Can’t Get Rid of Shoulder Tip Pain? – Think C4/5 Neck Facet

Various measures have been used for trapezius tip pains but they keep coming back. Now it’s confirmed the neck is a player.

Injection in the Cervical Facet Joint for Shoulder Pain With Myofascial Trigger Points in the Upper Trapezius Muscle

By Chien-Tsung Tsai, MD, MSc; Lin-Fen Hsieh, MD; Ta-Shen Kuan, MD, MS; Mu-Jung Kao, MD; Chang-Zern Hong, MD
ORTHOPEDICS 2009; 32:557

free full article here

• 89 people with unilateral trapezius tip pain and neck pain

Used 3 tests to suggest facet involvement:

• Cervical facet irritation test –  patient turns  head to pain side with pain, followed by neck extension – aggravation of upper trapezius myofascial trigger point found.  “To increase the degree of irritation to the C4-5 facet, the examiner’s index finger was placed just below the C4-5 facet joint before the rotation–extension movement of the neck. If the pain got stronger, this was considered a positive C4-5 facet sign.” I do a variation of this test where the neck is rotated to the same side, the thumb placed below sore level and the head side-bent – there will be pain and a sense of stiffness there.
• Cervical facet compression test. When the ipsilateral C4-5 facet joint was compressed with the examiner’s finger, pain in the myofascial trigger point of upper trapezius could be aggravated. This was considered a positive facet compression test.  Extreme version of this was the doorbell pushbutton phenomenon where pressure would actually radiate pain down.
• Another test I use I guess I can call the cervical traction test – Check the tenderness and resistance to massage of various triggers- trap tip, rhomboid minor, supra and infraspinatus,  deltoid,  latissimus dorsi – before and after application of an inflatable cervical traction unit – improvement would suggest either facet,  disc or radicular (nerve sciatica) disease. Facet disease is much more common though.

• Cervical facet tenderness versus disc tenderness – Local tenderness just back of the transverse processes. This tenderness should be more than the tenderness anteriorly over the disc which has been suggested as a reliable  test for disc disease by Dr. John Mc Fadden – differentiating it from “Fibromyalgia”
  Anterior Cervical Spine Tenderness: The Key to the Fibromyalgia Examination

Metal marker confirming
tenderness at disc position

• “1.0 mL of triamcinolone (40 mg/mL) and 1.0 mL of 1% lidocaine was prepared for injection. A 3-mL syringe and a #27 needle (diameter 0.4 mm) with a length of 1.25 inches were used for injection.”  – lateral technique described in article
• Control group just had deep paraspinous injection

Results:

“Half of the patients in the experimental group, but none of the control patients, reported being completely pain free 1 month after the injection.”

Comment – I think this is very exciting and explains why studies attempting to treat shoulder tip pains by local treatments all fail – It’s coming from neck in 1/2 of cases. Injecting local into area can kill if needle threads an external spinal artery called a radicular artery. Particulate material in steroid injections, by itself, can cause a stroke if gets stuck in a spinal vessel as well. I have been trying injection of plain Botox with results.