Skip to main content
NCBI home page
The Journal of Manual & Manipulative Therapy logoLink to The Journal of Manual & Manipulative Therapy
. 2024 Dec 20;33(3):253–261. doi: 10.1080/10669817.2024.2443134

The prevalence of subclassification-based diagnoses when considering cervical contribution in shoulder pain patients: a secondary analysis from a previous research

Alberto Roldán-Ruiz a,b, Javier Bailón-Cerezo c,d,✉, María Torres-Lacomba a,c,e
PMCID: PMC12090318  PMID: 39706149

ABSTRACT

Objectives

Determining the prevalence of different shoulder subclassification-based diagnoses using a defined exclusion-type diagnostic algorithm. Analyzing the relationships between cervical contribution and other shoulder diagnoses.

Methods

A proposal of a shoulder pain diagnosis based on functional subclassification was carried out in all subjects. The included diagnoses were cervical contribution, acromioclavicular joint pain, stiff shoulder, atraumatic unstable shoulder, rotator cuff-related shoulder pain, and ‘Others’. Each diagnosis was based on a defined exclusion-type diagnostic algorithm. Cervical contribution was considered if a > 30% shoulder symptom modification in pain intensity was recorded after a cervical spine screening. Since a > 30% change in symptoms does not definitively indicate a categorical diagnosis, cervical contribution was presumed to potentially coexist with other diagnostic labels in these cases. If there was a complete (100%) resolution of shoulder symptoms after the cervical spine screening, cervical contribution was deemed the sole diagnosis.

Results

Sixty subjects were analyzed. Rotator cuff-related shoulder pain was the most prevalent diagnosis (36.7%, n = 22), followed by stiff shoulder, being present in 30% (n = 18) of subjects. Cervical contribution (13.3%, n = 8), atraumatic unstable shoulder (11.7%, n = 7), others (6.7%, n = 4) and acromioclavicular joint pain (1,7%, n = 1) completed the results. In patients diagnosed with rotator cuff-related shoulder pain, cervical contribution coexisted in 71,4% of them. Thus, a statistically significant association between cervical contribution and rotator cuff-related shoulder pain was found (p = 0,002). This association was not observed in any of the other diagnoses.

Discussions/Conclusions

Rotator cuff-related shoulder pain was the most prevalent diagnosis, followed by stiff shoulder and cervical contribution. Cervical contribution may coexist with other diagnoses or even be considered as a unique diagnosis itself. Patients diagnosed with rotator cuff-related shoulder pain are more likely to have cervical contribution.

KEYWORDS: Shoulder pain, diagnosis, prevalence, neck, clinical reasoning

Highlights

  • Rotator cuff-related shoulder pain is the most prevalent diagnosis in shoulder pain.

  • Cervical contribution may coexist with other diagnoses or be a unique diagnosis.

  • Cervical contribution is the 3rd most prevalent diagnosis.

  • Rotator cuff-related shoulder pain patients are more likely to have cervical contribution.

Introduction

Shoulder pain is reported as the third most common cause of musculoskeletal pain [1], with an annual prevalence ranging between 5% and 47% [2]. The accurate diagnosis of this condition remains a challenge for clinicians due to the lack of consistency and uniformity in both the existing diagnostic labels and the criteria used to define them [3]. In this regard, pathoanatomical models do not seem to be supported by available scientific evidence, as imaging tests and orthopedic assessments do not appear to provide relevant information in shoulder pain patients [4–9,10–12]. Therefore, to facilitate the diagnostic process, it may be necessary to make diagnoses based on subclassifying patients who share easily and reliably reproducible characteristics [3].

Several shoulder subclassification-based diagnoses have been reported. In 2014, Juel and Natvig included the following 10 diagnoses: subacromial pain syndrome, shoulder muscle myalgia, adhesive capsulitis, complete rotator cuff tears, acromioclavicular joint (ACJ) osteoarthritis, glenohumeral joint osteoarthritis, instability or anterior labral lesions, SLAP lesions, and multidirectional instability. The most diagnosed entities were subacromial pain (36%), myalgia (17%) and adhesive capsulitis (11%). Similarly, different clinical reasoning algorithms, such as those by Mitchell et al. [13] and Artus et al. [14] in primary care, outlined classifications involving cervical spine pain, shoulder instability, glenohumeral joint disorders, and rotator cuff problems. Nevertheless, this kind of diagnostic approach has received little attention lately, especially when considering cervical contribution in shoulder pain patients seeking orthopedic/traumatology consultation.

