bicipital groove

Step 4: Neurological Examination (Critical for root-level localization)

• Hyperreflexia (brisk or spreading reflexes)
• Babinski sign
• Clonus (>3 beats)
• Hoffmann's sign: snap the distal phalanx of the middle finger — involuntary flexion/adduction of thumb and index = positive; perform this whenever cord pathology is suspected (Harrison's 22E)
• Spastic gait, inability to tandem walk

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PHASE 4 — SPECIAL PHYSICAL EXAMINATION TESTS

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TEST 1 — Spurling's Maneuver (Cervical Compression Test)

• Sn: 0.53 (pooled); improves to 0.67 when combined with neck rotation/extension
• Sp: 0.92 (highly specific)
• Clinical role: RULE IN / CONFIRM cervical radiculopathy — not a screening test. A positive Spurling's is strong evidence for nerve root compression.

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TEST 2 — Cervical Distraction Test

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TEST 3 — Shoulder Abduction Relief Sign (Bakody Sign)

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TEST 4 — Upper Limb Neurodynamic Tests (ULNT / Brachial Tension Tests)

1. Scapular depression
2. Shoulder abduction to 110°, external rotation
3. Forearm supination, wrist + finger extension
4. Elbow extension
5. Cervical lateral flexion away from the tested side (sensitizing maneuver)

• ULNT1: Sn 0.70, Sp 0.71
• Combined 4 ULNTs: Sn 0.97, Sp 0.51
• Clinical role: RULE OUT cervical radiculopathy — negative combined ULNTs effectively exclude it. A positive ULNT combined with a positive Spurling's significantly raises likelihood. (Verhagen et al. 2023, PMID 37967500)

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TEST 5 — Lhermitte's Sign

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TEST 6 — Hoffmann's Sign

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TEST 7 — Adson's Test (for Thoracic Outlet Syndrome — Arterial)

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TEST 8 — Roos Test / EAST Test (Elevated Arm Stress Test — Neurogenic TOS)

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TEST 9 — Shoulder Tests (to exclude primary shoulder pathology)

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PHASE 5 — DIAGNOSTIC DECISION ALGORITHM

Neck pain + shoulder/arm pain + numbness
           ↓
   RED FLAGS present?
   YES → Immediate imaging + urgent referral
           ↓
   NO → Does pain radiate in a dermatomal pattern?
         ↓
   YES → Neurological exam
          ↓
     Any REFLEX loss, MUSCLE WEAKNESS, or SENSORY DEFICIT?
          ↓
     YES → Which root level? (Use C5–T1 table)
           Perform Spurling's + Distraction + ULNTs
              ↓
        Spurling's POSITIVE (Sp 0.92) → Cervical Radiculopathy (CONFIRM)
        Combined ULNTs NEGATIVE (Sn 0.97) → Cervical Radiculopathy EXCLUDED
              ↓
        Check for myelopathy signs:
        Hoffmann's / Lhermitte's / Hyperreflexia / Clonus / Spastic gait?
        YES → Cervical Myelopathy → urgent MRI
              ↓
     NO neurological deficits found:
        Is pain medial arm + hand + worse overhead/supraclavicular fossa?
        YES → Perform Adson's + Roos → TOS / Brachial Plexopathy
              ↓
        Is pain localized to shoulder joint + worsened by shoulder ROM only?
        YES → Shoulder impingement tests (Neer's, Hawkins, Empty Can)
              → Shoulder pathology (Rotator cuff / bursitis)

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PHASE 6 — LOCALIZING SUMMARY TABLE

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PHASE 7 — INVESTIGATIONS (Guided by Clinical Findings)

• MRI cervical spine: First-line imaging for suspected radiculopathy or myelopathy (identifies disc herniation, foraminal stenosis, cord compression)
• CT myelography: When MRI contraindicated or post-surgical hardware present; distinguishes disc vs. osteophyte
• EMG/NCS: Differentiates radiculopathy from brachial plexopathy or peripheral neuropathy. In radiculopathy: CMAP amplitude may be reduced, but SNAP is preserved (because dorsal root ganglion is spared). (Bradley & Daroff's)
• Cervical X-ray: Low yield for radiculopathy; useful for alignment, fracture, atlantoaxial instability
• Chest X-ray/CT chest: If Pancoast tumor suspected (apical lung lesion + T1 root + Horner's triad)
• Vascular duplex: If arterial TOS suspected

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Evidence Summary

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