Additionally, studies investigating the reliability of shoulder pain diagnosis based on different subclassifications have shown moderate to substantial inter-examiner reliability results with Kappa coefficients ranging from 0,45 to 0,68 [15–17]. Nevertheless, these studies show some potential difficulties with the proposed subclassifications in order to achieve reliable diagnoses: lack of homogeneity in clinical characteristics in the proposed subclassifications, reliance on imaging and orthopedic tests, limited definition and precision of the diagnostic labels, or the use of numerous diagnostic labels. These issues can complicate the subclassification by separating subgroups with similar clinical presentations.

In this context, the shoulder region and the cervical spine should be understood as an inseparable functional unit due to their neurophysiological, metameric, biomechanical, and myofascial connections [18–28]. Normally, when patients report pain in the buttock, groin, or leg, one of the initial diagnostic hypotheses is often the lumbar origin or involvement [29–34]. However, the clinical reality is that when managing shoulder pain, the influence of the cervical spine is not commonly considered, or if this hypothesis is considered, defined, and standardized tools for its evaluation are not known [35]. Despite this, the idea that the cervical spine should be examined and ruled out prior to any specific diagnosis of the shoulder seems to be increasingly present in the literature [36–40]. However, the role of the cervical spine in shoulder pain, the most effective method to screen the cervical spine, and the implications of these aspects for clinical practice are still poorly understood. These factors limit the conclusions that can be drawn from the scientific literature and emphasize the need to increase research in this area [41].

Given the aforementioned, it appears that the need for shoulder pain diagnoses based on subclassification is gaining relevance in scientific research. Nonetheless, while there might be some agreement when considering subgroups such as acromioclavicular joint lesions, glenohumeral instability, rotator cuff-related shoulder pain (RCRSP), or glenohumeral mobility disorders, there is no definitive consensus on the diagnostic labeling, and standardized criteria are not shared. Therefore, the aims of this study were to determine the prevalence of different shoulder subclassification-based diagnoses using a defined exclusion-type diagnostic algorithm and to analyze the relationships between cervical contribution with other shoulder diagnoses.

Methods

Study design and setting

This paper reports a secondary analysis of the study ‘The prevalence of cervical contribution in patients reporting shoulder pain. An observational study’ [35] which was carried out between February 2020 and June 2022 at two Hospitals (Madrid, Spain).

This study was approved by the Research Ethics Committee from Hospital Universitario Príncipe de Asturias, with code OE 25/2019.

Participants

Consecutive participants (Figure 1) with a new episode of shoulder pain, seeking orthopedic/traumatology consultation for the first time, aged over 18 years, experiencing movement-related shoulder pain and reporting a ≥ 3 score on the Numeric Pain Rating Scale (NPRS) were eligible for inclusion in the study. Exclusion criteria were previous shoulder surgery, pain at rest that improves with movement, traumatic history, previous shoulder fractures, systemic disease diagnosis, radiculopathy, peripheral neuropathy, or radicular pain diagnosis; and local infiltration of analgesic or anti-inflammatory drugs during the 6 months prior to the examination; or intake of anti-inflammatory or analgesic drugs on the day of the examination.

Figure 1.

Figure 1.

Open in a new tab

Sample’s collection and analysis flowchart.

Details regarding sample size and sample recruitment are provided in the paper with the primary analysis conducted by [35]. Notably, no prevalence data on cervical contribution to shoulder pain were available, making it impossible to determine an a priori sample size. Therefore, our aim was to recruit the largest possible sample.

Procedure

Consent forms were signed, and data collection regarding clinical examination was carried out by the physical therapist that assessed the subjects. A proposal of a shoulder pain diagnosis based on functional subclassification was carried out in all subjects. Each subgroup diagnosis depended on a clearly defined algorithm based on diagnosis of exclusion. Thus, the diagnosis was not therapist-dependent. Subjects were evaluated by the same physiotherapist from February 2020 to June 2022, who had 6 years of experience in assessing and providing conservative treatment for shoulder pain patients.

The initial phase of the evaluation involved a cervical spine screening. Cervical contribution was considered if there was a > 30% reduction in shoulder pain intensity following the cervical spine screening [42,43]. Since a > 30% change in symptoms does not definitively indicate a categorical diagnosis, cervical contribution was presumed to potentially coexist with other diagnostic labels in these cases. If there was a complete (100%) resolution of shoulder symptoms after the cervical spine screening, cervical contribution was deemed the sole diagnosis. The cervical spine screening (Appendix 1) employed various shoulder symptom modification strategies integrated within an evaluative framework to identify potential intra-session changes. Following each intervention, participants were asked to repeat their most painful movement and to report their new pain intensity using the NPRS. Participants were subsequently categorized into cervical contribution and non-cervical contribution groups based on this assessment.

After cervical spine screening, all subjects were classified based on their clinical symptoms, with the primary aim of ruling out specific clinical presentations. This proposal was based on functional subclassification that considered terms such as cervical contribution, acromioclavicular joint pain, stiff shoulder, atraumatic unstable shoulder, RCRSP, and ‘others’. Each label had a proper definition and a checklist of characteristics that would include a subject in a particular subgroup after excluding the one/s prior. If the subject did not match in any of the mentioned labels, then he was grouped as ‘others’. In depth classification criteria can be observed in Table 1.

Table 1.

Subclassification-based diagnosis.

Diagnostic label Diagnostic criteria
Cervical contribution >30% shoulder symptom modification in pain intensity after cervical spine screening as a coexisting diagnosis.
100% shoulder symptom modification in pain intensity after cervical spine screening as a unique diagnosis itself.
Acromioclavicular joint pain Exclusion of the above diagnosis.
Pain in the joint area, pain and movement restriction in horizontal adduction and overhead movements. Positive cross-body adduction stress, resisted extension and O’Brien active compression tests.
Stiff shoulder Exclusion of the above diagnoses.
Multidimensional active and passive loss of mobility (<45º of external rotation and/or <50% global mobility compared to healthy shoulder), decreased rotations as the humerus increases abduction from 45° to 90°.
Patients aged 40 to 65 years, gradual and progressive onset of pain and stiffness, limitation of sleeping or dressing, symptom reproduction with end of range passive movements, restriction in all directions of accessory joint mobilization.
Atraumatic unstable shoulder Exclusion of the above diagnoses.
Patients aged under 25 years, >90º of external rotation and/or >180º of abduction and flexion, subjective sensation of loose or unstable shoulder, excessive glenohumeral accessory movements in multiple directions, ability to actively subluxate the shoulder. Positive apprehension-repositioning test, Jerk test, load-shift test and/or sulcus sign.
Rotator cuff related shoulder pain Exclusion of the above diagnoses.
Load changes reported, painful arch and/or active movement restriction, symptom reproduction with resisted external rotation and/or abduction.
Open in a new tab

Data analysis

Statistical analysis was carried out using the SPSS version 27.0 program (IBM Corp, Armonk, NY, USA). Continuous variables were described using their mean and standard deviation or median and interquartile range, depending on their distribution, previously determined with the Kolmogorov–Smirnov (K-S) test. Qualitative variables were described with absolute and relative percentage frequencies. Baseline personal and clinical variables related risk was estimated by calculating the Odds Ratio. Prevalence was calculated by estimating the number of subjects matching each diagnosis.

The measure of association between two categorical variables samples was calculated using Pearson’s chi-square, or Fisher’s exact test.

Results

A total of 60 subjects were finally included. Sociodemographic data and baseline clinical characteristics for the entire sample, as well as by subclassification-based diagnoses, are shown in Appendix 2 – Table.

The mean age of the whole sample was 48.78 years old, being 43.3% of participants female. 58.3% of subjects had a > 6 months duration of symptoms, 51.7% had upper limb radiating symptoms, 81.7% suffered from unilateral pain, 38.3% experienced neck pain prior to the onset of shoulder symptoms and 38.3% had concomitant neck pain.

Prevalence of subclassification-based diagnosis

Shoulder pain diagnosis based on a subclassification showed a distribution of 36,7% (n = 22) of subjects presented with RCRSP, making it the most prevalent subgroup. The next most prevalent diagnosis was stiff shoulder, being present in 30% (n = 18) of subjects, followed by cervical contribution, which ranked third at 13.3%. Finally, the unstable shoulder subgroups (11.7%), Others (6.7%), and ACJ pain (1.7%) completed the results (Figure 2).

Figure 2.

Figure 2.

Open in a new tab

Prevalence of diagnoses when considering CSPI as a unique diagnosis. Frequency (valid percentage).

The prevalence of subjects who experienced a 100% symptom modification that would have been diagnosed with another clinical label was distributed as follows: 6 subjects initially diagnosed with RCRSP experienced complete improvement, along with 1 subject from stiff shoulder group and 1 subject from the ‘Others’ group. The remaining subgroups had no participants who experienced 100% symptom modification. These results do not exclude cases when the modification was not a 100%, and thus cervical contribution could still coexist with different clinical subgroups.

Association between cervical contribution and other diagnoses

When analyzing cervical contribution coexisting with other subgroups, Table 2 also shows the prevalence of cervical contribution within different clinical subgroups when it is not considered a unique diagnosis. The RCRSP subgroup had the most cervical contribution coexisting diagnoses, indicating that 14 out of 22 experienced a >30% and <100% symptom modification after a cervical spine screening. On the other hand, the stiff shoulder subgroup had the highest proportion of non-cervical contribution diagnoses; out of the total 18 participants with stiff shoulder, 14 of them did not experience a coexisting cervical contribution diagnosis.

Table 2.

Cervical contribution distribution within diagnostic subgroups. Frequency (valid percentage).

Diagnosis Cervical contribution Non-cervical contribution
Acromioclavicular joint pain 0 (0) 1 (100)
Stiff shoulder 4 (22,2) 14 (77,8)
Atraumatic unstable shoulder 2 (28,6) 5 (71,4)
Rotator cuff related shoulder pain 14 (77,8) 8 (22,2)
Others 2 (50) 2 (50)
Open in a new tab

Upon analyzing associations between cervical contribution and diagnoses based on subclassification, the results have shown a statistically significant association between cervical contribution and the diagnosis of RCRSP (p = 0.008). This association was not observed when analyzing the presence of cervical contribution across the other diagnoses combined. Out of the 22 subjects with RCRSP, 14 of them had cervical contribution. However, among the remaining 30 participants, only 8 of them presented with cervical contribution.

Discussion

In the analyzed sample, the most prevalent diagnosis was the RCRSP subgroup, present in 36.7% of the subjects. This aligns with research suggesting that rotator cuff problems are the most prevalent diagnosis in shoulder problems [44–46]. Additionally, the stiff shoulder subgroup was present in 30% of the studied subjects, followed by cervical contribution (13,3%) and atraumatic unstable shoulder pain (11,7%). The fact that these four clinical entities are the most prevalent is supported by research that has typically considered these subgroups as the major diagnostic categories in shoulder conditions [13,14,47]. Finally, the least prevalent subgroups were Others (6,7%) and ACJ pain (1.7%). The traumatic history as an exclusion criterion in this study could explain the low prevalence of ACJ pain [48]. Similarly, given the difficulty in conclusively determining a specific diagnosis when managing pain patients, it is understandable that there were some subjects not matching the subclassification labeling, thus associated with the Others subgroup.

In this regard, our results have shown that patients presenting with the most prevalent shoulder condition, that is rotator cuff-related shoulder pain, are more likely to exhibit cervical contribution. Understanding this highlights the potential role of cervical contribution as a diagnostic hypothesis, which may help address the current lack of consistency in the diagnoses proposed for shoulder pain. Indeed, as previously reported [41], not identifying cervical contribution in shoulder pain patients may lead to: a) heterogeneous samples in research, b) incorrect treatments or treatments aimed at the wrong objective, as treating the shoulder in a patient with cervical contribution compromises treatment outcomes, and c) consequently, these two issues may lead to research and clinical applicability being imprecise. Certainly, it seems that cervical contribution may coexist with other diagnoses or even be considered a unique diagnosis, potentially challenging previous prevalence data, and even more importantly, potentially altering the treatment objectives for patients with cervical contribution. Similarly, assessing the cervical spine might help identify patients who could benefit from cervical rather than shoulder-focused interventions, which might also challenge current clinical practice.

Regarding subclassifications of shoulder pain diagnoses observed in the literature, different proposals have been reported: from ones similar to this research’s subclassification [13,14] to highly variable subclassifications with numerous non-homogeneous diagnostic labels that include terms not supported by current scientific evidence and whose aim has often been to identify possible underlying pathology, despite the aforementioned difficulties in identifying the specific pain generator [15–17,49]. In this respect, it is worth noting that the proposal presented in this paper is in line with the idea that managing patients with pain is inherently complex, particularly during the diagnostic process. The concept of diagnosis of exclusion emphasizes that the goal of evaluations is not to achieve absolute certainty in confirming a diagnosis, but rather to attain the highest possible certainty in ruling out diagnoses when the patient does not exhibit their associated characteristics. By excluding one or more diagnoses, the likelihood of accurately categorizing the patient within an appropriate clinical entity should increase, thereby enhancing the legitimacy of the final diagnosis.

With regard to the cervical contribution in shoulder pain, research has justified this phenomenon with the regional interdependence concept, where disorders in a remote anatomical region might contribute to or be associated with the patient’s chief complaint [50,51]. Furthermore, it seems that relying on the anatomical painful region may mislead the therapist in clinical decisions [36,38–40]. If spinal-origin pain is incorrectly interpreted as a local and distal problem, it can trigger a process of poor decision-making and inadequate patient management [52]. Considering this, a subject could be diagnosed with cervical contribution alongside any other shoulder pain diagnosis if there was a positive response to the cervical spine examination, or otherwise be classified into any of the other diagnostic subgroups after excluding cervical contribution. This consideration comes along with the idea that applying symptom modification strategies as a diagnostic and treatment-guided approach can enhance clinical practice, as identifying specific structures or regions where intervention leads to symptom improvement provides a framework for tailoring physical interventions [44].

In [44] physiotherapists could provide three diagnostic hypotheses during the participants’ clinical history. In that context, the study analyzed the coexistence of proposed shoulder diagnoses, including labels such as ‘Cervico-thoracic,’ ‘Glenohumeral,’ ‘Subacromial Impingement,’ and ‘Acromio or Sternoclavicular’ pain origins. The subgroup of subjects with shoulder pain of cervical or thoracic origin proposed a total of 122 times, coexisted in 70 instances with Subacromial Impingement, 24 instances with Acromio- or Sternoclavicular problems, and 25 instances with Glenohumeral problems. Similarly [45], described that 77% of the subjects presented with more than one diagnosis, once again focusing on the possibility of coexisting conditions. Additionally, of the eight subjects diagnosed with referred neck pain in that study, six also had diagnoses of tendinosis and impingement, while only two received the exclusive diagnosis of cervical referred pain [45]. This demonstrates the clinical complexity in shoulder pain diagnosis [3], where symptomatic patterns can be similar across various diagnostic labels, and where the coexistence of multiple diagnoses can be a real challenge for clinicians.

Indeed, in cases where the diagnosis of cervical contribution coexisted with other clinical entities, it cannot be argued that cervical contribution is more or less important than the other diagnosis. Thus, it would be necessary to analyze whether these subjects can exclusively improve with cervical treatment, compared to those receiving only shoulder treatment or combined treatment. In fact, the results showed a statistically significant association between the diagnosis of RCRSP and the presence of cervical contribution. This suggests that certain problems initially considered as cases of rotator cuff pathology might undergo a diagnostic change with a comprehensive examination, thus producing a change in treatment approach. Future studies are needed to shed light on this idea, as subjects who do not experience a 100% intrasession improvement exclusively with cervical treatment, but do so in the long term, could be diagnosed with exclusive cervical contribution as well.

In this regard, although low in prevalence (4 out of 18 subjects), the presence of cervical contribution has been reported in subjects categorized under the stiff shoulder subgroup. While the concept of stiff shoulder was not limited exclusively to frozen shoulder, clinically, there is a tendency to attribute limited movement to an intrinsic problem in the peripheral joint. However, in this study, changes in shoulder mobility associated with a potential cervical influence have been highlighted. A similar situation occurs with atraumatic unstable shoulder, where 2 out of 7 subjects showed cervical contribution. This situation may present a more challenging fact to understand, as articular instability typically suggests that the problem lies within the joint itself. For this reason, it would be particularly relevant to observe the potential evolution of these cases with exclusive cervical approaches, since the intrasession improvements obtained may be due to short-term effects of manual therapy and exercise [53,54]. Lastly, the only subject with ACJ pain was not diagnosed with cervical contribution, while 2 out of 4 subjects in the others subgroup received a cervical contribution diagnosis. Although the sample size is small, these data could highlight cervical contribution as a diagnosis that has not traditionally been considered, but could help address gaps in shoulder diagnostic issues [3].

Limitations and future perspectives

This study presents some limitations that are worth mentioning. First, the representativeness of the sample used in the study is a critical factor that needs to be addressed, as the included sample may not accurately reflect a broader population. As such, this may impact the generalizability of the findings. Additionally, the absence of studies examining the reliability of the algorithm used in the analysis prevents the assessment of the accuracy and consistency of the algorithm’s results. Given that the original observational study was not specifically designed for our research objectives, there may be some inherent limitations in the data collection process. Utilizing secondary data imposes certain constraints, such as the inability to control for all relevant variables and the potential for missing or outdated information. These limitations can affect the validity of the conclusions drawn from the study, and caution should be exercised when interpreting the results. Future research should aim to address these issues by employing more rigorous and targeted study designs.

Conclusions

Rotator cuff-related shoulder pain was the most prevalent diagnosis, followed by stiff shoulder and cervical contribution. Cervical contribution may coexist with other diagnoses or even be considered as a unique diagnosis itself. Patients diagnosed with rotator cuff-related shoulder pain are more likely to exhibit cervical contribution.

Supplementary Material

Supplemental Material
YJMT_A_2443134_SM7182.docx (31.4KB, docx)

Acknowledgements

We thank MD Álvaro Colino Castro (Clínica Cemtro, Madrid) for the referral of patients.

Biographies

Alberto Roldán-Ruiz, PhD. He is a physical therapist who works as a lecturer and researcher at Francisco de Vitoria University in Madrid, Spain. His primary research interest has focused on cervical contribution in shoulder pain, which he explored extensively during his PhD. Currently, he is actively involved in several multidisciplinary research projects, including: a) the effectiveness of immersive virtual reality in chronic shoulder pain; b) plant-based diets and cardiometabolic health; c) the relationship between dietary determinants, cardiometabolic biomarkers, and body composition with clinical characteristics in patients with migraines; and d) the impact of intermittent fasting and neuromuscular training on the microbiota of postmenopausal women with obesity.

Javier Bailón-Cerezo, PhD. He is a Spanish physiotherapist with a special interest in shoulder disorders and Sport Physiotherapy. He has been combining teaching physiotherapists and undergraduate students with clinical practice and research for the last 10 years. Currently, he teaches physiotherapy as full-time professor at La Salle Centro Universitario (Madrid, Spain) and supervises research for undergraduate, postgraduate, and doctoral physiotherapy students. He is member of the research groups “Physiotherapy in Women’s Health (Universidad de Alcalá)” and “CranioSpain” (La Salle Centro Universitario). Currently, he is working on several research projects related to Sport Physiotherapy and shoulder disorders and working as a Physiotherapist in National Teams of the Royal Swimming Spanish Federation.

María Torres-Lacomba, PhD. She is a senior lecturer at University of Alcalá, and the coordinator of the research group “Physiotherapy in Women’s Health Processes (FPSM)”. President of the Spanish Association of Physiotherapists in Women’s Health (AEF-SAMU). Director of the Official University Master’s Program “Physiotherapy in Women’s Health and Pelvic Health”, University of Alcalá. She is the lead investigator of 7 competitive research projects, and has participated in at least 40 JCR publications, 3 manuals, and 5 book chapters.

Funding Statement

The authors received no financial support for the research, authorship, and/or publication of this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author contributions statement

ARR was involved in the conception and design of JBC in the analysis and interpretation of the data. ARR wrote the paper and MTL reviewed it for the final approval of the version to be published. All authors agree to be accountable for all aspects of the work.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10669817.2024.2443134

References

  • [1].Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheumatic Dis. 1998;57(11):649–655. doi: 10.1136/ard.57.11.649 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [2].Luime JJ, Koes BW, Hendriksen IJM, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33(2):73–81. doi: 10.1080/03009740310004667 [DOI] [PubMed] [Google Scholar]
  • [3].Schellingerhout JM, Verhagen AP, Thomas S, et al. Lack of uniformity in diagnostic labeling of shoulder pain: time for a different approach. Man Ther. 2008;13(6):478–483. doi: 10.1016/j.math.2008.04.005 [DOI] [PubMed] [Google Scholar]
  • [4].Barreto R, Braman J, Ludewig P, et al. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg. 2019;28(9):1699–1706. doi: 10.1016/j.jse.2019.04.001 [DOI] [PubMed] [Google Scholar]
  • [5].Boettcher CE, Ginn KA, Cathers I.. The ‘empty can’ and ‘full can’ tests do not selectively activate supraspinatus. J Sci Med Sport. 2009;12(4):435–439. doi: 10.1016/j.jsams.2008.09.005 [DOI] [PubMed] [Google Scholar]
  • [6].Bradley MP, Tung G, Green A. Overutilization of shoulder magnetic resonance imaging as a diagnostic screening tool in patients with chronic shoulder pain. J Shoulder Elbow Surg. 2005;14(3):233–237. doi: 10.1016/j.jse.2004.08.002 [DOI] [PubMed] [Google Scholar]
  • [7].Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. Am J Roentgenol. 2011;197(4):W713–W719. doi: 10.2214/AJR.11.6971 [DOI] [PubMed] [Google Scholar]
  • [8].Lewis J. Rotator cuff related shoulder pain: assessment, management and uncertainties. Man Ther. 2016;23:57–68. doi: 10.1016/j.math.2016.03.009 [DOI] [PubMed] [Google Scholar]
  • [9].Schibany N, Zehetgruber H, Kainberger F, et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol. 2004;51(3):263–268. [DOI] [PubMed] [Google Scholar]
  • [10].Frost P, Andersen JH, Lundorf E. Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement? J Shoulder Elbow Surg. 1999;8(6):565–568. doi: 10.1016/S1058-2746(99)90090-3 [DOI] [PubMed] [Google Scholar]
  • [11].Milgrom C, Schaffler M, Gilbert S, et al. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br Volume. 1995;77(2):296–298. doi: 10.1302/0301-620X.77B2.7706351 [DOI] [PubMed] [Google Scholar]
  • [12].Sher JS, Uribe JW, Posada A, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–15. doi: 10.2106/00004623-199501000-00002 [DOI] [PubMed] [Google Scholar]
  • [13].Mitchell C, Adebajo A, Hay E, et al. Shoulder pain: diagnosis and management in primary care. BMJ. 2005;331(7525):1124–1128. doi: 10.1136/bmj.331.7525.1124 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [14].Artus M, Holt TA, Rees J. The painful shoulder: an update on assessment, treatment, and referral. Br J Gen Pract. 2014;64(626):e593–5. doi: 10.3399/bjgp14X681577 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [15].Carter T, Hall H, McIntosh G, et al. Intertester reliability of a classification system for shoulder pain. Physiotherapy. 2012;98(1):40–46. doi: 10.1016/j.physio.2010.12.003 [DOI] [PubMed] [Google Scholar]
  • [16].de Winter AF, Jans MP, Scholten RJ, et al. Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement. Ann Rheum Dis. 1999;58(5):272–277. doi: 10.1136/ard.58.5.272 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [17].Storheil B, Klouman E, Holmvik S, et al. Intertester reliability of shoulder complaints diagnoses in primary health care. Scand J Prim Health Care. 2016;34(3):224–231. doi: 10.1080/02813432.2016.1207139 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [18].Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: a clinical evaluation. Spine. 1990;15(6):458–461. doi: 10.1097/00007632-199006000-00005 [DOI] [PubMed] [Google Scholar]
  • [19].Asker M, Ravnanger J, Bjørnstad T, et al. Correlation between neck motor control impairment and shoulder pain in elite male handball players. J Sci Med Sport. 2014;18:e76. doi: 10.1016/j.jsams.2014.11.318 [DOI] [Google Scholar]
  • [20].Bogduk N. Innervation and pain patterns of the cervical spine. In: Grant R, editor. Physical therapy of the cervical and thoracic spine. Churchill Livingstone; 2002. p. 61–72. [Google Scholar]
  • [21].Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8(4):344–353. doi: 10.1111/j.1526-4637.2006.00201.x [DOI] [PubMed] [Google Scholar]
  • [22].Dean BJF, Gwilym SE, Carr AJ. Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. Br J Sports Med. 2013;47(17):1095–1104. doi: 10.1136/bjsports-2012-091492 [DOI] [PubMed] [Google Scholar]
  • [23].Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine. 1990;15(6):453–457. doi: 10.1097/00007632-199006000-00004 [DOI] [PubMed] [Google Scholar]
  • [24].Falla D, Jull G, Hodges PW. Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Exp Brain Res. 2004;157(1):43–48. doi: 10.1007/s00221-003-1814-9 [DOI] [PubMed] [Google Scholar]
  • [25].Falla D, Rainoldi A, Merletti R, et al. Spatio-temporal evaluation of neck muscle activation during postural perturbations in healthy subjects. J Electromyogr Kines. 2004;14(4):463–474. doi: 10.1016/j.jelekin.2004.03.003 [DOI] [PubMed] [Google Scholar]
  • [26].Fukui S, Ohseto K, Shiotani M, et al. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain. 1996;68(1):79–83. doi: 10.1016/S0304-3959(96)03173-9 [DOI] [PubMed] [Google Scholar]
  • [27].Gurfinkel VS, Lipshits MI, Lestienne FG. Anticipatory neck muscle activity associated with rapid arm movements. Neurosci Lett. 1988;94(1–2):104–108. doi: 10.1016/0304-3940(88)90278-9 [DOI] [PubMed] [Google Scholar]
  • [28].Takasaki H, Hall T, Kaneko S, et al. Cervical segmental motion induced by shoulder abduction assessed by magnetic resonance imaging. Spine. 2009;34(3):E122–E126. doi: 10.1097/BRS.0b013e31818a26d9 [DOI] [PubMed] [Google Scholar]
  • [29].Buckland AJ, Miyamoto R, Patel RD, et al. Differentiating hip pathology from lumbar spine pathology. J Am Acad Orthop Surg. 2017;25(2):e23–e34. doi: 10.5435/JAAOS-D-15-00740 [DOI] [PubMed] [Google Scholar]
  • [30].Falótico GG, Torquato DF, Roim TC, et al. Dor glútea em atletas – como investigar e tratar? Rev Bras Ortop. 2015;50(4):462–468. doi: 10.1016/j.rbo.2014.07.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [31].Govind J. Lumbar radicular pain. Aust Fam Physician. 2004;33(6):409–412. [PubMed] [Google Scholar]
  • [32].Kurosawa D, Murakami E, Aizawa T. Referred pain location depends on the affected section of the sacroiliac joint. Eur Spine J. 2015;24(3):521–527. doi: 10.1007/s00586-014-3604-4 [DOI] [PubMed] [Google Scholar]
  • [33].Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manipulative Ther. 2008;16(3):142–152. doi: 10.1179/jmt.2008.16.3.142 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [34].Reiman MP, Thorborg K. Clinical examination and physical assessment of hip joint-related pain in athletes. Int J Sports Phys Ther. 2014;9(6):737–755. [PMC free article] [PubMed] [Google Scholar]
  • [35].Roldán-Ruiz A, Bailón-Cerezo J, Falla D, et al. The prevalence of cervical contribution in patients reporting shoulder pain. An Observational Study. Musculoskelet Sci Pract. 2024;73:103158. doi: 10.1016/j.msksp.2024.103158 [DOI] [PubMed] [Google Scholar]
  • [36].Bokshan SL, DePasse JM, Eltorai AE, et al. An evidence-based approach to differentiating the cause of shoulder and cervical spine pain. Am J Med. 2016;129(9):913–918. doi: 10.1016/j.amjmed.2016.04.023 [DOI] [PubMed] [Google Scholar]
  • [37].Hawkins RJ, Bilco T, Bonutti P. Cervical spine and shoulder pain. Clin Orthop Relat Res. 1990;258(&NA;):142–146. doi: 10.1097/00003086-199009000-00017 [DOI] [PubMed] [Google Scholar]
  • [38].Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–268. doi: 10.1080/00913847.2015.1005542 [DOI] [PubMed] [Google Scholar]
  • [39].Katsuura Y, Bruce J, Taylor S, et al. Overlapping, masquerading, and causative cervical spine and shoulder pathology: a systematic review. Global Spine J. 2020;10(2):195–208. doi: 10.1177/2192568218822536 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [40].Throckmorton TQ, Kraemer P, Kuhn JE, et al. Differentiating cervical spine and shoulder pathology: common disorders and key points of evaluation and treatment. Instr Course Lect. 2014;63:401–408. [PubMed] [Google Scholar]
  • [41].Walker T, Salt E, Lynch G, et al. Screening of the cervical spine in subacromial shoulder pain: a systematic review. Shoulder Elb. 2019;11(4):305–315. doi: 10.1177/1758573218798023 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [42].Bahat HS, Kerner O. The Shoulder Symptom Modification Procedure (SSMP): a reliability study. J Nov Physiother. 2016;3(3):1–6. doi: 10.4172/2165-7025.S3-011 [DOI] [Google Scholar]
  • [43].Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? Br J Sports Med. 2009;43(4):259–264. doi: 10.1136/bjsm.2008.052183 [DOI] [PubMed] [Google Scholar]
  • [44].Karel Y, Scholten-Peeters G, Thoomes-de Graaf M, et al. Physiotherapy for patients with shoulder pain in primary care: a descriptive study of diagnostic- and therapeutic management. Physiotherapy. 2017;103(4):369–378. doi: 10.1016/j.physio.2016.11.003 [DOI] [PubMed] [Google Scholar]
  • [45].Ostör AJ, Richards CA, Prevost AT, et al. Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford). 2005;44(6):800–805. doi: 10.1093/rheumatology/keh598 [DOI] [PubMed] [Google Scholar]
  • [46].van der Windt DA, Koes BW, de Jong BA, et al. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995;54(12):959–964. doi: 10.1136/ard.54.12.959 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [47].Ludewig PM, Kamonseki DH, Staker JL, et al. Changing our diagnostic paradigm: movement system diagnostic classification. Int J Sports Phys Ther. 2017;12(6):884–893. doi: 10.26603/ijspt20170884 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [48].Mall NA, Foley E, Chalmers PN, et al. Degenerative joint disease of the acromioclavicular joint. Am J Sports Med. 2013;41(11):2684–2692. doi: 10.1177/0363546513485359 [DOI] [PubMed] [Google Scholar]
  • [49].Juel NG, Natvig B. Shoulder diagnoses in secondary care, a one year cohort. BMC Musculoskelet Disord. 2014;15(1):89. doi: 10.1186/1471-2474-15-89 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [50].Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manipulative Ther. 2013;21(2):90–102. doi: 10.1179/2042618612Y.0000000027 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [51].Wainner RS, Whitman JM, Cleland JA, et al. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658–660. doi: 10.2519/jospt.2007.0110 [DOI] [PubMed] [Google Scholar]
  • [52].Rosedale R, Rastogi R, Kidd J, et al. A study exploring the prevalence of extremity pain of spinal source (EXPOSS). J Man Manipulative Ther. 2020;28(4):222–230. doi: 10.1080/10669817.2019.1661706 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [53].Bialosky JE, Beneciuk JM, Bishop MD, et al. Unraveling the mechanisms of manual therapy: modeling an approach. J Orthop Sports Phys Ther. 2018;48(1):8–18. doi: 10.2519/jospt.2018.7476 [DOI] [PubMed] [Google Scholar]
  • [54].Naugle KM, Fillingim RB, Riley JL. A meta-analytic review of the hypoalgesic effects of exercise. The J Pain. 2012;13(12):1139–1150. doi: 10.1016/j.jpain.2012.09.006 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material
YJMT_A_2443134_SM7182.docx (31.4KB, docx)

Articles from The Journal of Manual & Manipulative Therapy are provided here courtesy of Taylor & Francis

RESOURCES